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13,261
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|
21028
|
Discharge summary
|
report
|
Admission Date: [**2106-3-31**] Discharge Date: [**2106-4-9**]
Date of Birth: [**2106-3-31**] Sex: M
Service: NEONATAL
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname **] is a 1580 gram, 29-5/7 week [**Known lastname **]
infant born to a 31 year old gravida 1, para 0-0-2-1 mother;
serologies were O positive, antibody negative, RPR
nonreactive, Hepatitis B surface antigen negative, Group B
strep unknown. The pregnancy was complicated by rupture of
membranes twelve days prior to delivery on [**2106-3-17**]. The
mother was treated with ampicillin, gentamicin and
Clindamycin. She was also treated with betamethasone times
two for contractions. The patient was delivered by a
spontaneous vaginal delivery after unstoppable preterm labor.
The patient was suctioned, dried and stimulated at the table
and was pink. He was bulb suctioned and received blow-by O2
and was transferred to the Neonatal Intensive Care Unit with
Apgars of 7 and 8.
PHYSICAL EXAMINATION: On admission, notable for a weight of
1580 grams, 75th to 90th percentile, length 37.5 cm which is
25th to 50th percentile. Vital signs were stable. This is
an appropriate for gestational age [**Year (4 digits) **]. Physical
examination was notable for symmetric facies. Soft pinna
with slight recoil. No ear pits or tags. He was noted to
have a cleft soft palate; hard palate and lip were intact.
His nares were patent. His neck was supple without clustered
masses. His heart was regular in rate and rhythm without a
murmur. He had a three vessel cord. His abdomen was soft,
nondistended, without hepatosplenomegaly. He is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 33542**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern1) **] with testes in the canal bilaterally. He had two plus
femoral pulses. His extremities were all intact, warm and
well perfused. He has a positive grasp, symmetric Moro and
tone was appropriate for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The patient was intubated upon arrival to
the Neonatal Intensive Care Unit. He received one dose of
Surfactant and was extubated within 24 hours to room air. He
has remained on room air since that time. He has had apnea
of prematurity with the first episode occurring on day of
life number four. He is currently on caffeine 10 mg per kg
per day and he has had one spell in the past 24 hours which
required mild stimulation.
2. CARDIOVASCULAR: The patient initially received normal
saline bolus of 10 cc per kilo due to slightly low blood
pressure with a MAP of 27. He has since remained
cardiovascularly stable. He has not had a murmur.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
initially NPO and started on TPN on his first day of life.
Fluids were gradually increased. Feedings were initiated on
day of life number one. He reached full enteral feedings on
day of life number seven and advanced to 24 kilocalories on
day of life number eight. He is currently taking breast milk
24/PE 24 and has occasional small spits and intermittent
aspirates of 2 to 4 cc. The patient was initiated on
Ferinsol on day of life number nine and he is currently
receiving 0.15 ml p.o. q. day. His current weight is 1.595
kilograms.
4. GASTROINTESTINAL: The patient's bilirubin at 24 hours of
life was ten. He had type and Coombs sent at that time.
Mother's blood type is O positive. Baby's blood type is O
negative. Coombs was negative. His initial hematocrit was
53 and a follow-up hematocrit done two days later was 44 with
a reticulocyte count of 12.2, indicating some degree of
hemolysis. However, he did not have schistocytes or other
breakdown products on his smear. His bilirubin peaked at 11
on day of life number four and responded nicely to triple
phototherapy. The phototherapy was discontinued on day of
life number eight. On day of life number nine, his bilirubin
was 8.2 / 0.3. He is due to have a repeat rebound bilirubin
on [**2106-4-10**].
A repeat hematocrit on day of life number five was stable at
47.7 with a reticulocyte count of 9% and a repeat Coombs was
negative. Recommend repeating maternal antibody screen in
search for an etiology of his transient hemolysis.
5. HEMATOLOGY: Please see above. The patient has not
received any transfusions during his hospital course. His
most recent hematocrit was 44.7 on [**2106-4-5**].
6. INFECTIOUS DISEASE: The patient's initial white blood
cell count was 11.2 with 39% neutrophils and zero bands. He
was started on ampicillin and gentamicin. Blood cultures
were sent and were negative. Antibiotics were discontinued
after 48 hours. The patient with no further signs of
infection.
7. PLASTICS: The patient has a cleft soft palate. When he
is older and ready for oral feedings, he will need a pigeon
nipple for feedings. He will have follow-up with Dr.
[**Last Name (STitle) 40701**]. His family should be in touch with [**First Name8 (NamePattern2) 40699**]
[**Last Name (NamePattern1) 7518**], with the Cleft Palate Team at [**Hospital3 1810**],
[**Location (un) 86**], once he begins to take p.o. feeding.
8. NEUROLOGY: The patient's head ultrasound done on day of
life number seven was normal.
9. SENSORY: Audiology hearing screen should be performed
prior to the patient's discharge.
10. OPHTHALMOLOGY: The patient's eyes have not yet been
examined. He will be due for his first eye examination at 32
weeks corrected gestational age which will be on [**2106-4-16**].
11. PSYCHOSOCIAL: [**Hospital1 69**]
Social Work was involved with the family. The contact social
worker is [**Name (NI) 553**] [**Name (NI) **].
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital3 **].
PRIMARY PEDIATRICIAN: Undecided.
CARE AND RECOMMENDATIONS:
1. Feedings at discharge are breast milk 24 fortified with
human milk fortifier or premature Enfamil 24 kilocalories per
ounce at 150 ml per kilogram per day.
2. Medications: 1) Caffeine 10 mg per kilogram per day; 2)
Ferinsol 0.15 ml q. day p.o. p.g.
3. Follow-up laboratory: Bilirubin on [**2106-4-10**].
4. Car Seat Position Screening to be done prior to
discharge.
5. State Newborn Screening on [**4-3**]; results are pending at
this time.
6. [**Known lastname **] has not yet received any immunizations.
7. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Known firstname 547**] for infants
who meet any of the following three criteria: 1) Born at
less than 32 weeks; 2) born between 32 and 35 weeks with two
of three of the following: Day care during RSV season; with
a smoker in the household; neuromuscular disease; airway
abnormalities; or school age siblings or, 3) with chronic
lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six 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 that of home care givers.
8. Follow-up appointments recommended: 1) With primary
pediatrician after discharge; 2) With plastic surgery, Dr.
[**Last Name (STitle) 40701**] at [**Hospital3 1810**] in [**Location (un) 86**]. Please contact as
[**Name (NI) **] begins to p.o. feed.
DISCHARGE DIAGNOSES:
1. Prematurity at 29-5/7 weeks.
2. Respiratory distress syndrome, resolved.
3. Transient hypotension, resolved.
4. Sepsis evaluation, negative.
5. Cleft palate.
6. Hyperbilirubinemia.
7. Transient hemolytic anemia of unknown etiology.
8. Feeding immaturity.
Thank you for assuming care of [**Known lastname **] [**Known lastname **]. Please feel free
to call with any questions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2106-4-9**] 13:51
T: [**2106-4-9**] 15:45
JOB#: [**Job Number 55862**]
|
[
"796.3",
"779.3",
"765.16",
"773.2",
"769",
"765.25",
"V30.00",
"774.2",
"749.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
7363, 8028
|
5833, 6354
|
2037, 5706
|
1016, 2009
|
5722, 5807
|
6382, 7342
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
511
| 136,962
|
8497
|
Discharge summary
|
report
|
Admission Date: [**2166-11-17**] Discharge Date: [**2166-11-24**]
Date of Birth: [**2087-4-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
chest pain - pressure, heaviness
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2166-11-17**]
Coronary Artery Bypass Graft x3 (Left internal mammary artery ->
left anterior descending, saphenous vein graft -> obtuse
marginal. saphenous vein graft -> right coronary artery) [**2166-11-18**]
History of Present Illness:
74 year old female presented to OSH with chest pressure and
heaviness. Pain lasted 20-25 minutes, denies any associsted
symptoms. Transferred for further cardiac workup.
Past Medical History:
Coronary Artery Disease s/p CABG
Hypertension
Diabetes Mellitus
Hyperlipidemia
Chronic renal insufficiency Baseline 1.6
TIA
Aortic stenosis
tonsillectomy
Polio with residual right sided weakness
Dementia
Social History:
smoked quit 20 years ago
ETOH 1 watered down port per day
Lives with son
Family History:
NC
Physical Exam:
Admission
General NAD
Vitals HR 60, RR 17, 197/68 right arm B/P
Pulm CTA
Cardiac RRR no murmur/rub/gallop
Neck supple full ROM
Abd soft, nontender, nondistended
Ext warm well perfused pulses +2
Neuro decrease strength RLE some confusion re: situation, walks
with cane
Pertinent Results:
[**2166-11-21**] 05:50AM BLOOD WBC-11.4* RBC-2.99* Hgb-9.4* Hct-27.3*
MCV-92 MCH-31.5 MCHC-34.4 RDW-14.3 Plt Ct-146*
[**2166-11-17**] 02:25PM BLOOD WBC-7.9 RBC-4.60 Hgb-14.6 Hct-43.3 MCV-94
MCH-31.8 MCHC-33.8 RDW-13.3 Plt Ct-220
[**2166-11-17**] 04:20PM BLOOD Neuts-57.9 Lymphs-33.6 Monos-5.9 Eos-2.2
Baso-0.4
[**2166-11-21**] 05:50AM BLOOD Plt Ct-146*
[**2166-11-20**] 04:00AM BLOOD PT-12.9 PTT-33.9 INR(PT)-1.1
[**2166-11-17**] 02:25PM BLOOD Plt Ct-220
[**2166-11-17**] 02:25PM BLOOD PT-12.3 PTT-30.1 INR(PT)-1.1
[**2166-11-21**] 05:50AM BLOOD Glucose-264* UreaN-12 Creat-0.8 Na-136
K-3.3 Cl-100 HCO3-31 AnGap-8
[**2166-11-17**] 02:25PM BLOOD Glucose-82 UreaN-17 Creat-0.8 Na-140
K-3.8 Cl-102 HCO3-29 AnGap-13
[**2166-11-17**] 04:20PM BLOOD ALT-29 AST-43* AlkPhos-68 Amylase-46
TotBili-0.3
TEE [**11-18**]
Conclusions:
PRE-CPB The left atrium is moderately dilated. Mild spontaneous
echo contrast
is seen in the body of the left atrium. No atrial septal defect
is seen by 2D
or color Doppler. There is mild symmetric left ventricular
hypertrophy. There
is mild regional left ventricular systolic dysfunction with mild
hypokinesis
of the inferior wall. The remaining left ventricular segments
contract
normally. Overall left ventricular systolic function is normal.
Right
ventricular chamber size and free wall motion are normal. There
are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly
thickened. Mild (1+) mitral regurgitation is seen.
Brief Hospital Course:
Transferred from OSH for cardiac catherization [**2166-11-17**] which
revealed LM and 3 Vessel CAD and was referred to cardiac
surgery. She underwent preoperative work up and on [**2166-11-18**] was
transferred to the operating room for coronary artery bypass
graft surgery. Please see operative report for further details.
She was transfered to the cardiac surgery recover unit for
further hemodynamic monitoring. In the first 24 hours she awoke
and was extubated without difficulty. She was alert and
following commands but unable to answer questions. On
postoperative day 2 she was weaned from IV nitroglycerin and was
transferred to [**Hospital Ward Name **] 2. She has continued to progress working
with physical therapy. Neurologically she remains oriented to
person not place and time. On postoperative day 4 she was ready
for discharge to rehab, but did not get a bed until postop day
6. Discharged on [**11-24**]. Pt. to make all follow-up appts. as per
discharge instructions.
Medications on Admission:
ASA, Lovenox, Atenolol, Glyburide, lipitor, Norvasc, Oscal,
Zantac, Zoloft, plavix, lisinopril
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 7 days.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 2 mg [**Hospital1 **] for 2 days, then 1 mg [**Hospital1 **] for 2 days then D/c.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Hypertension
Diabetes Mellitus
Hyperlipidemia
Chronic renal insufficiency Basline 1.6
TIA
Aortic stenosis
tonsillectomy
Polio with residual right sided weakness
Dementia
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr [**Last Name (Prefixes) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**Last Name (STitle) 17863**] in 1 week ([**Telephone/Fax (1) 29933**]) please call for appointment
Dr [**Last Name (STitle) 11493**] in [**1-17**] weeks ([**Telephone/Fax (1) 11650**]) please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2166-11-24**]
|
[
"250.00",
"414.01",
"272.4",
"410.71",
"138",
"585.9",
"294.8",
"403.90",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.55",
"39.61",
"88.52",
"99.04",
"37.22",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5420, 5506
|
3133, 4128
|
319, 556
|
5753, 5760
|
1399, 3110
|
1091, 1095
|
4273, 5397
|
5527, 5732
|
4154, 4250
|
5784, 6202
|
6253, 6713
|
1110, 1380
|
247, 281
|
584, 757
|
779, 984
|
1000, 1075
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,362
| 160,831
|
36628
|
Discharge summary
|
report
|
Admission Date: [**2106-7-28**] Discharge Date: [**2106-8-2**]
Date of Birth: [**2052-5-8**] Sex: M
Service: SURGERY
Allergies:
Oxacillin / Aspirin / Ibuprofen / Demerol / Famotidine /
Amoxicillin / Lansoprazole / Nsaids / Statins-Hmg-Coa Reductase
Inhibitors
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Perc choly tube and LUQ drain
History of Present Illness:
Mr. [**Known lastname 2093**] is a 54yo gentleman with PMHx of mild mental
retardation, DM2, ESRD on HD on MWF, and recent acute
cholecystitis s/p perc cholecystostomy tube placement and
removal who presents from rehab with fever and chills. He began
with malaise 3 days ago. He also felt feverish with rigors;
temp was 103.2. He also had nausea and vomiting and vomited
twice 2 days ago (nonbilious, nonbloody). He had an episode of
diarrhea 2 days ago; no BRBPR, melena. He reports RUQ pain as
well.
.
He has a complicated recent past medical history. He had a R
hip arthroplasty in [**2106-4-11**], which was apparently complicated
by ?colon perforation requiring ex-lap. He eventually needed a
tracheostomy and PEG, both now removed. He has been recovering
at a rehab facility. His recovery was complicated by acute
cholecystitis, for which he had a perc cholecystostomy tube
placed. This was removed about 1 month ago.
.
He was first taken to [**Hospital3 **]. He had a Tmax of 103.
He had a hypotensive episode to ?SBP 80s that responded to 500cc
IVF bolus, with improvement of BP to 95/34. Exam was sig. for
RUQ TTP. TBili was 4. RUQ US showed sludge, no stone, dilated
CBD to 13 mm, and mild intrahepatic biliary dilation. He
received Vanc and ceftaz. BCxs grew GNRs (2/2 bottles). He was
transferred to [**Hospital1 18**] for emergent ERCP.
.
In the ED at [**Hospital1 18**], initial VS were: 97.6 64 92/43 100%.
Exam here showed TTP to RUQ, guaiac negative. Labs here show TB
4.7, AP 1349, ALT 41, AST 64, lip 76. WBC is 10.8. Lactate is
0.6. RUQ US showed no biliary dilitation (CBD of 6-9mm) but
could not visualize the gallbladder (?collapse v. irregular GB
wall edema). CT abd was sig. for adjacent organized fluid
collection of 7x4 cm lateral to the stomach. He did not receive
further Abx here. ERCP and surgery were consulted and advised
that he be admitted to the [**Hospital Unit Name 153**] and undergo ERCP.
.
Upon arrival to the ICU, he stated he was comfortable but
sleepy. He denied abdominal pain.
Past Medical History:
PMH:
Diabetes mellitus type II: diagnosed in his 30s
ERSD on HD MWF
HTN
PVD
h/o MRSA abdominal wound infection
.
PSH:
1. R hip THA [**4-/2106**] - [**Hospital 46**] Hosp.
2. ex. lap. - ?bowel perforation - [**Hospital 46**] Hosp.
3. R TMA 14 years ago after non-healing ulcer
Social History:
Lived in a group home until his hip operation; has been at
[**Hospital 671**] Healthcare in rehab since. Smokes about 6
cigarettes/day.
Denies EtOH.
Family History:
Mother died of complications after brain surgery at age 64.
Father died at age 83, had PD. 2 healthy siblings who live in
[**State 16269**] and [**Location (un) 3844**]. No children.
Physical Exam:
96.6 110/63 72 24 98% 2L
Overweight man in no distress, sleepy but rousable.
Mild scleral icterus. Pupils equal and reactive. Dry mucous
membranes.
Neck supple, no thyroid enlargement or cervical adenopathy
S1, S2, RRR, no murmur.
Lungs clear b/l without crackles. Good air movement. Has
episodes of apnea associated with desaturations.
Abd: +BS, soft and not tender. ?? mass in RUQ, but not tender
to palpation throughout. No rebound or guarding. No [**Doctor Last Name 515**]
sign. Erythematous abdominal scar with some scabs.
Neuro: Oriented to self and sister as well as able to say where
he lives. Answers questions appropriately but is very tired.
Strength 5/5 b/l in UE and LE.
Ext: s/p amputation of toes of right foot. Chronic venous
stasis changes in LE b/l. Difficult to appreciate distal pulses
but feet are warm without any ulcers. No LE edema
.
At discharge:
V.S: 97.8, 72, 118/63, 18, 95% RA
GEN: a and o x 3, nad
RESP: LSCTA, bilat
ABD: soft, NT, ND, sl. tender at RUQ and LUQ drain site,
Erythematous abdominal scar with some scabs.
Drain sites: D/C/I no s/s of infection.
Ext: s/p amputation of toes of right foot. Chronic venous
stasis changes in LE b/l. Difficult to appreciate distal pulses
but feet are warm without any ulcers. No LE edema
Pertinent Results:
LABS ON ADMISSION TO [**Hospital1 18**]:
[**2106-7-27**] 10:04PM BLOOD WBC-6.4 RBC-2.34* Hgb-6.3* Hct-21.5*
MCV-92 MCH-27.0 MCHC-29.4* RDW-16.0* Plt Ct-150
[**2106-7-27**] 10:04PM BLOOD Neuts-92.8* Lymphs-4.7* Monos-2.2 Eos-0.3
Baso-0.1
[**2106-7-28**] 01:03AM BLOOD PT-16.0* PTT-31.5 INR(PT)-1.4*
[**2106-7-27**] 10:04PM BLOOD Glucose-74 UreaN-13 Creat-1.4* Na-150*
K-1.5* Cl-128* HCO3-14* AnGap-10
[**2106-7-27**] 10:04PM BLOOD Lipase-30
[**2106-7-27**] 10:04PM BLOOD Phos-0.6* Mg-0.6*
.
RADIOLOGY:
RUQ U/S ([**7-27**]):
IMPRESSION: No evidence of biliary ductal dilatation. Findings
likely
represent either collapsed gallbladder with emphysematous wall
and
extraluminal fluid and gallstones, OR gallbladder with stones
and non-
specific lesion along the anterior fundus, possible adherent
sludge ball or post-inflammatory tissue from ?prior percutaneous
cholecystostomy tube, and pericholecystic fluid.
As the current study does not exclude ruptured or emphysematous
gallbladder, CT is recommended for further assessment. Findings
and recommendations were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] upon
completion of the study.
.
[**7-28**]: CT Abd/Pelvis - 10mm CBD, ++GB wall edema, fluid
collections around stomach with ++stranding, 1.5cm fluid
collection in [**Last Name (un) 103**]. wall, sigmoid colon-containing RIH
(reducible)
.
[**7-28**]: ERCP - Dilated CBD 15 mm s/p stent
.
[**Numeric Identifier 10268**] GUIDANCE FOR DRAINAGE/SPECIMEN COLLECTION [**2106-7-29**] 10:35
AM
Successful placement of left upper quadrant drainage catheter
and
a separate percutaneous cholecystostomy tube placed without
complication.
.
Labs at discharge:
[**2106-8-2**] 08:15AM BLOOD WBC-6.7 RBC-3.64* Hgb-9.9* Hct-33.0*
MCV-91 MCH-27.1 MCHC-29.8* RDW-17.9* Plt Ct-271
[**2106-8-2**] 08:15AM BLOOD Plt Ct-271
[**2106-8-2**] 08:15AM BLOOD Glucose-150* UreaN-28* Creat-4.9*# Na-138
K-4.0 Cl-100 HCO3-27 AnGap-15
[**2106-8-2**] 08:15AM BLOOD ALT-12 AST-17 AlkPhos-596* TotBili-0.8
[**2106-8-2**] 08:15AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.9
Brief Hospital Course:
In short, 54M w DM2, HTN, ESRD on HD, now presenting with likely
cholangitis in setting of recent percutaneous tube for
cholecystitis.
.
# Sepsis: [**3-15**] cholangitis and ? cholecystitis. GNR bacteremia at
OSH. ERCP showed sludge, pus, stones in the CBD, stented. Fluid
collection around biliary system drained by radiology. Treated w
broad-spectrum abx (vanc/ceftazidime/metronidazole), fluids and
supportive measures. Evaluated for surgical resection, but
deferred.
.
# ESRD on HD: Pt would be due for HD today, although his fluid
status and electrolytes are all reasonably good.
- spoke with renal fellow; will likely due HD tomorrow
- continue Aranesp, Nephrocaps, Phoslo
- vanc and ceftazidime are eliminated with HD; will dose per
protocol
.
# h/o MRSA abdominal wound infection:
Appears to be healing, but will continue to cover with
vancomycin for now x 24-48 hours pending more final culture
data.
- wound care consult
.
# DM2: Currently diet controlled
- FS QID, ISS
.
# HTN:
- hold home metoprolol for now
.
# Episodes of apnea:
[**Month (only) 116**] have undiagnosed sleep apnea, but also unclear if he had
narcotics in the [**Name (NI) **] that may be contributing.
- hold off on narcotics
- may need CPAP at night
.
# Depression/anxiety:
- continue citalopram
.
CODE: FULL (not confirmed)
Communication: sister [**Name (NI) **] is HCP [**Telephone/Fax (1) 82880**] (attempted
to contact, no answer)/ [**Hospital 671**] Healthcare [**Telephone/Fax (1) 82881**]
.
Patient was transferred to surgical/medical floor on HD 3. His
diet was advanced from clears to regular, tolerated well. He was
continued on vanc/ceftaz per HD protocol and had HD on [**8-2**]. The
patient will return to radius with two drains, HD MWF with IV
abx and will follow up with Dr. [**First Name (STitle) **] in [**2-12**] weeks. All questions
were answered and paper work was reviewed.
Medications on Admission:
lactulose 15ml po BID
Aranesp 100mcg q week
citalopram 20mg po daily
pantoprazole 40mg po daily
Nephrocap po daily
PhosLo 667mg po tid
metoprolol 25mg po bid
albuterol neb inh qid
"IV levaquin at dialysis for pending BCx"
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**]
Discharge Diagnosis:
Primary:choledocholithiasis and cholangitis
.
Secondary:
DM, ERSD on HD, HTN, PVD, mild developmental delay
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.
Discharge Instructions:
Rehab:
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.
.
Drains:
1. Closed suction drain RUQ bulb suction
Flush w/ 5 mL normal saline daily.
Please continue to strip and empty/record drain output daily or
as needed.
Please change dressing daily or as needed.
2. Closed suction drain LUQ bulb suction
DO NOT flush this drain.
Please continue to strip and empty/record drain output daily or
as needed.
Please change dressing daily or as needed.
Followup Instructions:
1. Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], ([**Telephone/Fax (1) 6347**], to make a follow
up appoinmtnet in [**2-12**] weeks.
Completed by:[**2106-8-2**]
|
[
"250.00",
"574.50",
"V49.73",
"V43.64",
"403.91",
"317",
"585.6",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95",
"51.85",
"51.01",
"96.04",
"51.88",
"96.71",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
8754, 8861
|
6598, 8481
|
392, 424
|
9013, 9092
|
4503, 6175
|
10677, 10877
|
2994, 3179
|
8882, 8992
|
8507, 8731
|
9116, 10654
|
3194, 4076
|
4090, 4484
|
347, 354
|
6194, 6575
|
452, 2507
|
2529, 2810
|
2826, 2978
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,794
| 101,589
|
10196+10197+56119
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2115-8-6**] Discharge Date: [**2115-8-10**]
Date of Birth: [**2069-11-17**] Sex: M
Service: VSU
HISTORY OF PRESENT ILLNESS: This is a 45-year-old male with
a left leg plantar ischemic ulcer admitted to the vascular
surgery service for a left femoral artery to anterior tibial
artery bypass. The patient was recently admitted on [**2115-7-28**]. During his admission he underwent a left lower
extremity angiogram which demonstrated occlusive disease in
the left superficial femoral artery, popliteal artery, and
tibial artery. These were reconstituted in the distal
anterior tibial artery and peroneal artery. It was felt that
a bypass operation would alleviate his ischemic symptoms.
PAST MEDICAL HISTORY: Significant for diabetes mellitus type
1 for which the patient self-administers an insulin pump.
Past medical history is also significant for a kidney and
pancreas transplant in the past.
PAST SURGICAL HISTORY:
1. Simultaneous pancreas/kidney transplant in [**2112**].
2. Cadaveric pancreas transplant in [**2114-11-2**].
3. Phlegmon evacuation in [**2114-12-3**] including washout,
debridement, and closure in [**2114-12-3**].
4. Fistula tract embolization in [**2115-3-5**].
MEDICATIONS:
1. Prograf 5 mg b.i.d.
2. Prednisone 5 mg daily.
3. CellCept [**Pager number **] mg b.i.d.
4. Aspirin 325 mg daily.
5. Celexa 40 mg daily.
6. Midodrine 10 mg daily.
7. Florinef 0.4 mg daily.
8. Pravachol 80 mg daily.
9. Folic acid 1 tablet daily.
PHYSICAL EXAMINATION: The patient is a middle-aged male in
no acute distress. Appears his stated age. He is awake and
oriented x 3. The patient is afebrile. His vital signs are
stable. Chest is clear. Heart is regular. Abdomen is soft,
nontender, and nondistended. There is an old healing surgical
scar with 2 approximately 2- x 2-cm granulating areas.
Pulses: The patient has 2+ femoral pulses bilaterally. No
palpable popliteal pulse on the left, and barely audible
dorsalis pedis and posterior tibial pulses on Doppler exam on
the left side.
LABORATORY DATA ON ADMISSION: Complete blood count: The
patient's hematocrit is 40.4 preoperatively. Electrolytes:
Sodium of 140, potassium of 4.6, chloride of 112, bicarbonate
of 21, BUN of 26, creatinine of 0.9, glucose of 163. Calcium
of 8.9, phosphorous of 2.8, magnesium of 1.8.
DICTATION ENDED
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 30134**]
MEDQUIST36
D: [**2115-8-9**] 16:07:48
T: [**2115-8-9**] 20:51:38
Job#: [**Job Number 33999**]
Admission Date: [**2115-8-6**] Discharge Date: [**2115-8-10**]
Date of Birth: [**2069-11-17**] Sex: M
Service: VSU
ADDENDUM:
BRIEF HOSPITAL COURSE: The patient was admitted to undergo a
left femoral artery to anterior tibial artery bypass
operation which he successfully underwent on [**2115-8-6**]. He
tolerated the procedure well. However, after the procedure
anesthesia elected to keep the patient intubated overnight in
order to protect his airway. He was a difficult intubation
during induction of anesthesia, and it was felt that to
protect his airway he should remain intubated until he could
be successfully weaned in the post anesthesia care unit. His
blood gas at this time was 7.39/36/438/23 on 100% FiO2. This
was weaned to 40%. The patient was successfully extubated the
following morning without incident. He was then transferred
to the VICU.
On postoperative day 1, the patient's vital signs remained
stable. The patient remained in the PACU until late on
postoperative day 1 when he was transferred to the VICU. He
was continued on his home diabetic regimen [**First Name8 (NamePattern2) **] [**Last Name (un) **]. He was
monitored q. hour with hourly Doppler checks, and the
dorsalis pedis and posterior tibial arteries were noted to be
biphasic on Doppler exam.
On postoperative day 2, the patient's vital signs remained
stable. His laboratories were also within normal limits, and
it was felt that he could be transferred to the regular
vascular floor.
The patient continued to recover well on postoperative days 3
and 4. He got out of bed with physical therapy and was able
to walk successfully. During this time there was some
question about the frequency of his anti-rejection
medications for his transplants, and the renal medical
transplant service was consulted. After drawing a Prograf
level which came back at 5.4, at the low end of normal, the
renal transplant service recommended decreasing his regimen
of Prograf to 4 mg twice daily and decreasing CellCept to 500
mg twice daily.
After the patient had successfully undergone a course of
physical therapy in which he was able to walk stairs and his
laboratory values remained stable, it was felt the patient
was ready for discharge home. He was discharged on [**2115-8-10**].
PROCEDURES PERFORMED: Left femoral to anterior tibial artery
bypass graft.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged tomorrow
morning; that is [**2115-8-10**].
DISCHARGE INSTRUCTIONS:
1. The patient is to call Dr.[**Name (NI) 1392**] office or return to
the ER if he notices increased redness or drainage around
his leg or abdominal wounds.
2. The patient is to change a dry dressing daily on the
abdominal wound.
3. The patient may shower.
DISCHARGE FOLLOWUP: In approximately 10 days with Dr.
[**Last Name (STitle) 1391**].
MEDICATIONS ON DISCHARGE: Aspirin 325 mg daily, citalopram
20 mg 2 tablets daily, prednisone 5 mg daily, pravastatin 20
mg 4 tablets daily, Bactrim strength of 80 to 400 mg 1 tablet
daily, fludrocortisone 0.1 mg 4 tablets daily, midodrine 5 mg
2 tablets daily, Percocet 5/500 mg 1 to 2 tablets p.o. q.4-
6h. p.r.n. (pain), insulin pump per routine, Prograf 1-mg
capsules 4 capsules twice daily, CellCept [**Pager number **] mg 1 tablet
twice daily.
DISCHARGE DIAGNOSES:
1. Status post left femoral to anterior tibial artery bypass
graft.
2.
Difficult airway.
3. Status post renal and kidney transplants.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 30134**]
MEDQUIST36
D: [**2115-8-9**] 16:27:16
T: [**2115-8-9**] 20:33:24
Job#: [**Job Number 34000**]
Name: [**Known lastname 5756**],[**Known firstname **] P Unit No: [**Numeric Identifier 5757**]
Admission Date: [**2115-8-6**] Discharge Date: [**2115-8-13**]
Date of Birth: [**2069-11-17**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Morphine
Attending:[**First Name3 (LF) 2129**]
Addendum:
Patient is a 45 yo caucasian male with history of CAD s/p stent
placement in [**2114**], DM type 1, HTN and CHF, who was admitted to
the hospital on [**2115-8-6**] for a left femoral artery to anterior
tibial artery bipass. Patient had surgery for bypass and
recovered well postop. He was transferred to the CCU on [**8-9**]
because of chest pain and concern for acute myocardial
infarction.
.
CAD: On [**8-9**] he began to c/o [**6-11**] midsternal chest pain with no
radiation, associated with nausea, diaphoresis and SOB. Says it
lasted about 5 minutes (although he mentioned to someone else
that it lasted an hour) and resolved with no meds. He also
developed a cough with productive sputum. Cardiac enzymes were
drawn and showed a bump in troponin to 0.37. His EKG read: LVH
with secondary ST-T changes, ST segment elevation in leads V2-V3
probably repolarization secondary to left ventricular
hypertrophy, but cannot rule out anterior wall myocardial
infarction. This appeared changed from his prior EKG on [**8-6**].
The patient was transferred to the CCU and started on a bicarb
drip,mucomyst and integrilin in anticipation of a cath. He was
continued on his statin and ASA and a beta blocker was started.
Ace inhibitors were held because he had a renal transplant. His
cardiac enzymes were checked and he ruled in for MI. He had a
cardiac cath on [**8-12**]. Cath showed 2 vessel disease. The LAD
had a proximal 80% lesion and a previous stent was patent. The
D1 was a small artery with a 90% stenosis. The LCX had no flow
limiting lesions. The RCA was a dominant vessel with a proximal
90% stenosis. Two overlapping Cypher drug-eluting stents were
placed in the proximal LAD and a Cypher drug-eluting stent was
placed in the proximal RCA. Bicarb drip was continued after the
cath and a dye load of only 100 cc was used. Patient remained
chest pain free post cath. He was discharged on ASA,
pravastatin, metoprolol and enalapril (after consulting with
renal).
.
Pump: Patient had a h/o of CHF. Last echo on [**2115-6-23**] showed EF
60-65%. He developed a mild cough and some bilateral crackles
during his admission and responded well to lasix. CXR showed
bilateral diffuse pulmonary opacities in a perihilar
distribution, which could have been secondary to pulmonary edema
and was thought to be worsening CHF. He was continued on lasix
and improved. His CXR on [**8-12**] read mild CHF. At the time of
discharge, the patient had transient desaturation to 88% with
walking. After deep breaths and further ambulation, his sats
were 93% on Room Air. After he walked again, his sats acutally
increased from his baseline. He was aware to notify Dr. [**First Name (STitle) **]
immediately should he develop shortness of breath.
.
DM: Patient had a long h/o diabetes type 1. He had a pancreas
transplant but was on an insulin pump. He continued with his
insulin pump in the hospital and FSBG were checked.
.
? PNA: He was started on ceftriaxone for a possible pneumonia
because of his cough and what appeared to be a left lower lobe
opacity in his chest x-ray. The cxr was later read as pulmonary
edema or possible viral pneumonia. Later chest x-rays showed no
evidence for pneumonia and patient was afebrile so ceftriaxone
was dc'd.
.
S/P Renal Transplant: Patient had one kidney s/p renal
transplant. Cr was elevated at transfer. Bicarb and mucomyst
started prior to cath. Renal was consulted and tacrolimus,
cell-cept and prednisone were continued. Given slightly
elevated FK levels, the FK dose was decreased to 3mg po bid.
Ace-inhibitor was restarted at discharge, and patient was
instructed to check creatinine level within one week.
.
Orthostatic Hypotension: The patient carries this diagnosis but
was persistently hypertensive throughtout this hospital stay
irrespective of position. As such, midodrine and florinef were
discontinued. The patient tolerated this well throughout his
admission and was able to walk with physical therapy without
orthostasis.
.
Abdominal Wound: Patient had a slowly healing wound on his
abdomen that was colonized with VRE. He was placed on contact
precautions and followed by the wound care nurse.
Chief Complaint:
CC:chest pain
Major Surgical or Invasive Procedure:
left femoral to anterior tibial artery bypass graft
Cardiac catheterization [**2115-8-12**] with 2 stents placed in the
proximal LAD and a stent placed in the proximal RCA
History of Present Illness:
HPI: Patient is a 45 you caucasian male with history of CAD s/p
stent placement in [**2114**], DM type 1, HTN and CHF, who was
admitted to the hospital on [**2115-8-6**] for a left femoral artery to
anterior tibial artery bipass.
Patient had surgery for bypass and recovered well postop.
However, on [**8-10**] he began to c/o [**6-11**] midsternal chest pain with
no radiation, associated with nausea, diaphoresis and SOB. Says
it lasted 5 mins and resolved with no meds. He also developed a
cough with productive sputum. Cardiac enzymes were drawn and
showed a bump in troponin to 0.37. His EKG showed ????
Past Medical History:
PMH: DM type 1
CAD s/p stent placemetn in [**7-6**]
HTN
CHF
LLE angiogram demonstrated occlusive dz in left superficial
femoral artery, popliteal artery and tibial artery [**2115-7-28**]
[**2112-6-22**] echo: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is 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 leaflets are mildly
thickened. There is no mitral valve prolapse. There is systolic
anterior motion of the mitral valve leaflets. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
[**7-6**] cath:1. Two-vessel coronary artery disease.
2. Mild diastolic ventricular dysfunction.
3. Successful stenting of the mid-LAD.
4. Successful stenting of the diagonal-2.
5. Successful stenting of the distal LAD.
PAST SURGICAL HISTORY:
1. Simultaneous pancreas/kidney transplant in [**2112**].
2. Cadaveric pancreas transplant in [**2114-11-2**].
3. Phlegmon evacuation in [**2114-12-3**] including washout,
debridement, and closure in [**2114-12-3**].
4. Fistula tract embolization in [**2115-3-5**].
.
Social History:
soc hx:lives with mother and brother not working
Family History:
Family hx: noncontributory
Physical Exam:
PE:
VS:
Gen: a & O x3, NAD, not diaphoretic or SOB
HEENT: JVP about [**2-4**] way up neck
Cardio: RRR, nl S1 S2, no murmurs, rubs, gallops
Pulm: crackles at lung bases B
Abd: soft, NT, nd, +bS
Ext: no edema, dp pulses difficult to palpate, L leg surgical
site covered in dressing. 1 cm dry ulcer on plantar aspect of
left foot, dry, non purulent.
Pertinent Results:
wbc hgb hct plts
[**2115-8-13**] 03:52AM 7.0 8.7* 26.7* 257
[**2115-8-12**] 05:27AM 4.7 3 9.9* 30.9* 251
[**2115-8-11**] 05:30AM 8.9 10.8* 34.8* 296
[**2115-8-10**] 08:15AM 10.1 12.1* 39.2* 276
[**2115-8-10**] 12:16AM 8.6 * 11.5* 36.0* 213
.
diff [**8-10**]: PMNs 91.2* lymphs 3.2* monos 3.2
.
INR 1.1
.
Na K cl HCO3 BUN Cr Gluc
[**8-13**] 136 3.8 103 25 26 1.3 194
[**8-11**] 136 4 104 20 35 1.2 271
.
CK(CPK)
[**2115-8-13**] 03:52AM 80
[**2115-8-12**] 12:00PM 45
[**2115-8-12**] 05:27AM 23*
[**2115-8-10**] 04:14PM 231*
[**2115-8-10**] 08:15AM 300*
[**2115-8-9**] 08:50PM 255*
.
CPK ISOENZYMES CK-MB cTropnT
[**2115-8-12**] 04:52PM NotDone1
[**2115-8-12**] 12:00PM NotDone1 1.80
[**2115-8-11**] 05:30AM 7 1.47
[**2115-8-10**] 04:14PM 7.8* 1.35
[**2115-8-10**] 08:15AM * 8.7* 1.46
[**2115-8-10**] 12:16AM 0.76
[**2115-8-9**] 08:50PM 8.2* 0.37
.
TSH 3.8
.
cxr [**2115-8-9**]: IMPRESSION: New interstitial opacities may represent
pulmonary edema or viral pneumonia.
cxr [**2115-8-10**]: IMPRESSION: Worsening CHF.
cxr [**2115-8-12**]: IMPRESSION: Improving mild congestive heart
failure. No evidence of focal consolidation to suggest
pneumonia.
.
Cardiac cath [**2115-8-12**]: COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel coronary artery disease. There were no angiographically
flow
limiting lesions in the LMCA. The LAD had a proximal 80% lesion
in the
LAD and previous stent was patent. The D1 was a small artery
with a 90%
stenosis. The LCX had no flow limiting lesions. The RCA was a
dominant
vessel with a proximal 90% stenosis.
2. Limited resting hemodynamics revealed elevated systemic
pressures and
severely elevated left sided pressures with no gradient upon
pullback of
the catherter from the ventricle to the aorta.
3. Left ventriculography was deferred due to elevated filling
pressures.
4. Successful placement of two overlapping Cypher drug-eluting
stents in
the proximal LAD (3.0 x 8 mm proximally and 3.0 x 18 mm more
distally).
Final angiography demonstrated no residual stenosis, no
angiographically
apparent dissection, and normal flow (See PTCA Comments).
5. Successful placement of a 2.5 x 23 mm Cypher drug-eluting
stent in
the proximal RCA postdilated with a 2.75 mm balloon. Final
angiography
demonstrated no residual stenosis, no angiographically apparent
dissection, and normal flow (See PTCA Comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Elevated systemic pressures and severely elevated LVEDP.
3. Successful placement of drug-eluting stents in proximal LAD.
4 . Successful placement of drug-eluting stent in proximal RCA.
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel coronary artery disease. There were no angiographically
flow
limiting lesions in the LMCA. The LAD had a proximal 80% lesion
in the
LAD and previous stent was patent. The D1 was a small artery
with a 90%
stenosis. The LCX had no flow limiting lesions. The RCA was a
dominant
vessel with a proximal 90% stenosis.
2. Limited resting hemodynamics revealed elevated systemic
pressures and
severely elevated left sided pressures with no gradient upon
pullback of
the catherter from the ventricle to the aorta.
3. Left ventriculography was deferred due to elevated filling
pressures.
4. Successful placement of two overlapping Cypher drug-eluting
stents in
the proximal LAD (3.0 x 8 mm proximally and 3.0 x 18 mm more
distally).
Final angiography demonstrated no residual stenosis, no
angiographically
apparent dissection, and normal flow (See PTCA Comments).
5. Successful placement of a 2.5 x 23 mm Cypher drug-eluting
stent in
the proximal RCA postdilated with a 2.75 mm balloon. Final
angiography
demonstrated no residual stenosis, no angiographically apparent
dissection, and normal flow (See PTCA Comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Elevated systemic pressures and severely elevated LVEDP.
3. Successful placement of drug-eluting stents in proximal LAD.
4 . Successful placement of drug-eluting stent in proximal RCA.
Brief Hospital Course:
CAD: On [**8-9**] he began to c/o [**6-11**] midsternal chest pain with no
radiation, associated with nausea, diaphoresis and SOB. Says it
lasted about an hour and resolved with no meds. He also
developed a cough with productive sputum. Cardiac enzymes were
drawn and showed a bump in troponin to 0.37. EKG showed NSR and
did not appear changed from his prior EKG on [**8-6**]. The patient
was transferred to the CCU and started on a bicarb drip,
mucomyst and integrilin in anticipation of a cath. He was
continued on his statin and ASA and a beta blocker was started.
Ace inhibitors were held because he had a renal transplant.
Patient was set-up for cardiac cath on [**8-12**]. His cath showed 2
vessel disease. The LAD had a proximal 80% lesion and a previous
stent was patent. The D1 was a small artery with a 90% stenosis.
The LCX had no flow limiting lesions. The RCA was a dominant
vessel with a proximal 90% stenosis. Two overlapping Cypher
drug-eluting stents were placed in the proximal LAD and a Cypher
drug-eluting stent was placed in the proximal RCA. Bicarb drip
was continued after the cath and a dye load of only 100 cc was
used. Patient remained chest pain free post cath. He was
discharged on ASA, plavix, pravastatin, metoprolol and enalapril
(after consulting with renal).
.
Pump: Patient had a h/o of CHF but appeared
Possible Pneumonia: He was started on ceftriaxone for a possible
pneumonia because of his cough and what appeared to be a left
lower lobe opacity in his chest x-ray. The cxr was later read as
pulmonary edema or possible viral pneumonia. Later chest x-rays
showed no evidence for pneumonia and patient was afebrile so
ceftriaxone was dc'd.
Renal: Cr was elevated at transfer. Bicarb and mucomyst started
prior to cath. Renal was consulted and tacrolimus, cell-cept and
prednisone were continued.
Renal: Ace-inhibitor was restarted at discharge, and patient was
instructed to check Creatinine level within one week.
Orthostatic Hypotension: The patient carries this diagnosis but
was persistently hypertensive throughout this hospital stay
irrespective of position. As such midodrine and florinef were
discontinued. The patient tolerated this well throughout his
admission and was able to walk with physical therapy without
orthostasis.
S/p Transplant: Given slightly elevated FK levels, the FK dose
was decreased to 3mg po bid
Hypoxia without shortness of breath: At the time of discharge,
the patient had transient desaturation to 88% with walking.
After deep breaths and further ambulation, his sats were 93% on
Room Air. After he walked again, his sats acutally increased
from his baseline. He was aware to notify Dr. [**First Name (STitle) **] immediately
should he develop shortness of breath.
S/p vascular surgery: Vascular followed the patient and noted he
was stable from their point of view.
Medications on Admission:
MEDICATIONS:
1. Prograf 5 mg b.i.d.
2. Prednisone 5 mg daily.
3. CellCept [**Pager number **] mg b.i.d.
4. Aspirin 325 mg daily.
5. Celexa 40 mg daily.
6. Midodrine 10 mg daily.
7. Florinef 0.4 mg daily.
8. Pravachol 80 mg daily.
9. Folic acid 1 tablet daily.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pravastatin Sodium 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Insulin Pump IR1250 Miscell.
8. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
Disp:*200 Capsule(s)* Refills:*2*
9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
10. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*1*
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*1 Tablet(s)* Refills:*1*
12. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY
(Daily) for 14 days.
Disp:*28 Capsule(s)* Refills:*0*
13. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO four times a day as needed for pain.
Disp:*21 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
FK level. Chem-7. This week
16. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
you need to have your kidney function checked while on this
medication.
Disp:*30 Tablet(s)* Refills:*2*
17. Aquacel-Ag 1.2-3/4 x 18 %- Bandage Sig: One (1) bandage
Topical twice a day.
Disp:*qs 2 weeks* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 50**] VNA
Discharge Diagnosis:
1) s/p left femoral to anterior tibial artery bypass graft
2) difficult airway
3) s/p renal and kidney transplants
4) Acute MI s/p cardiac catheterization with stent placement
Discharge Condition:
Stable at 92% on Room Air, with transient desaturation to 88%
with walking.
Discharge Instructions:
1) Place a dry dressing over abdominal wound. Change daily. You
may cleanse the area with a gauze soaked with normal saline.
2) Call Dr.[**Name (NI) 1588**] office or return to ER if you notice
increased drainage or redness around your leg or abdominal
wounds.
3) You may shower.
4) You will need to check labwork this week and discuss the
results with your tranplant or primary doctor.
5) Call you doctor [**First Name (Titles) 644**] [**Last Name (Titles) 1956**], pain, chest discomfort, shortness
of breath, palpitations, bleeding or any other concerns.
Followup Instructions:
1) Follow up in 1 week with Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 236**] for
appt.
2) Please follow-up with your primary care doctor: [**Last Name (LF) 5959**],[**First Name3 (LF) 133**]
F. [**Telephone/Fax (1) 5960**] this week for LABWORK CHECK.
3) Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5961**] Appointment should
be in [**8-11**] days
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 189**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 5815**] Date/Time:[**2115-9-4**] 9:30
4) Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 853**], MD Where: LM [**Hospital Unit Name 4975**] CENTER Phone:[**Telephone/Fax (1) 242**] Date/Time:[**2115-9-12**] 9:20
[**First Name11 (Name Pattern1) 448**] [**Last Name (NamePattern4) 2130**] MD [**MD Number(1) 2131**]
Completed by:[**2115-11-19**]
|
[
"707.15",
"414.01",
"486",
"440.23",
"428.0",
"V42.0",
"996.86",
"583.81",
"410.71",
"250.41",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"37.22",
"88.56",
"36.05",
"99.20",
"39.29",
"38.22",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
22880, 22937
|
18063, 20910
|
10971, 11145
|
23157, 23234
|
13705, 16347
|
23840, 24845
|
13271, 13299
|
5954, 10900
|
21221, 22857
|
22958, 23136
|
5509, 5933
|
20936, 21198
|
17810, 18040
|
23258, 23817
|
12919, 13189
|
13314, 13663
|
1517, 2057
|
10917, 10933
|
5416, 5482
|
11173, 11787
|
2072, 2762
|
11809, 12896
|
13205, 13255
|
5000, 5103
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,578
| 193,459
|
53659
|
Discharge summary
|
report
|
Admission Date: [**2198-8-13**] Discharge Date: [**2198-8-16**]
Date of Birth: [**2141-2-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Bright red blood per rectum, hematemesis
Major Surgical or Invasive Procedure:
[**2198-8-16**]: Dobhoff feeding placement under fluroscopy
[**2198-8-15**]: Colonoscopy
[**2198-8-14**]: EGD
History of Present Illness:
57yoM with h/o HCV (cleared, last HCV w/PCR negative [**4-/2198**])
and hilar HCC s/p cyberknife radiotherapy and percutaneous
transhepatic biliary catheters x3 (internal-external
non-draining 6 Fr pigtails in R ant, R post, and L biliary
system; recently downsized in IR [**2198-7-27**]), admitted yesterday
with BRBPR and hematemesis. Reportedly, had episode of BRBPR 3d
prior to admission in association with 1 episode of hematemesis
followed by another episode of BRBPR 2d prior to admission. He
did not seek medical treatment but went to transplant surgery
clinic yesterday for routine app't and was sent to ED for
further evaluation. In ED, he reportedly had one brown
non-bloody BM. Denies lightheadedness, visual changes,
nausea/vomiting, chest/abdominal/back pain, and dysuria. He
denies h/o any previous episodes. No recent NSAID or aspirin use
and currently not on anticoagulation. No varices (EGD [**2194**]),
although h/o GERD symptoms yet controlled on PPI. No hemodynamic
instability and no features of hepatic decompensation, jaundice,
encephalopathy, or coagulopathy. Of note, most recent CT
([**2198-8-11**]) demonstrated tumor 3.8 x 3.5cm with slight interval
reduction in size. Has been evaluated for liver transplant. MELD
on admit: 7
.
In the SICU, his hct was serially followed and remained stable.
He was placed on IV PPI and IV ocreotide. No further GI bleed
was noted in the Unit. GI performed an EGD and did not find the
source of his bleed. He is being transfered to the floor for
colonoscopy prep and scope in the am.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, nausea, vomiting, hematochezia,
dysuria, hematuria.
Past Medical History:
- Obstructive jaundice from hepatocellular CA, PTBD placement
- Hepatitis C infection (dx [**1-/2194**] s/p short treatment of
interferon/ribavirin for 4 months; PCR neg [**4-/2198**])
- HCV/EtOH Cirrhosis
- Prior alcohol abuse (none since [**2193**])
- MRSA pneumonia while immunosuppressed during hep C treatment
requiring a 2 week hospitalization
- Chronic back pain [**3-8**] herniated discs s/p injections [**2182**]
- Emphysema
Social History:
Lives in [**Hospital1 8**]. Daughter, [**Name (NI) **], is his HCP.
[**Name (NI) 1139**] - smokes 2 pks/day and wants to quit.
Alcohol - No alcohol at present. Pt was drinking non-alcoholic
beer up until his most recent admission. According to him, he
has been sober since [**2195**]; however, has a lengthy history of
heavy drinking consisting of [**1-19**] beers daily for most of his
life.
Marijuana - Last use was 30+ years ago.
IV Drug Use - Used as a teenager.
Cocaine - Last snorted cocaine 27 years ago and was arrested for
selling it in the late [**2166**].
Family History:
Father passed away at 80 from emphysema, mother passed away at
90, had diabetes, denies family history of cancer, liver
disease, bile duct disease
Physical Exam:
Admission:
VS:T 98.2, BP 118/71, HR 61, RR 20 97%2L
GENERAL: frail appearing gentleman, older appearing than stated
age.
HEENT: EOMI.
NECK: Supple with low JVP
CARDIAC:RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, RUQ TTP. No HSM or tenderness.
EXTREMITIES: thin Warm and well perfused, no clubbing or
cyanosis. 2+ [**Location (un) **] bilaterally to knees.
Discharge:
VS - Tc 97 89/55 95 (70-90) 18 100 RA
Telemetry: SR at 50-70
I/O: Not well recorded
GENERAL: frail appearing gentleman, older appearing than stated
age.
HEENT: EOMI.
NECK: Supple with low JVP
CARDIAC:RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, RUQ TTP. No HSM or tenderness.
EXTREMITIES: thin Warm and well perfused, no clubbing or
cyanosis. 2+ LE edema bilaterally to knees.
Pertinent Results:
I. Labs
A. Admission
[**2198-8-13**] 11:55AM BLOOD WBC-11.8* RBC-4.21* Hgb-13.1* Hct-39.4*
MCV-94 MCH-31.1 MCHC-33.2 RDW-15.5 Plt Ct-337
[**2198-8-13**] 06:00PM BLOOD WBC-7.2 RBC-3.68* Hgb-11.5* Hct-34.3*
MCV-93 MCH-31.3 MCHC-33.6 RDW-15.7* Plt Ct-273
[**2198-8-13**] 11:55AM BLOOD PT-12.5 PTT-30.8 INR(PT)-1.2*
[**2198-8-13**] 11:55AM BLOOD Glucose-107* UreaN-11 Creat-0.6 Na-134
K-4.1 Cl-95* HCO3-29 AnGap-14
[**2198-8-13**] 06:00PM BLOOD ALT-47* AST-55* AlkPhos-147* TotBili-0.4
DirBili-0.2 IndBili-0.2
[**2198-8-13**] 06:00PM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9
B. Hgb/Hct trend
[**2198-8-13**] 11:55AM BLOOD WBC-11.8* RBC-4.21* Hgb-13.1* Hct-39.4*
MCV-94 MCH-31.1 MCHC-33.2 RDW-15.5 Plt Ct-337
[**2198-8-13**] 06:00PM BLOOD WBC-7.2 RBC-3.68* Hgb-11.5* Hct-34.3*
MCV-93 MCH-31.3 MCHC-33.6 RDW-15.7* Plt Ct-273
[**2198-8-14**] 12:18AM BLOOD Hct-33.2*
[**2198-8-14**] 03:55AM BLOOD WBC-7.0 RBC-3.61* Hgb-11.4* Hct-33.8*
MCV-94 MCH-31.4 MCHC-33.5 RDW-15.7* Plt Ct-283
[**2198-8-14**] 10:36AM BLOOD WBC-7.8 RBC-3.62* Hgb-11.5* Hct-34.1*
MCV-94 MCH-31.7 MCHC-33.6 RDW-15.4 Plt Ct-272
[**2198-8-14**] 05:00PM BLOOD Hct-34.9*
[**2198-8-15**] 05:30AM BLOOD WBC-6.2 RBC-3.68* Hgb-11.6* Hct-34.7*
MCV-94 MCH-31.4 MCHC-33.3 RDW-15.1 Plt Ct-319
[**2198-8-15**] 03:25PM BLOOD WBC-7.8 RBC-3.95* Hgb-12.3* Hct-37.3*
MCV-94 MCH-31.1 MCHC-32.9 RDW-15.3 Plt Ct-331
[**2198-8-15**] 09:15PM BLOOD WBC-9.1 RBC-3.73* Hgb-11.8* Hct-34.9*
MCV-94 MCH-31.6 MCHC-33.8 RDW-15.4 Plt Ct-288
C. Discharge
[**2198-8-16**] 05:20AM BLOOD WBC-7.4 RBC-3.82* Hgb-11.9* Hct-35.9*
MCV-94 MCH-31.1 MCHC-33.0 RDW-15.2 Plt Ct-342
[**2198-8-16**] 05:20AM BLOOD PT-11.4 PTT-30.0 INR(PT)-1.1
[**2198-8-16**] 05:20AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-132*
K-4.0 Cl-97 HCO3-28 AnGap-11
[**2198-8-16**] 05:20AM BLOOD ALT-37 AST-46* LD(LDH)-136 AlkPhos-115
TotBili-0.3
II. GI Reports
EGD ([**2198-8-14**])
The esophagus appeared normal, no esophageal varices were seen.
The GE junction was regular and located at approximately 40cm
from the incisors. The stomach was entered and closely examined.
Mild portal gastropathy seen throughout the stomach (snake skin
appearance) moderate degree in the fundus with some cherry red
spots. No signs of active bleeding, no ulcers, erosions. The
duodenal bulb was normal. The descending duodenum and duodenal
folds were normal. Retroflexed view in the stomach fundus
revealed small hiatal hernia, no gastric varices. Otherwise
normal EGD to third part of the duodenum
Recommendations: No evidence of active GI bleed to explain
anemia and melena. We will proceed with Colonoscopy. Please keep
patient on clear diet today, start 4L Golytely in PM, drink [**7-13**]
oz every 10-15 min. NPO qith midnight for colonoscopy tomorrow
Colonoscopy ([**2198-8-15**])
Medium grade 1 internal hemorrhoids were noted.
Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
57M history of hepatocellular carcinoma treated with cyberknife
therapy secondary to HCV and alcoholic cirrhosis, non-oxygen
dependent emphysema admitted with gastrointestinal bleeding from
uncertain source with resolution with normal colonoscopy and EGD
except for hemorrhoids and mild portal gastropathy.
# Gastrointestinal bleeding
Patient presented with hemetemsis, then bright red blood per
rectum, followed by melena per history. EGD on [**2198-8-14**] showed
mild portal gastropathy with no varices. Colonscopy on [**2198-8-15**]
showed internal hemorrhoids. He has been hemodynamically stable
and with stable serial Hgb. Admission Hgb was 13.1 (uncertain if
hemoconcentrated) with discharge Hgb stable at 11.9. He required
no blood products during hospitalization. He was briefly treated
with ceftriaxone 1 gm IV while NPO for SBP prophylaxis. He will
continue on ciprofloxacin 500 mg PO qD since now taking PO.
The ultimate source of his GIB is uncertain but has resolved
with conservative measures. He will be discharged on protonix 40
mg PO BID instead of his home omeprazole 20 mg PO qD.
# COPD: FEV1 52% predicted on PFTs from [**7-17**]. No wheeze on exam
and no increased WOB. He was continued on home spiriva.
# Hepatocellular carcinoma: HCC has been managed as an
outpatient with recent cyberknife treatment. He has been
requiring feeding tube to meet caloric intake. A Dobhoff was
re-placed after GIB under IR guidance. He was re-started on home
tube feeds.
# Chronic back pain
He was continued on oxycodone and acetaminophen.
# Biliary obstuction due to HCC
Transplant surgery had placed recent PTBD due to obstruction.
His drains remained capped during hospitalization. He remained
on ursodiol 300 mg PO BID.
# GERD
He was changed to protonix as above.
# Hyponatremia
Patient had Na trend from 136 to 132 in setting of NPO status.
This is likely hypovolemic hyponatremia and will improve with
intake. He should have a repeat sodium at follow-up with Dr.
[**Last Name (STitle) **].
# Communication: Patient, daughter [**Name (NI) **]
# Code: Full code
# Tubes/drains: PTBD x3 (6Fr pigtails in R ant, R post, and L
biliary system), Dobhoff tube placed by interventional
radiology.
# Transitional issues
- follow-up with Dr. [**Last Name (STitle) **] regarding liver issues
- will continue to follow-up with transplant surgery for tube
maintenance
- re-check sodium at next clinic visit
Medications on Admission:
Acetaminophen 325-650 mg daily
ciprofloxacin 500 mg daily
omeprazole 20 mg daily
xycodone 5-10 mg q.6h
tiotropium bromide one capsule daily
ursodiol 300 mg b.i.d.
Actigall 300 mg one capsule by mouth twice daily
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
Do not exceed greater than 2 grams of tylenol per day
2. Ciprofloxacin HCl 500 mg PO Q24H
Indication: Spontaneous bacterial peritonitis prophylaxis
3. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
hold for sedation, RR < 10
Do not drive, drink alcohol, or perform activities that require
concentration while on this medication. Take a bowel regimen to
prevent constipation.
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Capsule Refills:*0
5. Tiotropium Bromide 1 CAP IH DAILY
6. Ursodiol 300 mg PO BID
Discharge Disposition:
Home With Service
Facility:
CareGroup Home Care
Discharge Diagnosis:
Primary: gastrointestinal bleed
Secondary: cirrhosis, malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a gastrointestinal bleed.
You had both a colonoscopy (to look at your lower bowel system)
and an endoscopy (to look at your esophagus and stomach). This
showed no obvious source of bleeding. Multiple measurements of
your blood count showed that it was stable. You had no further
episodes of bleeding.
You also had a feeding tube replaced by the radiologists and
will re-start tube feeds at home. The instructions for
re-starting your tube feeds are below.
Followup Instructions:
Department: HEMATOLOGY/BMT
When: WEDNESDAY [**2198-8-29**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 3237**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2198-8-29**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT
When: THURSDAY [**2198-8-30**] at 9:10 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"571.2",
"338.29",
"530.81",
"456.21",
"155.0",
"V49.83",
"305.1",
"578.9",
"455.0",
"537.89",
"276.1",
"305.03",
"263.9",
"724.5",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
10936, 10986
|
7630, 10047
|
347, 459
|
11097, 11097
|
4718, 7607
|
11767, 12708
|
3303, 3451
|
10310, 10913
|
11007, 11076
|
10073, 10287
|
11248, 11744
|
3466, 4699
|
266, 309
|
487, 2243
|
11112, 11224
|
2265, 2701
|
2717, 3287
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,448
| 134,363
|
26252
|
Discharge summary
|
report
|
Admission Date: [**2117-2-6**] Discharge Date: [**2117-2-15**]
Date of Birth: [**2070-3-9**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Codeine / Shellfish Derived
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
esrd
Major Surgical or Invasive Procedure:
[**2117-2-6**] renal transplant
History of Present Illness:
46-year-old African-American male with
end-stage renal disease secondary to membranous nephropathy and
HIV admitted for renal transplantation. He is active on the
kidney transplant list blood type O. He has 1288 days on the
list with a peak and current PRA of 100% and 41%. He has
antibodies to A29, A43, A80 and B8, B41, B44, B45, B76 and B82.
He continues to be active in the HIV and solid organ transplant
study protocol and continues to meet our criteria for
transplantation. His last CD4 count was 805 and viral load less
than 48 copies/mL ([**7-29**]). He gets dialyzes MWF, his
interdialytic
weight gain is five and a half kilos, and his last dialysis was
yesterday at 11 am. He dialyzes through a right IJ tunelled
catheter. He has had two clotted AV grafts in his LUE.
He has been feeling well, he denies any fevers, chills, night
sweats, shortness of breath, chest pain, nausea or vomiting. His
does have some fatigue and hip pain when he walks more than 2
blocks. He has had no recent hospitalizations, blood
transfusions or infections.
.
Past Medical History:
Past Medical History: End-stage renal disease, hypertension, and
HIV+, hyperparathyroidism, s/p parathyroidectomy
.
Past Surgical History:
Spinal decompression
Multiple attempts at a dialysis access fistula in his LUE.
Hand surgery in the [**2082**] requiring a blood transfusion, which is
presumably the etiology of his HIV.
Left upper extremity AV grafts (x2) - both clotted/never used.
Bilateral hip replacements due to avascular necrosis [**8-25**]
Social History:
Social History: Lives with partner of in [**Name (NI) 3914**]. No children,
worked as a customer service manager for [**Company **] until medically
disabled. Does not smoke, drink ETOH or use recreational
.
Family History:
Family History: Father is deceased- had CRF, HTN, DM; Mother is
deceased- had colon CA. Twin Brother is deceased from HIV
related complications and renal failure; sister is alive and
healthy and has offered a kidney.
Physical Exam:
Vital Signs: T 98.6 HR 100 BP 115/84 RR 20 SO2 98/RA
Weight: 126 kg
General: No acute Distress
Neuro: Awake, alert, cooperative with exam, normal affect,
oriented to person, place and date.
Lungs: Clear to Auscultation bilaterally
Cardiac: Regular rate and rhythm, S1/S2
Abd: Obese, Soft, Nontender, nondistended. +BS
Extrem: Warm, well-perfused, palpable distal pulses in all
distal
extremities
LABS:
137 | 102 | 30 /
-------------
4.5 | 20 | 8.1 \
Ca: 9.6 Mg: 2.2 P: 3.0
\ 9.7 /
8.8 ---- 258
/26.5 \
PT: 13.4 PTT: 27.3 INR: 1.1
Ca: 9.6 Mg: 2.2 P: 3.0
ALT: 21 Alb: 4.1
AST: 20
UA: pnd
IMAGING AND STUDIES:
CXR: no acute process
EKG: sinus rythm
.
Pertinent Results:
[**2117-2-12**] 07:10AM BLOOD WBC-10.8 RBC-3.22* Hgb-9.5* Hct-27.0*
MCV-84 MCH-29.5 MCHC-35.2* RDW-16.1* Plt Ct-269
[**2117-2-6**] 03:28PM BLOOD PT-13.4 PTT-27.3 INR(PT)-1.1
[**2117-2-12**] 07:10AM BLOOD Glucose-107* UreaN-44* Creat-6.0*# Na-138
K-3.5 Cl-97 HCO3-29 AnGap-16
[**2117-2-12**] 07:10AM BLOOD Calcium-7.0* Phos-5.3*# Mg-1.9
[**2117-2-12**] 07:10AM BLOOD tacroFK-7.2
Brief Hospital Course:
On [**2117-2-6**], he underwent renal transplant to right iliac fossa
using the right kidney from a high risk donor. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please refer to operative notes for complete details.
A ureteral stent was placed. Induction immunosuppression
consisted of solumedrol, cellcept and ATG.
Postop, he experienced delayed graft function requiring
continuation of hemodialysis. Urine output was minimal
268-0cc/day. Creatinine remained in the 6-8.5 range on
hemodialysis ([**2-10**], [**2-11**] & [**2-12**]).
Diet was advanced and tolerated. He did experience hyperglycemia
from steroids. [**Last Name (un) **] was consulted and initiated insulin ([**Hospital1 **]
NPH & sliding scale humalog). He developed diarrhea. This was
negative on [**2-10**]. Adjustment of cellcept was considered, but the
patient felt that a 4x/day regemin would be too difficult to
remember.
The right lower quadrant incision was intact with staples.
Steroids were tapered to prednisone 20mg daily. A total of 4
doses of ATG (150mg each dose)was administered. Cellcept
remained at 1 gram twice daily and prograf was dosed
intermittently given interaction with Tenofovir. He received 1mg
on [**2-8**].5mg on [**2-10**] and 1mg on [**2-11**]. Trough prograf level was
7.2. He received 1mg on [**2-13**] and [**2-14**] for troughs of 6.1 and 11.
Physical therapy worked with him. Crutches were used as weight
adjusted Canadian Crutches were not available. PT cleared him
for home.
The plan is for him to remain on dialysis with twice weekly lab
draws at his outpatient dialysis unit ([**First Name8 (NamePattern2) 7635**] [**Last Name (NamePattern1) **] in VT). He
will resume sessions on Monday [**2-15**].
Medications on Admission:
ABACAVIR - (Prescribed by Other Provider) - 300 mg Tablet - 2
Tablet(s) by mouth daily
ALBUTEROL - (Prescribed by Other Provider) - 90 mcg Aerosol - 2
puffs orally [**Hospital1 **] as needed
ATAZANAVIR - (Prescribed by Other Provider) - 300 mg Capsule -
1
Capsule(s) by mouth daily
B COMPLEX-VITAMIN C-FOLIC ACID [DIALYVITE] - (Prescribed by
Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth once a day
CINACALCET [SENSIPAR] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 60 mg Tablet - 1 Tablet(s) by mouth
once a day
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other
Provider)
- 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth
daily
EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily
METOCLOPRAMIDE [REGLAN] - (Prescribed by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth twice daily
OXYCODONE-ACETAMINOPHEN [ROXICET] - (Prescribed by Other
Provider) - 5 mg-325 mg Tablet - 2 Tablet(s) by mouth three
times
a day as needed for pain
RITONAVIR - (Prescribed by Other Provider) - 100 mg Capsule - 1
Capsule(s) by mouth daily
SEVELAMER HCL [RENAGEL] - (Prescribed by Other Provider) - 800
mg Tablet - 3 Tablet(s) by mouth three times a day
TENOFOVIR DISOPROXIL FUMARATE - (Prescribed by Other Provider)
-
300 mg Tablet - 1 Tablet(s) by mouth weekly
ZOLPIDEM [AMBIEN] - (Prescribed by Other Provider) - 10 mg
Tablet - 2 Tablet(s) by mouth at bedtime as needed for insomnia
Discharge Medications:
1. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
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 DAILY (Daily).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
6. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for prn pain.
9. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,TH).
11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO 1X/WEEK (MO).
13. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
16. Tacrolimus
dose to be determined
you will have levels checked twice weekly and will be called
with dose to take
17. Insulin Syringe 1 mL 30 x [**4-4**] Syringe Sig: One (1)
Miscellaneous every 4-6 hours.
Disp:*120 syringes* Refills:*2*
18. Insulin Needles (Disposable) 31 X [**4-4**] Needle Sig: One (1)
Miscellaneous every 4-6 hours.
Disp:*120 needles* Refills:*2*
19. One Touch Test Strip Sig: One (1) In [**Last Name (un) 5153**] every [**2-23**]
hours.
Disp:*200 strips* Refills:*2*
20. Lancets, Super Thin Misc Sig: One (1) Miscellaneous
every 4-6 hours.
Disp:*200 lancets* Refills:*2*
21. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Nine
(9) units Subcutaneous once a day: 3 units every pm.
Disp:*1 bottle* Refills:*1*
22. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Three
(3) units Subcutaneous supper.
23. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day.
Disp:*1 bottle* Refills:*1*
24. Sevelamer HCl 400 mg Tablet Sig: Eight (8) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 43512**] Area VNA
Discharge Diagnosis:
esrd
htn
s/p renal transplant with delayed graft function
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you experience
any of the warning signs listed below
Resume dialysis at your home dialysis center on Monday [**2-15**]
You will need to have lab work done every Monday and Wednesday
with results fax'd to [**Telephone/Fax (1) 697**] attention Transplant Nurse
coordinator
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2117-2-18**]
10:00
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2117-2-23**] 11:20
f/u with Dr. [**Known firstname **] [**Last Name (NamePattern1) 724**] on [**2-18**]
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2117-3-4**]
10:15
Completed by:[**2117-2-15**]
|
[
"249.00",
"276.7",
"585.6",
"403.91",
"E932.0",
"042",
"582.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"00.93",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
9078, 9143
|
3476, 5233
|
304, 338
|
9245, 9245
|
3074, 3453
|
9753, 10328
|
2160, 2364
|
6756, 9055
|
9164, 9224
|
5259, 6733
|
9393, 9730
|
1585, 1901
|
2379, 3055
|
260, 266
|
366, 1424
|
9260, 9369
|
1468, 1562
|
1933, 2128
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,043
| 128,989
|
32558
|
Discharge summary
|
report
|
Admission Date: [**2141-10-21**] Discharge Date: [**2141-10-25**]
Date of Birth: [**2087-11-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypotension, respiratory distress
Major Surgical or Invasive Procedure:
Multi Lumen - [**2141-10-21**] 09:09 AM
Arterial Line - [**2141-10-21**] 05:30 PM
Midline placed - [**2141-10-25**]
Trach placement - [**2141-10-21**]
History of Present Illness:
53 yoM w/ a h/o severe COPD s/p prolonged hospitilation for COPD
flare, s/p trach and 1.5 years trach / vent dependent due to PNA
and ARDS / COPD flare now s/p trach removal 3-5 days ago
presents w/ respiratory distress and hypotension. EMS was
called mainly due to increased secretions and hypoxia however
his hypoxia had resolved when EMS had arrived, on a different O2
sat monitor he was in the 90s on room air rather than in the 60s
as they were initially called for.
.
The patient is unable to converse but is able to answer yes or
no questions. Upon questioning he is able to say that he has
had a cough for at least months, over the past few weeks it is
worsening, not in frequency but it is more productive. He has
not felt short of breath but does have some orthopnea. He has
no functional capacity at baseline. He denies any pain
anywhere, no chest pain, no abdominal pain. He denies any
lightheadedness. He feels generally well and states he feels
fine.
.
Labile blood pressures despite 3.5 liters of fluid now but
intermittently with SBPs in the 80s.
.
Patient initially refused any medical care and seemed to have
capacity. Patient has schizoaffective disorder, psych was
called and he was more delierious at that time and he was not
answering questions and therefore deemed uncapable.
.
VBG drawn and increased CO2 so a thought was CO2 narcosis, but
w/ supplemental O2 3L NC and mental status improved but not CO2.
.
rec'd levo / vancomycin zosyn, 3.5 liters of fluid as above and
decadron 10mg IV x 1. afebrile.
Past Medical History:
Past Medical History:
- Chronic vent/trach/PEG for hypercarbic respiratory failure at
the beginning of [**2140-10-10**], ?reportedly due to COPD
exacerbation
- Severe COPD, home O2 dependent in the past
- Per rehab admission note, questionable old granulomatous lung
disease with calcified hilar LAD
- Remote L CVA with residual right sided weakness
- New onset generalized TC seizures on [**2140-11-5**] per rehab neuro
note, thought to be [**2-11**] post-CVA and metabolic abnormalities (on
transfer from rehab on Keppra, Depakote)
- Diabetes mellitus, on 16U Lantus at rehab and RISS
- Depression
- Schizophrenia, on effexor and risperdal
- Past h/o EtOH abuse
- GERD
- Afib/sinus tach
- Pseudomonas PNA resistant to cephalosporins and quinolones
[**1-17**]
- [**2140-12-19**] TTE: LVEF 50-60% w/dilated right ventricular cavity
and depressed right ventricular systolic function
- h/o diverticulitis
- h/o questionable old granulomatous lung disease with calcified
hilar LAD.
Social History:
Divorced. Former smoking. h/o etoh abuse. Was living at a rehab
facility prior to admission.
Family History:
Non-contributory
Physical Exam:
Tmax: 37.3 ??????C (99.1 ??????F)
Tcurrent: 37.3 ??????C (99.1 ??????F)
HR: 110 (70 - 111) bpm
BP: 131/69(92) {78/40(54) - 137/69(92)} mmHg
RR: 25 (7 - 25) insp/min
SpO2: 97%
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, thrush
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline, trach inplace
COR: tachycardic, no M/G/R, normal S1 S2, radial pulse 1+ R and
2+ L
PULM: Lungs diminshed air movement bilaterally but patient has
poor inspiratory effort, he is in no respiratory distress, no
paradoxical breathing or accessory muscle use, diffuse ronchi
bilaterally
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, upon yes / no questioning aox 1 only. CN2-10 and
12 normal, CN11 on R impaired. R arm 4/5 weakness of grip,
bicep, tricep, wrist flex / extend, deltoid [**3-15**]. LUE [**5-15**]
stregnth to all modalities. RLE able to move toes but otherwise
unable. LLE [**5-15**] stregnth to dorsiflex / plantarflex, quad,
hamstring.
Pertinent Results:
[**2141-10-25**] 04:13AM BLOOD WBC-8.1 RBC-3.30* Hgb-9.6* Hct-28.9*
MCV-88 MCH-29.0 MCHC-33.0 RDW-15.3 Plt Ct-360
[**2141-10-24**] 04:07AM BLOOD Neuts-87.4* Lymphs-6.6* Monos-5.0 Eos-0.9
Baso-0.1
[**2141-10-25**] 04:13AM BLOOD PT-13.4 PTT-23.5 INR(PT)-1.2*
[**2141-10-25**] 04:13AM BLOOD Glucose-123* UreaN-8 Creat-0.3* Na-143
K-3.8 Cl-102 HCO3-35* AnGap-10
[**2141-10-21**] 04:00AM BLOOD ALT-7 AST-20 AlkPhos-49 Amylase-61
TotBili-0.2
[**2141-10-25**] 04:13AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.9
[**2141-10-22**] 04:11AM BLOOD calTIBC-251* Hapto-204* Ferritn-193
TRF-193*
[**2141-10-22**] 12:06AM BLOOD Cortsol-0.9*
[**2141-10-24**] 04:07AM BLOOD Valproa-52
[**2141-10-23**] 04:57AM BLOOD Type-ART Temp-37.9 Rates-[**10-15**] Tidal V-600
PEEP-5 FiO2-40 pO2-69* pCO2-55* pH-7.43 calTCO2-38* Base XS-9
-ASSIST/CON Intubat-INTUBATED
[**2141-10-22**] 10:17AM BLOOD Lactate-1.0
CXR Portable ([**2141-10-25**]): The tracheostomy tube tip is
approximately 3 cm above the carina. No significant change in
the right lung consolidation, bilateral pleural effusion, and
perihilar vascular engorgement is demonstrated compared to the
prior study. The right internal jugular line was removed in the
meantime interval.
CXR Portable ([**2141-10-21**]): Interval removal of tracheostomy tube.
There is persistent collapse of the right middle and lower
lobes. Right-sided pleural effusion is seen. There is no
pneumothorax. The cardiac silhouette cannot be evaluated due to
opacities from collapsed lung. The trachea is deviated to the
right and unchanged.
Brief Hospital Course:
53M with COPD and history of chronic respiratory failure; s/p
recent trach removal at rehab and here w/ increased secretions;
now s/p replacement of trach and continued labile BP of unclear
etiology.
#. Hypercarbic respiratory failure: Trach replaced on admission
- had been removed 5 days prior to admission. Chest radiograph
with white out of right middle and lower lung fields ??????improved
on discharge. Mucus plugging was high on differential. Possible
pneumonia hidden within white out. Sputum culture grew
Pseudomonas and Staph aureus ?????? unclear if this was colonizer or
actual infection. COPD exacerbation also on differential given
considerable wheezing on admission. Initially treated with
vancomycin, ceftaz, and TMP-SMX (given history of
Stenotrophomonas). As no clear indication of active pneumonia
(afebrile, slightly elevated WBC count which may be due to
steroid therapy, and + culture thought to be colonizers), was
started on treatment with short course of ceftaz for bronchitis.
Tobramycin, which was initially added for double coverage of
pseudomonas, and vancomycin were discontinued. Ceftaz day 4 on
[**2141-10-25**]; midline placed for additional 3 days of
administration.
- Steroids initially increased and tapered to home dose on
discharged (hydrocortisone 20mg PO QAM, 5mg PO QPM)
- Needs aggressive sunctioning for continued considerable
secretions
- Staying on vent may be best option given patient??????s level of
discomfort off of vent
- Flovent started [**2141-10-24**] for severe COPD
#. Hypotension: Occasionally pressured dropped to MAPs in 50s.
Thought initially to be related to adrenal insufficiency. No
evidence of autopeep, hypovolemia, sepsis, or autonomic
insufficiency. Has history of adrenal insufficiency, now on high
dose steroids. On discharge decreased steroid dose to home
regimen as above.
# Schizoaffective d/o vs. schizophrenia: Per psych patient did
not have capacity to refuse medical care on admission. Continued
effexor, risperdal and depakote. Valproic acid level within
normal range on [**2141-10-24**].
# Seizures: Tonic-clonic seizures in past, thought to be related
to previous CVA and 'toxic metabolic disturbances' upon previous
admissions. Continued Keppra 250mg po bid. Continued valproic
acid as above.
# DM: Blood glucose range 120-180
- Lantus increased to 12U QHS + SSI.
# FEN:
- Tube feeds via PEG tube
# Access:
- Midline placed [**2141-10-24**]
- Arterial line, central line removed [**2141-10-24**]
# Code: FULL CODE
- Social work involved and attempted to contact patient??????s
healthcare proxy/guardian to assess goals of care. Unable to
contact - will follow-up with this. Patient reports different
goals of care, but as above was deemed incompetent to make such
a decision.
Medications on Admission:
Docusate Sodium 100mg po bid
Senna 8.8 mg/5 mL- 10 ml PO qhs
latulose prn
Dulcolax 10 mg PR prn
Heparin sc tid
Acetaminophen 325 mg [**1-11**] po q6hrs prn
Folic Acid 1 mg po daily
Risperidone 2 mg po bid
Divalproex 875mg po tid
Venlafaxine 75 mg po bid
Keppra 250mg po bid
Nexium 40 mg po daily
Combivent 2 puffs q4hrs prn
atrovent nebs prn
albuterol nebs prn
Hydrocortisone 5mg po qpm
hydrocortisone 20mg po qam
Insulin Lantus 10uqhs, Humalog SS
Oxycodone 5mg po q6hrs prn
MVI daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
5. Risperidone 2 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day).
6. Therapeutic Multivitamin Liquid [**Month/Day (2) **]: One (1) Tablet PO
DAILY (Daily).
7. Nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO QID
(4 times a day) as needed.
8. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical QID
(4 times a day) as needed.
9. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup [**Month/Day (2) **]: Eight
[**Age over 90 12887**]y Five (875) mg PO Q8H (every 8 hours).
10. Chlorhexidine Gluconate 0.12 % Mouthwash [**Age over 90 **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
11. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2)
Puff Inhalation QID (4 times a day).
13. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Twelve (12) units
Subcutaneous at bedtime.
14. Hydrocortisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO QAM (once
a day (in the morning)).
15. Hydrocortisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QPM (once
a day (in the evening)).
16. Azithromycin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO QMOWEFR
(Monday -Wednesday-Friday).
17. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
18. Pantoprazole 40 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
19. Ceftazidime 1 gram Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours): Last dose in evening on [**10-28**].
20. Keppra 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day.
21. Insulin Regular Human 100 unit/mL Cartridge [**Month/Year (2) **]: Sliding
scale per home regimen Injection QACHS.
22. Effexor 75 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Chronic vent/trach/PEG for hypercarbic respiratory failure with
acute exacerbation
Severe COPD
Hypotension
Depression
Diabetes mellitus
Discharge Condition:
On pressure support; bed bound; hemodynamically stable
Discharge Instructions:
Patient was admitted on [**2141-10-21**] with hypercarbic respiratory
failure and hypotension. Trach was replaced, and patient
maintained on mechanical ventilation (pressure support).
Changes to medication regimen:
- Ceftazidime for additional 4 days - total 7 days therapy,
ending [**2141-10-28**]
- Azithromycin QMWF for chronic secretions, airway inflammation
- Lantus increased to 12U QHS
- Fluticasone
Patient also needs:
- frequent suctioning for secretions.
- to be maintained with trach.
- intermittent EKGs given risk of prolonged QT on risperdal +
azithromycin.
- referral to endocrinology for further management of adrenal
insufficiency.
Followup Instructions:
At rehab facility
Completed by:[**2141-10-29**]
|
[
"518.84",
"491.22",
"728.89",
"295.62",
"428.0",
"311",
"519.19",
"428.22",
"934.1",
"438.89",
"530.81",
"V44.1",
"345.90",
"255.41",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.91",
"96.71",
"38.93",
"33.24",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
11664, 11719
|
5928, 8694
|
360, 513
|
11899, 11956
|
4362, 5905
|
12655, 12705
|
3209, 3227
|
9229, 11641
|
11740, 11878
|
8720, 9206
|
11980, 12632
|
3242, 4343
|
286, 322
|
541, 2079
|
2123, 3082
|
3098, 3193
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,957
| 105,364
|
6962
|
Discharge summary
|
report
|
Admission Date: [**2160-8-23**] Discharge Date: [**2160-9-9**]
Date of Birth: [**2082-3-31**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Left suboccipital craniotomy
Right external ventricular drain
Tracheostomy
PEG
History of Present Illness:
78yo Chinese-speaking M h/o HTN, DM2, CRI and smoking
presented with N/V and complaining of dizziness on [**8-23**]. He was
well upon going to bed [**8-22**] but awoke on [**8-23**] at 2am complaining
that he did not feel well. At 3:30am, he tried to go to the BR
but fell onto his knees. He was then helped back to bed but then
experienced N/V and tinnitus in both ears and vertigo. He was
brought to the ED in the morning when symptoms persisted when
sitting up or standing.
In the ED, his V/S were 97.2 120 (in new onset afib) 150/70 10
95% ra. Neuro exam was "non-focal" and CT of the head was
negative for acute bleed or signs of infarction and the patient
was admitted to medicine for syncope workup. The morning of
[**8-24**],
the patient vomited again and was somnolent, per the hospitalist
note. He opened his eyes to his daughter, denied dizziness,
headache or CP but was not sure of the year and he was
hypertensive. His neuro exam at this time by medicine was
"somnolent. Opens eyes to daughter command. Follows commands.
With symmetric grip strength. Toes down bilaterally. Moves all
4.
Can't identify year or week." He was sent for MRI with and
without gadolinium to r/o posterior circulation stroke. When
this
showed a cerebellar infarct, neurology consult was called.
Exam at this time showed the patient unable to be aroused with
voice or sternal rub. He opened his eyes for 4-5 seconds to
nailbed pressure to his toes but he did not follow commands.
With
coaxing from his wife, he squeezed her hand on the left but then
let go. Pupils were 2->1.5mm bilaterally but sluggish. Gaze was
midline. He had no blink to threat and oculocephalics were
unable
to be assessed. Corneal reflexes were intact b/l. He had
preferential turning of the head to the right. Tongue was
midline. On motor exam, his right leg was hypotonic and
externally rotated. His right arm was hypotonic and the left was
slightly anti-gravity. Both arms localized to pain, L>R. His
legs
withdrew to pain, again L>R. He had a babinski on the R but not
on the left. He was unable to walk.
After neuro evaluation, stat neurosurgery consult was called.
The
patient was sent for stat CT. While there, around 9:30pm, while
being seen with the neurosurgery team, the ED attending was
called to the resuscitation room by the neurosurgery team after
the patient vomited in the scanner and had "decreased MS" since.
CT showed large evolving L cerebellar infarct and potential
brainstem infarction, with mass effect on the brainstem and
likely cerebellar herniation. The patient was intubated for
airway protection, confirmed by postintubation CXR, and admitted
to the SICU.
Overnight, the patient underwent emergent left suboccipital
craniotomy with placement of EVD on the right. Postop CT showed
postsurgical pneumocephalus in the left cerebellum, possible
left
mass effect, s/p R EVD with new right lateral ventricle
hemorrhage. The patient was transferred back to the SICU and
placed on mannitol, propofol gtt, nicardipine gtt, nitroglycerin
gtt and in the morning of [**8-25**], started on dexamethasone 4mg IV
q6. He is now transferred to our care from the neurosurgery
service.
Past Medical History:
DM2 (HgbA1c 6.0% [**6-/2160**])
HTN
Tobacco abuse
CRI (followed by Dr. [**Last Name (STitle) **], b/l Cre 1.5)
gout
cataracts
glaucoma
s/p left inguinal hernia repair
h/o TB (while in [**Country 651**] in his 30's, denies ever being treated)
Social History:
Retired machinist, moved to the United States 13 years ago from
[**Country 651**]. He
lives with his wife. His daughter lives nearby. Long-time
smoker. He denies any alcohol or illicit drug use.
Family History:
deferred
Physical Exam:
Opens eyes to voice. Blinks to threat on the left. Pupils
reactive. Moves left side spontaneously. Trace but inconsistent
movement of right side. Does not follow commands.
Pertinent Results:
[**2160-9-8**] 04:08AM BLOOD PT-18.7* PTT-53.5* INR(PT)-1.8*
Brief Hospital Course:
The patient was admitted to medicine after a possible syncopal
episode, with dizziness and vomiting. Head CT in the ED was
negative. He was found to be in atrial fibrillation with RVR and
placed on metoprolol for rate control.
The morning of [**8-24**],the patient vomited again and was somnolent,
per the hospitalist
note. He opened his eyes to his daughter, denied
dizziness,headache or CP but was not sure of the year and he was
hypertensive. His neuro exam at this time by medicine was
"somnolent. Opens eyes to daughter command. Follows commands.
With symmetric grip strength. Toes down bilaterally. Moves all
4.
Can't identify year or week." A posterior circulation stroke was
considered by the medicine team and a stat neurology consult was
called when MRI revealed "Multifocal areas of acute infarction
most pronounced in the left superior cerebellar territory
suggesting an embolic source to the basilar artery".
Exam at this time showed the patient unable to be aroused with
voice or sternal rub. He opened his eyes for 4-5 seconds to
nailbed pressure to his toes but he did not follow commands.
With
coaxing from his wife, he squeezed her hand on the left but then
let go. Pupils were 2->1.5mm bilaterally but sluggish. Gaze was
midline. He had no blink to threat and oculocephalics were
unable
to be assessed. Corneal reflexes were intact b/l. He had
preferential turning of the head to the right. Tongue was
midline. On motor exam, his right leg was hypotonic and
externally rotated. His right arm was hypotonic and the left was
slightly anti-gravity. Both arms localized to pain, L>R. His
legs
withdrew to pain, again L>R. He had a babinski on the R but not
on the left. He was unable to walk.
After neuro evaluation, stat neurosurgery consult was called.
The
patient was sent for stat CT/CTA. While there, around 9:30pm,
while
being seen with the neurosurgery team, the ED attending was
called to the resuscitation room by the neurosurgery team after
the patient vomited in the scanner and had "decreased MS" since.
CT showed large evolving L cerebellar infarct and potential
brainstem infarction, with mass effect on the brainstem and
likely cerebellar herniation. The patient was intubated for
airway protection, confirmed by postintubation CXR, and admitted
to the SICU. CTA was unable to be obtained.
Postoperatively, the patient continued ICU care, with intubation
and was placed briefly on dexamethasone, and he was then
transferred back to the neurology service. His blood pressure
was allowed to autoregulate, to allow for adequate perfusion of
the brain, with the hope of reducing damage to any surrounding
zone of ischemia. He was placed on mannitol and dexamethasone
was discontinued. Postop CT showed: "1) S/p left suboccipital
craniotomy, with expected postoperative change in the left
cerebellar hemisphere in the region of evolving infarct.
Differences in obliquity and positioning compared to the
preoperative scan make assessment for interval change in mass
effect and potential cerebellar herniation difficult. 2)
Interval placement of right intraventricular catheter, with
layering hemorrhage within the right lateral ventricle and small
amount of hemorrhage along the entry tract"
Repeat MRI/A on [**8-25**] showed "A large left PCA infarct as well as
an acute infarct within the left cerebral peduncle. Relating to
the left PCA infarct, there are scattered infarcts within the
left thalamus.Interval development of intraparenchymal and
intraventricular blood, some of which relates to the recent
surgeries.
MRA: Nonvisualization of the left posterior cerebral artery
consistent with the acute left posterior cerebral artery
infarct. Small basilar artery. Poor visualization of the distal
V4 segment of the left vertebral artery."
From the time of his admission to the ICU, extensive discussions
were carried out with the family, informing them of the
patient's extremely guarded prognosis. He remained comatose off
sedation throughout. Hospital course was complicated by
ventilator-associated pneumonia and on [**8-29**], the patient was
started on cefepime, with sputum culture positive for GNRs. He
also intermittently went into afib with rapid ventricular
response, for which he was placed on diltiazem or labetalol
drip, with the restriction that it not lower his blood pressure
beyond goal of 150-160 systolic.
He was extubated but was not able to be weaned off of facemask.
After discussion with the family, he received a trach/PEG. Their
desire though is for him to be DNR but not DNI.
He was evaluated by cardiology for atrial fibrillation with
rapid ventricular response and placed on oral amiodarone and
labetalol for rate control, as well as enalapril for blood
pressure management. Despite these medications, he has been
difficult to control, but for the most part, his pulse rate has
stayed below 100. He transiently and asymptomatically drops his
heart rate to 40s. He is now discharged on coumadin, with goal
INR [**12-28**], to minimize the risk of cardiac embolism, particularly
to the posterior circulation, where another embolic stroke would
be devastating.
Neurologically, he has most likely reached his baseline and it
remains likely that he will enter a persistent vegetative state.
His prognosis remains guarded. Follow-up head CT's have been
stable. The most recent, on [**9-7**], showed: "Again seen are
changes within the left suboccipital region from hemicraniotomy.
There is some prolapse of left cerebellum through the craniotomy
defect, though this is unchanged in comparison to prior study.
Again seen is an area of parenchymal edema within the left
occipital region, corresponding to area of infarct, which has
increased slightly in comparison to prior study. There is
slightly increased mass effect on the left occipital [**Doctor Last Name 534**] of the
left lateral ventricle compared to the prior study. There is
stable appearance of foci of intraventricular hemorrhage.
Additionally there is continued evolution of blood products
within the right frontal lobe in the area of the prior
ventriculostomy catheter tract. The caliber of the ventricles is
otherwise unchanged in comparison to prior exam. No new foci of
intracranial hemorrhage are identified. The soft tissue and
osseous structures are stable in appearance." Goal sbp is <160.
In terms of pulmonary, the patient was started on [**9-7**] on
ceftriaxone/vancomycin for the possibility of pneumonia. He has
been having low-grade fevers and there was possibly an
infiltrate on chest x-ray. There is no clear evidence for or
against a pneumonia; he should complete a 7-day course (ie, 5
more days, as written) and then discontinue antibiotics. He
should receive chest PT, pulmonary toilet and trach care.
Nutrition: tube feeds as written.
He will be seen in neurology clinic with the stroke fellow and
attending.
Medications on Admission:
Methyldopa 250mg [**Hospital1 **]
Nifedipine XL 60mg QD
Allopurinol 100mg QD
Triamterene/HCTZ 37.5/25mg 1 tab QD
Lisinopril 40mg [**Hospital1 **]
Actos 30mg QD
Aspirin 325mg QD
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed.
4. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
5. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection QACHS: Per insulin sliding scale.
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 5 days.
14. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4415**]
Discharge Diagnosis:
Stroke
Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
Continue to take all medications as prescribed. Return to ER
with any recurrent symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 843**] [**Name8 (MD) 844**], MD Phone:[**Telephone/Fax (1) 10533**]
Date/Time:[**2160-10-13**] 11:15
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2160-10-22**] 1:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2160-9-8**]
|
[
"433.01",
"780.03",
"434.11",
"585.9",
"331.4",
"427.31",
"305.1",
"518.81",
"274.9",
"427.81",
"401.9",
"250.00",
"482.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.39",
"43.11",
"96.72",
"96.6",
"31.1",
"96.04",
"01.14"
] |
icd9pcs
|
[
[
[]
]
] |
12692, 12738
|
4394, 11251
|
325, 406
|
12809, 12818
|
4309, 4371
|
12956, 13384
|
4092, 4102
|
11479, 12669
|
12759, 12788
|
11277, 11456
|
12842, 12933
|
4117, 4290
|
276, 287
|
434, 3598
|
3620, 3863
|
3879, 4076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,169
| 159,137
|
52750
|
Discharge summary
|
report
|
Admission Date: [**2162-10-20**] Discharge Date: [**2162-10-30**]
Date of Birth: [**2116-1-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Hydralazine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
Emergent replacement of ascending aorta/hemiarch replacement/
resuspension of the aortic valve [**2162-10-20**]
History of Present Illness:
Mr. [**Known lastname 41476**] is a 46 year old male with end stage kidney disease
on peritoneal dialysis, hypertension, complete heart block and
coronary artery disease who presented to [**Hospital6 13185**] with acute onset of back, chest, and jaw pain. A chest
CT scan showed a Type A dissection of the aorta. He was
intubated and sedated. A TEE showed a Type A dissection as
well. He transferred to [**Hospital1 18**] for emergency surgery.
Past Medical History:
ESRD on PD, hypertension, congestive heart failure, obesity,
coronary artery disease
Social History:
unobtainable
Family History:
unobtainable
Physical Exam:
PE: BP 110/67 by aline HR 80 (SR)
General - intubated and sedated, aline left radial
HEENT - intubated, central line RIJ
Lungs - BS bilaterally
Cardio - NSR, TEE - trace to mild AI, EF around 35%, Type A
Dissection
Abdomen - PD catheter LLQ, soft
Ext - +1 edema
Neuro - intubated and sedated
Pertinent Results:
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 108799**] (Complete)
Done [**2162-10-20**] at 10:52:12 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2116-1-23**]
Age (years): 46 M Hgt (in):
BP (mm Hg): 110/70 Wgt (lb): 220
HR (bpm): 65 BSA (m2):
Indication: Acute Type A Aortic Dissection. Evaluate Valves,
Ventricular Function, Wall motion
ICD-9 Codes: 441.00
Test Information
Date/Time: [**2162-10-20**] at 22:52 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine: u/s 6
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.5 cm <= 4.0 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 50% >= 55%
Left Ventricle - Stroke Volume: 44 ml/beat
Left Ventricle - Cardiac Output: 2.87 L/min
Left Ventricle - Peak Resting LVOT gradient: 1 mm Hg <= 10 mm
Hg
Aorta - Annulus: 2.6 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.6 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Arch: *3.6 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.3 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 0.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 3 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 1 mm Hg
Aortic Valve - LVOT VTI: 9
Aortic Valve - LVOT diam: 2.5 cm
Aortic Valve - Valve Area: *2.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: [**Last Name (NamePattern4) **] LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Severely dilated LV cavity.
Mild global LV hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal aortic
arch diameter. Mildly dilated descending aorta. Ascending aortic
intimal flap/dissection.. Aortic arch intimal flap/dissection.
Descending aorta intimal flap/aortic dissection.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+)
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. [**Last Name (NamePattern4) **]
(2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
PERICARDIUM: Small pericardial effusion.
Conclusions
[**Last Name (NamePattern4) **] Bypass: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is severely dilated. There is mild global left
ventricular hypokinesis (LVEF = 40-50%) with some [**Last Name (NamePattern4) 1192**]
inferior wall hypokinesis. The descending thoracic aorta is
mildly dilated. A mobile density is seen in the ascending aorta
consistent with an intimal flap/aortic dissection. A mobile
density is seen in the aortic arch consistent with an intimal
flap/aortic dissection. A mobile density is seen in the
descending aorta consistent with an intimal flap/aortic
dissection. The dissecton appears roughly 2 cm above the
sinotubular junction and exents as far into the descending aorta
as can be visualized. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. [**Last Name (NamePattern4) **] (2+)
mitral regurgitation is seen. There is a small pericardial
effusion.
Post Bypass: Patient is on epinepherine 0.1-0.2 mcg/kg/min, a
paced, phenylepherine infusion. There is a tube graft in the
ascending aorta above the sinus of valsva with laminar flow.
Native aortic valve with trace to mild MR [**First Name (Titles) 3**] [**Last Name (Titles) **] bypass. LVEF
remains unchanged 45%. MR [**First Name (Titles) 19947**] [**Last Name (Titles) 1192**]. TR is now at least
[**Last Name (Titles) 1192**]. RV with mild hyokinesis and enlargement. Remaining
exam is unchanged. All finidings discussed with surgeons at the
time of the exam.
[**2162-10-30**] 05:00AM BLOOD WBC-8.2 RBC-2.93* Hgb-9.1* Hct-26.5*
MCV-91 MCH-31.0 MCHC-34.3 RDW-15.6* Plt Ct-277
[**2162-10-29**] 05:27AM BLOOD PT-14.8* PTT-28.1 INR(PT)-1.3*
[**2162-10-30**] 05:00AM BLOOD Glucose-84 UreaN-60* Creat-10.5*# Na-134
K-4.3 Cl-93* HCO3-25 AnGap-20
[**2162-10-30**] 05:00AM BLOOD ALT-41* AST-25 LD(LDH)-255* AlkPhos-79
Amylase-98 TotBili-0.3
Brief Hospital Course:
On [**2162-10-20**] Mr. [**Known lastname 41476**] [**Last Name (Titles) 1834**] an emergent replacement of
ascending aorta and hemiarch with resuspension of the aortic
valve performed by Dr. [**Last Name (STitle) 914**]. Please see the operative note
for details. He tolerated the procedure well and was
transferred in critical but stable condition to the surgical
intensive care unit. The renal service was consulted to manage
his dialysis needs. On postoperative day one, he awoke
neurologically intact and was extubated. CVVHD was initiated for
volume management. He was dialyzed via an IJ catheter to remove
excess fluid and improve respiratory status. His blood pressure
medications were uptitrated. He was placed on antibiotics for
sternal erythema. He was transferred to the step down floor. A
tunneled line dialysis line was placed. Transplant surgery was
consulted and a plan was made to remove the PD catheter and
create a left AV fistula as an outpatient. On post-operative day
ten was dialyzed and then sent to [**Hospital **] [**Hospital3 7665**] in
[**Hospital1 **]. All follow-up appointments were advised.
Medications on Admission:
ASA (81 mg QD), amlodipine (10 mg QD), Butalbital APAP, caffeine
(1 tab q4 hours as needed for headache), cinacalcet (30 mg QD),
darbepoetin ALFA (60 mcb SC weekly), ergocalcifero (5000 units
weekly), KCL slow release tab (40 meq [**Hospital1 **]), labetalol hcl (300
mg q 12), lactulose (30 ml qid prn constipation), losartan (25
mg qd), metolazone (2.5 mg qd), moxifloxacin(400 mg qd),
nephro-vit rx (1 qd), polethylene glycol (17 gm [**Hospital1 **]), sevelamer
carbonate (1600 mg before meals), zestril (20 mg [**Hospital1 **])
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-17**]
Drops Ophthalmic Q6H (every 6 hours) as needed for dry eyes.
Disp:*qs * Refills:*0*
5. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2
times a day) for 1 days.
Disp:*qs * Refills:*0*
9. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
10. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*2*
13. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
14. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1800 ML(s)* Refills:*2*
15. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
16. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
ONCE (Once) for 1 doses.
Disp:*40 Tablet(s)* Refills:*0*
17. oxymetazoline 0.05 % Aerosol, Spray Sig: [**1-17**] Sprays Nasal
[**Hospital1 **] (2 times a day) for 3 days.
Disp:*qs * Refills:*0*
18. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for pruitis.
Disp:*qs * Refills:*0*
20. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK ([**Doctor First Name **]).
Disp:*30 Capsule(s)* Refills:*2*
21. ipratropium bromide 0.02 % Solution Sig: 1-2 puffs
Inhalation Q6H (every 6 hours) as needed for dyspnea.
Disp:*qs puffs* Refills:*0*
22. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO BID (2 times a day).
Disp:*qs * Refills:*2*
23. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as
needed for dyspnea.
Disp:*qs puffs* Refills:*0*
24. heparin (porcine) 1,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
Disp:*qs * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Type A Aortic Dissection
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Trace Bilateral Leg Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] in [**1-17**] weeks ([**Telephone/Fax (1) 11763**]
Cardiologist:Please find a cardiologist as soon as possible.
You primary physician can help make a referral if you need one.
Transplant Surgery: Please call to make an appointment in [**2-18**]
weeks with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 16915**] to make a plan for PD
catheter removal and creation of left brachiocephalic AV fistula
Please call to schedule appointments with your
Primary Care Dr.[**First Name (STitle) **],[**First Name3 (LF) **] R [**Telephone/Fax (1) 25050**] in [**4-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2162-10-30**]
|
[
"278.00",
"443.22",
"518.52",
"585.6",
"276.69",
"414.01",
"276.7",
"441.01",
"250.00",
"403.91",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.62",
"38.45",
"35.11",
"38.95",
"39.95",
"96.71",
"86.05",
"35.39"
] |
icd9pcs
|
[
[
[]
]
] |
10913, 10988
|
6215, 7348
|
303, 417
|
11057, 11241
|
1393, 6192
|
12165, 13061
|
1049, 1063
|
7931, 10890
|
11009, 11036
|
7374, 7908
|
11265, 12142
|
1078, 1374
|
254, 265
|
445, 894
|
916, 1003
|
1019, 1033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,184
| 108,121
|
35599
|
Discharge summary
|
report
|
Admission Date: [**2122-3-12**] Discharge Date: [**2122-3-28**]
Date of Birth: [**2056-8-28**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Atraumatic Subarachnoid Hemorrhage
Major Surgical or Invasive Procedure:
angiograms
extraventricular drain
VP shunt placement
History of Present Illness:
Patient is a 65 yo woman with no PMH who was found down tonight
by family members, wedged between the bed and the wall. She was
confused, moaning and complaining of a headache. She was taken
to [**Last Name (un) 1724**] where a CT showed diffuse SAH particularly in basilar
cistern, with no vascular anomaly on CTA.
Transferred here where she continues to be confused, but awake
and alert. Currently only complaining of headache and neck
ache.
Past Medical History:
none per niece
Social History:
lives with family in 2 family. no tob/etoh.
Family History:
Heart Dz, choesterol
Physical Exam:
PHYSICAL EXAM:
O: T: na BP: 135/86 HR: 92 R 23 O2Sats 92% NC
Gen: WD/WN, comfortable, NAD.
HEENT: MMM an intact
Neck: in hard collar
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.
Confused.
Oriented to [**Hospital6 **], [**2123**], self. Language intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields difficult to assess.
III, IV, VI: bilateral 6th N palsies.
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 [**6-2**] triceps and antigravity legs.
Sensation: Intact to light touch x 4
Reflexes: B T Br Pa Ac
Right 2 throughout
Left 2 throughout
Toes up bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
CT: Diffuse SAH with greatest concentration at basilar cistern.
CTA [**First Name8 (NamePattern2) **] [**Last Name (un) 1724**] radiologist does not show vascular abnormalities.
[**2122-3-12**] 01:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]->1.050
[**2122-3-12**] 01:50AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2122-3-12**] 01:50AM URINE RBC-0-2 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2122-3-12**] 01:50AM PT-14.0* PTT-25.2 INR(PT)-1.2*
[**2122-3-12**] 01:50AM WBC-21.3* RBC-5.38 HGB-13.8 HCT-42.1 MCV-78*
MCH-25.7* MCHC-32.9 RDW-14.5
[**2122-3-12**] 01:50AM NEUTS-90* BANDS-0 LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2122-3-12**] 01:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2122-3-12**] 01:50AM CALCIUM-9.6 PHOSPHATE-2.7 MAGNESIUM-2.0
[**2122-3-12**] 01:50AM CK(CPK)-222*
[**2122-3-12**] 01:50AM cTropnT-0.33*
[**2122-3-12**] 01:50AM GLUCOSE-220* UREA N-19 CREAT-0.9 SODIUM-139
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-18* ANION GAP-24*
Brief Hospital Course:
Was transferred from OSH and was admitted to the ICU where she
then had an EVD placed due to hydrocephalus. She was also found
to have a small troponin leak which peaked at .37.
Hemodynamically stable. On [**3-12**] she was then intubated for a
cerebral angiogram which did not show an aneurysm. She remained
intubated due to concern for aspiration because a carrot was
seen in ETT after intubation. Later in the evening she
self-extubated and she was stable on face tent. On admission she
was found to have bilateral 6th nerve palsies which opthalmology
recommended f/u in 1 month. She failed clamping trials of her
EVD, and was taken to the OR for a VP shunt placement on [**3-23**].
Postoperatively she was transferred to the floor. She continues
to have diarrhea and is C.diff negative x 2. On [**3-28**] she was
stable for d/c to rehab. She will f/u with opthalmology in 1
month and continue on her nimodipine for 21 days. She will f/u
with Dr. [**First Name (STitle) **] in 1 month with an MRI/MRA.
Medications on Admission:
none
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed.
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6HRS
PRN () as needed for SBP > 140.
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed).
12. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours).
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
subarachnoid hemorrhage
Discharge Condition:
stable
Discharge Instructions:
General Instructions
?????? 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 have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
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:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need an MRI/MRA of the brain prior to your
appointment. This can be scheduled when you call to make your
office visit appointment.
Follow up with your ophthomologist within one month.
|
[
"780.39",
"518.0",
"E915",
"276.8",
"378.54",
"486",
"362.81",
"430",
"934.0",
"331.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.34",
"02.2",
"03.31",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5778, 5857
|
3327, 4333
|
352, 407
|
5925, 5934
|
2177, 3304
|
7299, 7672
|
1001, 1024
|
4388, 5755
|
5878, 5904
|
4359, 4365
|
5958, 7276
|
1054, 1288
|
278, 314
|
435, 884
|
1436, 2158
|
1303, 1420
|
906, 922
|
938, 985
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,573
| 169,754
|
16353+16354
|
Discharge summary
|
report+report
|
Admission Date: [**2155-1-16**] Discharge Date: [**2155-2-3**]
Date of Birth: Sex: M
Service:
PRINCIPAL DIAGNOSIS: Right neck abscess/airway obstruction.
HISTORY OF PRESENT ILLNESS: This is a 38-year-old male with
a history of nasopharyngeal carcinoma first diagnosed in
[**2154-2-13**].
He completed chemotherapy in [**2154-9-13**] and radiation
therapy to the neck in [**2154-5-14**]. He underwent modified
radical neck dissection in [**2154-10-14**] which was
complicated by a fluid collection that was drained
incompletely by placement of an IR drain. He subsequently
underwent incision and drainage of the collection. On
[**2155-1-9**] (the day after discharge), the patient
presented to the Emergency Room with fevers to 102, right
neck pain, chills, and dyspnea. At the time of admission,
the [**Location (un) 1661**]-[**Location (un) 1662**] drain was holding suction and had drained
approximately 45 cc of serosanguineous fluid over the last 24
hours. He denied any dysphagia, odynophagia, or difficulty
breathing. The patient completed a course of antibiotics.
He was maintained on airway observation. He demonstrated no
airway compromise. A chest x-ray revealed no evidence of
pneumonia. By hospital day four, the patient's fevers
ceased. Blood cultures were all negative. He was discharged
to home on hospital day five in stable condition. On
[**2155-1-16**], the patient was readmitted for recurrent
dyspnea, dysphagia, and neck swelling.
PAST MEDICAL HISTORY:
1. Nasopharyngeal cancer (as above).
2. Hepatitis B.
MEDICATIONS ON ADMISSION: Lamivudine and Pepcid.
ALLERGIES: ASPIRIN.
SUMMARY OF HOSPITAL COURSE: The patient was taken back to
the operating room on [**2155-1-16**] for incision and
drainage of the right neck abscess. The wound was left open.
It was packed with Nu-Gauze, and two Penrose drains were left
in place.
Postoperatively, the patient complained of shortness of
breath. He maintained his oxygen saturations on 50% shovel
mask. He denied odynophagia or dysphagia. There were no
changes in his voice. Fiberoptic examination revealed
supraglottic edema. Neck examination revealed no fluctuant
fluid collection. The patient was treated with 10 mg of
Decadron intravenously. His oxygen saturations remained
stable, and the patient reported feeling better.
By postoperative day two, the patient was tolerating oral
intake. However, later that evening he complained of throat
swelling and dysphagia. His oxygen saturations remained
100%. Fiberoptic examination revealed a swollen epiglottis
with pooling of secretions at the malicola. The airway was
narrowed but not significantly changed from prior
examination. He was again treated with intravenous steroids.
On postoperative day seven, the patient again complained of
subjective shortness of breath with oxygen saturations
remaining above 92%. He was started on a trial of Heliox
without effect. On examination, he was found to have
bilateral neck edema, anteriorly and posteriorly. He had
harsh breath sounds, but no stridor. He was again given
intravenous steroids, and he consented to a tracheostomy for
airway protection.
On [**2155-1-22**], the patient underwent an uncomplicated
tracheostomy placement. He tolerated the new tracheostomy
well. He was able to clear his secretions. His oxygen
saturations remained satisfactory. On [**2155-1-23**], the
Plastic Surgery Service was consulted for placement of a vac
sponge over the neck wound.
On [**2155-1-24**], a trial with a Passy-Muir valve was
attempted; however, he could not tolerate the valve, likely
due to swelling at the level or above the tracheostomy tube.
He also developed left arm and left face swelling.
Ultrasound studies demonstrated no deep venous thrombosis.
The edema improved with arm elevation.
On [**2155-1-27**], the patient's tracheostomy was changed
to a Shiley #4 cuffless fenestrated tube. He again attempted
a Passy-Muir trial. He demonstrated a hoarse voice but
immediately complained of difficulty breathing; especially
upon exhalation. Poor tolerance of the Passy-Muir valve was
felt to be due to continuing edema. However, he was able to
speak with finger occlusion of the tracheostomy.
On [**2155-1-28**], the patient underwent a repeat computed
tomography scan of the neck. It demonstrated less gas within
the fluid collection in the right neck; although the size of
the collection was similar, the left internal jugular
appeared patent.
The following day, the patient's left subclavian Port-A-Cath
was removed given suspicion that it was contributing to the
patient's facial and upper extremity edema. He was also
started on clindamycin for mild cellulitis of the right neck.
By [**2155-2-1**] the superior and lateral half of the
wound contained healthy granulating tissue. The lower aspect
of the wound still revealed fibrinous exudate. There was no
recurrent collection and no surrounding erythema. He
continued to have vac changes every two to three days by the
Plastic Surgery Service.
The patient's diet was advanced. He ambulated and voided
without assistance. Given difficulties with his insurance
coverage, the patient's vac was removed and he was discharged
to home on [**2155-2-2**] with wet-to-dry dressing
changes.
COMPLICATIONS: None apparent.
MEDICATIONS ON DISCHARGE:
1. Keflex 500 mg by mouth four times per day (for five
days).
2. Lamivudine 100 mg by mouth once per day.
3. Roxicet elixir 5 cc to 10 cc by mouth q.4-6h. as needed
(for pain).
4. Pepcid 20-mg tablets one tablet by mouth twice per day.
5. Clindamycin 600 mg by mouth three times per day (for five
days).
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**First Name (STitle) **].
[**Name6 (MD) **] [**Last Name (NamePattern4) 13798**], M.D. [**MD Number(1) 13799**]
Dictated By:[**Name8 (MD) 46551**]
MEDQUIST36
D: [**2155-5-27**] 08:45
T: [**2155-5-27**] 08:47
JOB#: [**Job Number 46573**]
Admission Date: [**2155-1-16**] Discharge Date: [**2155-2-3**]
Date of Birth: [**2116-5-16**] Sex: M
Service: Otolaryngology
[**Last Name **] PROBLEM: [**Name (NI) 167**] neck collection.
OTHER PROBLEMS: Respiratory difficulties.
HISTORY OF PRESENT ILLNESS: This is a 38-year-old man with a
history of nasopharyngeal cancer status post chemoradiation
and a right modified radical neck dissection, who was
admitted on [**2155-1-16**] with a right neck fluid collection.
PAST MEDICAL HISTORY:
1. Hepatitis B.
2. Nasopharyngeal cancer as above.
MEDICATIONS ON ADMISSION:
1. Keflex.
2. Lamivudine.
3. Clindamycin.
4. Oxycodone.
5. Pepcid.
ALLERGIES: Aspirin.
HOSPITAL COURSE: The patient was admitted on [**2155-1-16**] for
incision and drainage of a right neck fluid collection. His
postoperative course and his hospital course was as follows
by organ systems: Neurology: Patient is intact through the
duration of his hospital course. His pain was well
controlled.
Cardiovascular: Immediately post incision and drainage,
patient had tachycardia with occasional junctional rhythms
that appear to resolve over the course of his
hospitalization.
Pulmonary: The patient had increasing respiratory difficulty
postoperatively, and eventually had a tracheostomy placed on
[**2155-1-22**]. The trach that was placed was a Shiley #6
cuffless. This was changed to a #4 fenestrated cuffless on
[**1-27**] with a Passy-Muir valve, which the patient tolerated at
the time of discharge.
GI: No issues.
GU: No issues.
ID: The patient's right neck wound was left open initially
with wet-to-dry dressing changes. Interval CT on [**2155-1-19**]
showed no new collection or seroma. The wound had a VAC
placed by the Plastic Surgery team on [**2155-1-23**]. Starting on
[**2155-1-24**], the patient had increased swelling first of the
left upper extremity and then over the bilateral face with
the right being worse than the left side. Left lower
extremity was evaluated by Doppler for DVT that was found to
be negative. CT of the neck and upper torso was inadequate
to assess the patency of the internal jugular. A repeat
ultrasound demonstrated patency of this ruling out a DVT.
A follow-up CT on [**2155-1-28**] done due to failure of the edema
to resolve showed no change in the fluid collection. Patient
was also treated for a right neck cellulitis by antibiotics.
The patient had a left subclavian Port-A-Cath removed on
[**2155-1-29**] after which the swelling seemed to decrease. The
patient was discharged home with wet-to-dry dressings, where
the VAC previously was as the patient's insurance would not
cover him going home with a VAC.
Endocrine: On admission, patient had an elevated TSH, but
subsequent Endocrine consult deemed the patient to be
euthyroid and recommended an outpatient workup.
Patient was discharged on [**2155-2-3**] in stable condition with
instructions to followup with Plastic Surgery for possible
reconstruction of the open wound and with Dr. [**First Name (STitle) **] in [**2-14**]
weeks, and to call for an appointment.
DISCHARGE MEDICATIONS:
1. Keflex 500 mg q.i.d. x5 days.
2. Lamivudine 100 mg q.d.
3. Percocet elixir [**6-22**] mL q.4-6h. prn pain.
4. Pepcid 20 mg one tablet b.i.d.
5. Clindamycin.
He was discharged home with VNA for b.i.d. wet-to-dry
dressing changes to the right neck. Tolerating a house diet
supplied by Boost with activity as tolerated. Patient also
had VNA for tracheotomy care.
Patient was discharged as previously noted in stable
condition to home with services with the aforementioned
followup.
[**Name6 (MD) **] [**Last Name (NamePattern4) 13798**], M.D. [**MD Number(1) 13799**]
Dictated By:[**Last Name (NamePattern1) 46574**]
MEDQUIST36
D: [**2155-5-25**] 12:28
T: [**2155-5-28**] 09:31
JOB#: [**Job Number 46575**]
|
[
"478.74",
"998.13",
"E878.8",
"V10.02",
"998.59",
"682.1",
"070.30",
"518.81",
"478.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"86.04",
"31.1",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
9235, 9984
|
5357, 5677
|
6713, 6803
|
6821, 9212
|
5791, 6372
|
1680, 5331
|
5692, 5757
|
6401, 6613
|
6635, 6687
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,832
| 138,915
|
35443
|
Discharge summary
|
report
|
Admission Date: [**2146-3-26**] Discharge Date: [**2146-4-1**]
Date of Birth: [**2119-12-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Bicycle accident, back pain, respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
26 M s/p dirt bike accident at unknown speed. Was found
combative, moving all extremeties, and apneic. He was intubated
and med-flighted to [**Hospital1 18**]. Pt was found to have sever mid-back
pain and T7 and T8 fractures. Also found to have collapsed RUL.
Past Medical History:
Asthma
Social History:
Lives at home w/ others. Denies ETOH or drug abuse
Employment status: Employed. Pt self-employed as landscaper.
Family History:
Non-contributory
Physical Exam:
Upon Discharge:
VS:
NAD, AAOX3
RRR, S1S2
CTAB
SOFT, NON-TENDER, NON-DISTENDED
BACK - TTP at mid-thoracic spine. mild edema. no ecchymosses.
EXT - no C/C/E
Pertinent Results:
[**2146-3-26**] 07:00PM BLOOD WBC-30.2* RBC-5.02 Hgb-15.0 Hct-42.7
MCV-85 MCH-29.9 MCHC-35.1* RDW-13.6 Plt Ct-295
[**2146-3-27**] 04:29AM BLOOD WBC-17.0* RBC-4.16* Hgb-13.2* Hct-35.8*
MCV-86 MCH-31.7 MCHC-36.8* RDW-13.5 Plt Ct-255
[**2146-3-28**] 02:11AM BLOOD WBC-11.9* RBC-4.00* Hgb-12.6* Hct-34.2*
MCV-86 MCH-31.6 MCHC-36.9* RDW-13.3 Plt Ct-249
[**2146-3-29**] 01:57AM BLOOD WBC-15.9* RBC-3.78* Hgb-12.0* Hct-32.7*
MCV-87 MCH-31.7 MCHC-36.6* RDW-13.8 Plt Ct-249
[**2146-3-30**] 02:03AM BLOOD WBC-13.3* RBC-3.80* Hgb-11.9* Hct-32.7*
MCV-86 MCH-31.3 MCHC-36.4* RDW-13.9 Plt Ct-208
[**2146-3-31**] 01:25AM BLOOD WBC-15.3* RBC-3.99* Hgb-12.0* Hct-34.5*
MCV-87 MCH-30.2 MCHC-34.9 RDW-13.8 Plt Ct-239
[**2146-4-1**] 06:30AM BLOOD WBC-12.0* RBC-4.66 Hgb-13.7* Hct-40.5
MCV-87 MCH-29.3 MCHC-33.7 RDW-13.5 Plt Ct-263
[**2146-4-1**] 06:30AM BLOOD Neuts-72.3* Lymphs-18.3 Monos-4.9
Eos-4.3* Baso-0.1
[**2146-3-26**] 07:00PM BLOOD PT-12.4 PTT-24.7 INR(PT)-1.0
[**2146-3-27**] 04:29AM BLOOD PT-12.8 PTT-28.8 INR(PT)-1.1
[**2146-3-28**] 04:30AM BLOOD PT-12.2 PTT-25.9 INR(PT)-1.0
[**2146-3-26**] 10:49PM BLOOD Glucose-96 UreaN-16 Creat-0.8 Na-139
K-4.8 Cl-107 HCO3-22 AnGap-15
[**2146-3-27**] 04:29AM BLOOD Glucose-112* UreaN-14 Creat-0.7 Na-138
K-4.5 Cl-105 HCO3-24 AnGap-14
[**2146-3-28**] 02:11AM BLOOD Glucose-155* UreaN-10 Creat-0.7 Na-141
K-4.3 Cl-103 HCO3-29 AnGap-13
[**2146-3-29**] 01:57AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-140
K-3.9 Cl-103 HCO3-29 AnGap-12
[**2146-3-30**] 02:03AM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-139
K-3.7 Cl-96 HCO3-33* AnGap-14
[**2146-3-31**] 01:25AM BLOOD Glucose-104 UreaN-10 Creat-0.6 Na-137
K-4.1 Cl-95* HCO3-29 AnGap-17
[**2146-3-27**] 04:29AM BLOOD CK(CPK)-491*
[**2146-3-27**] 02:28PM BLOOD CK(CPK)-809*
[**2146-3-28**] 02:11AM BLOOD CK(CPK)-729*
[**2146-3-26**] 10:49PM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8
[**2146-3-27**] 04:29AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0
[**2146-3-28**] 02:11AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.3
[**2146-3-29**] 01:57AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.4
[**2146-3-30**] 02:03AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.9
[**2146-3-31**] 01:25AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2
[**2146-3-26**] 07:19PM BLOOD Glucose-154* Lactate-1.7 Na-143 K-3.9
Cl-107 calHCO3-19*
[**2146-3-27**] 05:02AM BLOOD Lactate-2.1*
[**2146-3-27**] 09:11AM BLOOD Glucose-155* Lactate-1.7
[**2146-3-27**] 08:03PM BLOOD Glucose-169*
[**2146-3-26**] 11:00PM BLOOD freeCa-1.17
[**2146-3-28**] 08:32AM BLOOD freeCa-1.16
CT Torso [**3-26**]:
1. Comminuted fracture of T7 vertebra and superior endplate of
T8. Minimal
loss of vertebral body height and minimal T7 fracture
retropulsion. MRI may be obtained to further assess for spinal
cord injury.
2. Right upper lobe consolidation, left upper and lower lobe
segmental
consolidation which may be related to aspiration.
3. ET and NG tubes in appropriate position.
CT C-spine [**3-26**]:
1. No evidence of acute fracture or abnormal alignment in the
cervical spine.
2. Right upper lobe collapse better demonstrated on CT torso.
CT Head [**3-26**]:
No acute intracranial hemorrhage, edema or mass. Paranasal sinus
disease as described above.
CXR [**3-27**]:
The monitoring and support devices are in unchanged position.
The
right upper lobe atelectasis is also unchanged. The preexisting
left upper
lobe opacity has partially cleared, there is now no evidence of
left apical fluid; however, a large discoid atelectasis is seen
at the level of the left hilus. There is evidence of increasing
intravascular fluid. The size of the cardiac silhouette is
unchanged.
Right Shoulder Xrays [**3-27**]:
No fracture is detected about the right shoulder. Some support
tubing
overlies the scapula. The AC joint is congruent on these
nonstress views.
The glenohumeral joint is grossly unremarkable.
CXR [**3-31**]:
Progressive clearing of pulmonary opacifications.
T-spine Xrays [**4-1**]:
Brief Hospital Course:
Pt was [**Last Name (un) **]-flighted in from the scene of the accident and
admitted to the TSICU. A neurosurgery consult was obtained for
his thoracic spine fractures, which were deemed non-operable and
stable. He was fitted for a TLSO brace for the fractures and was
wearing it prior to discharge.
The patient remained in the TSICU intubated and sedated until
[**2146-3-30**]. After extubating, the patient passed a bedside swallow
evaluation and began tolerating a reguar diet.
RUL Collapse/PNA: The patient was found also to have a RUL
collapse on his CT Torso. He was also noted to have a PNA on CXR
and was treated with ceftriaxone and flagyl for suspected
aspiration.
Pain: His pain was difficult to control. Adequate analgesia was
well controlled, but with very high doses of IV and then PO pain
medications.
His foley catheter was removed prior to discharge.
He was evaluated by physical therapy and deemed safe for
discharge home.
The patient was discharged in stable condition with a TLSO brace
on [**2146-4-1**]
Medications on Admission:
Albuterol MDI, Advair
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
6. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
Disp:*3 Patch Weekly(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
8. OxyContin 15 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO twice a day.
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0*
9. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. T7 and T8 vertebral body fractures
2. Collapse of RUL of lung
3. Pneumonia
Discharge Condition:
Stable. TLSO in place.
Discharge Instructions:
You must wear your TLSO brace at all times when out of bed, or
sitting up in bed. You may remove the brace when lying flat in
bed only.
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.
* 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.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 739**] in 4 weeks. Call his
office at ([**Telephone/Fax (1) 88**] to make an appointment. Make sure to
tell his office you will need AP and lateral thoracic spine
xrays the day of your appointment.
Call ([**Telephone/Fax (1) 2537**] during business hours if you have any
concerns.
Completed by:[**2146-4-1**]
|
[
"285.1",
"850.11",
"338.11",
"719.41",
"507.0",
"493.90",
"E821.0",
"805.2",
"860.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"33.24",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7221, 7227
|
4929, 5960
|
364, 371
|
7349, 7374
|
1045, 4906
|
8705, 9065
|
836, 854
|
6032, 7198
|
7248, 7328
|
5986, 6009
|
7398, 8682
|
869, 869
|
275, 326
|
885, 1026
|
399, 660
|
682, 690
|
706, 820
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,902
| 144,444
|
8031
|
Discharge summary
|
report
|
Admission Date: [**2184-6-30**] Discharge Date: [**2184-8-23**]
Date of Birth: [**2134-1-8**] Sex: M
Service: SURGERY
Allergies:
Avelox
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Abdominal wound dehiscence, necrotic stoma and intra-abdominal
sepsis, s/p ex lap for perforated diverticulitis at other
facility,
transfer for further care.
Major Surgical or Invasive Procedure:
[**2184-7-1**] Left colectomy with mobilization of splenic flexure,
re-siting of colostomy, debridement of necrotic abdominal wall,
complex fascial repair of approximately 20 cm and kidney biopsy.
[**2184-7-7**] Exploratory laparotomy with repair of abdominal wound
with Vicryl mesh, revision of colostomy.
[**2184-7-21**] Tracheostomy, bronchoscopy, placement of left internal
jugular tunneled hemodialysis catheter.
[**2184-7-28**] Wound exploration and debridement for necrotic abdominal
wound with fascial dehiscence.
History of Present Illness:
Mr. [**Known lastname **] is a 51 year old gentleman who had a kidney transplant
many years ago. He was admitted to an outside hospital with
intra-abdominal sepsis
and was taken to the operating room for a sigmoid resection and
colostomy. One week after that procedure, the patient was
continuing not to do well. We were contact[**Name (NI) **] by his physician to
transfer him to [**Hospital1 18**] for maximal care.
On arrival, he was found to be hypotensive and febrile, with an
hematocrit of 20 and a platelet count of 33. He was medically
maximized during the first initial hour and prepared for the
operating room, to repair what was obviously a fascial
dehiscence and a necrotic stoma and possible intra-abdominal
sepsis. After a long discussion with the brother about the
critical nature of his care, his brother (his health care proxy)
consented to an operation.
Past Medical History:
DM
ESRD on HD (crea baseline [**4-9**])
renal Tx in '[**78**] c/b chronic rejection
COPD
CHF
perforated diverticulitis
obesity
h/o lumbar surgery
PAF
anemia
active smoker
sleep apnea
hypercholesterolemia
CHF
h/o lumbar laminectomy
HTN
CAD, s/p CABG x4 [**10-7**]
bilateral knee surgery.
Social History:
active smoker
[**Hospital 28720**] [**Hospital **]
transfer from OSH for maximal care
Physical Exam:
VS T102.1; BP 104-140/40s-60s; HR 80s-100s; RR 20s-30s; O2 sat
100% on vent (SIMV with PS)
Obese man, intubated, diffusely edematous. Eyes spontaneously
open. Visually fixes to voice. Follows some midline commands,
but inconsistently. Did not nod or shake his head to command.
Blinks weakly to visual threat from either side. Will sometimes
look towards a finger on either side to command, with full and
conjugate EOMs, but sometimes requires repeated commands. No
nystagmus. Strong symmetric corneal reflexes. Bifacial weakness,
with incomplete closer of right eye, and only weak but full
closure of the left. No movement of the lower face. Diffusely
hypotonic. No spontaneous movements of the extremities.
Diffusely areflexic. Toes mute.
RRR, B CTA
Abd distended, necrotic stoma, no BS
diffusely edematous
Brief Hospital Course:
After his initial operation, Mr. [**Known lastname **] was admitted to the
surgical ICU for further care. He was ventilated and maintained
on CVVHD. He mental status improved but he never followed
commands. he did not improve much over his first week. On [**7-7**],
he was taken back to the OR for repair of dehissence of his
abdominal repair. His ostomy was starting to work and he was
started on enteral feedings. He continued to be in sepsis and
repiratory failure and a tracheostomy had to be placed on [**7-21**]
as well as a temporary tunneled dialysis line. He continued to
be ventilator dependent with intermittent hypotensive episode
during which he was started on pressors. He received antibiotic
treatment during most of his stay. On [**7-28**], he was taken back to
the operating room for revision of his vicryl mesh repair.
Postoperatively, he continued to be in a critical condition
without major improvement despite maximal ICU care. he never
regained full conciousness. After several weeks, his family
decided that that Mr. [**Known lastname **] would not have wanted to remain in
this chronic condition. They decided to make him DNR and later
to allow comfort measures only. With his extended family at his
bedside, Mr. [**Known lastname **] [**Last Name (Titles) **] peacefully in the ICU on [**2184-8-23**]. His
family did not consent to an autopsy. the medical examiner was
informed about his case but deferred the case.
Discharge Disposition:
[**Date Range **]
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
Sepsis
Multiorgan failure
Discharge Condition:
[**Hospital1 **].
Discharge Instructions:
Autopsy was denied by the family.
Followup Instructions:
None
Completed by:[**2184-11-17**]
|
[
"357.0",
"038.44",
"276.8",
"V58.67",
"428.0",
"250.40",
"518.83",
"112.5",
"285.1",
"567.2",
"211.3",
"427.31",
"276.1",
"780.57",
"585",
"557.0",
"569.69",
"038.49",
"496",
"584.5",
"558.9",
"996.81",
"287.5",
"995.91",
"998.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"45.75",
"96.72",
"00.17",
"38.91",
"00.14",
"54.91",
"55.23",
"31.1",
"55.24",
"38.93",
"83.39",
"99.15",
"33.21",
"86.07",
"45.25",
"54.61",
"46.43",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
4574, 4623
|
3109, 4551
|
423, 946
|
4692, 4711
|
4793, 4829
|
4644, 4671
|
4735, 4770
|
2276, 3086
|
226, 385
|
974, 1848
|
1870, 2158
|
2174, 2261
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,439
| 157,032
|
13536
|
Discharge summary
|
report
|
Admission Date: [**2134-4-23**] Discharge Date: [**2134-4-26**]
Date of Birth: [**2070-1-11**] Sex: M
Service: PCE
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old man
with a history of coronary artery disease status post
percutaneous transluminal coronary angioplasty in [**2118**],
status post percutaneous transluminal coronary angioplasty
with an right coronary artery stent in [**2134-3-15**], status
post coronary artery bypass grafting times four (SVG to OM1,
SVG to OM2, SVG to diagonal, and LIMA to LAD), who presented
with 5 out of 10 substernal chest pain after a short walk
associated with diaphoresis. The patient denied any
shortness of breath but noted that his symptoms persisted
with rest. He called EMS and was given Nitroglycerin and
Aspirin with no change in his chest pain.
He presented to the outside hospital. He was given
Nitroglycerin, Heparin, Integrilin, Lopressor, Morphine, with
a decrease in his pain to [**12-16**] out of 10. Electrocardiogram
there was read as inferior ST elevations with no change on
right-sided leads. The patient was transferred to [**Hospital6 1760**] for catheterization.
Catheterization revealed 100% right coronary artery occlusion
at the stent and underwent Angioject with stent times two
proximal and distal to the original stent. The patient had
TIMI3 flow achieved. The patient's grafts were patent.
Catheterization was complicated by hypotension. The patient
was treated with Dopamine.
An echocardiogram done at that time to evaluate for tamponade
revealed a small effusion without any signs of tamponade
physiology. The patient admitted to recently stopping his
Aspirin.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post percutaneous transluminal coronary angioplasty in [**2118**],
the patient percutaneous transluminal coronary angioplasty
and stent to his right coronary artery in [**2134-3-15**], status
post coronary artery bypass grafting times four in [**2134-3-15**]. The patient had saphenous vein graft to OM1, saphenous
vein graft to OM2, saphenous vein graft to diagonal, and LIMA
to left anterior descending. 2. Hypertension. 3.
Hypercholesterolemia. 4. Diverticulosis status post GI
bleed. 5. Ulcerative colitis. 6. Barrett's esophagus.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: Aspirin 325 mg p.o. q.d., Plavix 75 mg p.o.
q.d., Diovan 160 mg p.o. q.d., Hydrocortisone enema q.12
days, Lopressor 50 mg p.o. b.i.d., Prednisone forte
ophthalmic 1% one drop O.U. q.i.d., Imdur 60 mg p.o. q.d.,
Milk of Magnesia p.r.n., Tylenol p.r.n., Asacol 800 mg p.o.
t.i.d., Lipitor 20 mg p.o. q.h.s., Zantac 150 mg p.o. b.i.d.,
Klonopin p.r.n.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] quit
smoking in [**2118**].
FAMILY HISTORY: Coronary artery disease.
PHYSICAL EXAMINATION: Vital signs: The patient's
temperature was 97??????, blood pressure 112/53, respirations 20,
oxygen saturation 97% on 100% nonrebreather. General: The
patient was a fairly well-appearing man in no apparent
distress. HEENT: Extraocular movements intact. Pupils
equal, round and reactive to light. Neck: No jugular venous
distention. No bruits. No lymphadenopathy. Cardiovascular:
Regular, rate and rhythm. Normal S1 and S2. No murmurs,
rubs or gallops. Pulmonary: Lungs clear to auscultation
bilaterally. Abdomen: Belly was soft, nontender,
nondistended. Normoactive bowel sounds. Extremities: No
edema. There were 2+ dorsalis pedis and posterior tibial
pulses.
LABORATORY DATA: The patient had a hematocrit of 28;
creatinine 1.3, initial CK from the outside hospital was 44.
Outside electrocardiogram showed normal sinus rhythm, normal
axis, left atrial abnormalities in Q, II, III, and AVF, with
ST elevations of 2 mm in II, III, and AVF. There were
reciprocal ST depressions in I and AVL.
Review of the right-sided electrocardiogram revealed 0.[**Street Address(2) 18425**] elevations in V4. Electrocardiogram done at [**Hospital6 1760**] revealed ST elevations
improved in II, and III, and AVF, as well as reversal of
T-wave inversions in I and AVL.
Chest x-ray revealed slight cardiomegaly and sternal wires.
Echocardiogram revealed mild depression of the left
ventricle, posterior hypokinesis, trace mitral regurgitation,
ejection fraction of 50-55%. ................ ratio was
1.10.
Catheterization revealed 100% right coronary artery stent
occlusion. The patient was stented times two proximal and
distal to the stent. The stent was Angiojected. The patient
had an open graft.
HOSPITAL COURSE: The patient is a 64-year-old man with a
history of coronary artery disease status post percutaneous
transluminal coronary angioplasty in [**2118**], status post
percutaneous transluminal coronary angioplasty in [**2134-3-15**],
for inferior myocardial infarction, with right coronary
artery stent, status post coronary artery bypass grafting
times four in [**2134-3-15**], who presented with inferior
myocardial infarction with right ventricular extension status
post right coronary artery stent.
1. Cardiovascular: The patient presented with an inferior
myocardial infarction with right ventricular extension. He
had total occlusion of his right coronary artery stent and
underwent Angioject and stenting proximal and distal to the
original stent. This occlusion occurred in the setting of
the patient's self-discontinuing his Aspirin. From a
coronary artery disease standpoint, the patient underwent
intervention to treat 100% occlusion of his right coronary
artery. He was then continued on Aspirin, Plavix, and
Lipitor.
From a myocardial standpoint, the patient had severe right
ventricular hypokinesis. He was initially hypotensive
requiring Dopamine likely secondary to decreased preload
state. He was given intravenous repletion, and the Dopamine
was able to be weaned off. The patient was restarted on his
beta-blocker and ACE inhibitor. He was discharged on
Metoprolol 25 mg p.o. b.i.d. and Zestril 5 mg p.o. q.d. The
patient's rhythm remained in sinus rhythm. The patient had a
second echocardiogram performed on the evening of admission
which revealed no change in the pericardial effusion which
was thought to be likely secondary to his surgery.
2. Gastrointestinal: The patient has a history of GI bleed
in the setting of ulcerative colitis and diverticular
disease. He had received a ................, Heparin,
Aspirin, and Plavix. He was followed closely for upper GI
bleed and had a hematocrit drop to about 26 the day after his
procedure. He was given 1 U packed red blood cells with an
appropriate increase in his hematocrit to 28.5 on the day of
discharge. He was maintained on Protonix for his Barrett's
esophagus. His hematocrit remained stable.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient was discharged for follow-up
with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1557**] his cardiologist on [**Last Name (LF) 2974**], [**4-30**], 9:15
a.m.
DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., Plavix 75
mg p.o. q.d., Zestril 5 mg p.o. q.d., Hydrocortisone enema 1
p.r. every 12 days, Lopressor 25 mg p.o. b.i.d., Prednisone
forte 1% drops 1 to both eyes 4 times a day as directed,
Tylenol 650 mg p.o. q.4-6 hours p.r.n. pain, Asacol 800 mg
p.o. t.i.d., Lipitor 10 mg p.o. q.h.s., Zantac 150 mg p.o.
b.i.d., Klonopin 0.5 mg p.o. at bedtime as needed.
The patient was advised not to take Imdur or Diovan until
seeing his primary cardiologist Dr. [**First Name (STitle) 1557**].
DISCHARGE DIAGNOSIS:
1. Inferior myocardial infarction with right ventricular
extension with right coronary artery total occlusion status
post Angioject and stenting times two.
2. Coronary artery disease status post coronary artery
bypass graft times four.
3. Hypertension.
4. Hypercholesterolemia.
5. History of gastrointestinal bleed with diverticulosis.
6. Ulcerative colitis.
7. History of Barrett's esophagus.
8. Small pericardial effusion.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2134-4-26**] 14:40
T: [**2134-4-26**] 14:48
JOB#: [**Job Number 40917**]
cc:[**Last Name (NamePattern1) 40918**]
|
[
"410.41",
"414.01",
"458.9",
"996.72",
"272.0",
"V45.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"36.06",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
2828, 2854
|
7073, 7584
|
7605, 8360
|
4614, 6804
|
2877, 4596
|
154, 167
|
196, 1707
|
1730, 2714
|
2731, 2811
|
6829, 7049
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,020
| 170,641
|
25192
|
Discharge summary
|
report
|
Admission Date: [**2180-7-22**] Discharge Date: [**2180-8-14**]
Date of Birth: [**2105-10-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Craniotomy with evacuation of acute on chronic subdural hematoma
History of Present Illness:
Asked to eval this 74 y/o WF s/p 2 week history of HA, on
coumadin, now with 1 day history of ataxia, incontinence (not
able to make it to bathroom although knows she has to go).
History obtained from husband. [**Name (NI) **] pt. was seen by PCP for
HA
- placed on Tylenol. HA's persisted then she became ataxic and
altered in her mental status / lethargic. called pcp again [**Name Initial (PRE) **]
was
not able to get into office so went to [**Last Name (un) 1724**] at 2:30pm [**2180-7-21**]. CT
scan at [**Last Name (un) 1724**] revealed acute on chronic R subdural collection with
1cm of MLS (R->L). No intra-axial collections, intraventricular
hemorrhage or HCP noted - official read pending. Husband and
son
deny nausea, vomiting or seizure like activity in patient.
Past Medical History:
PMH: afib, High cholesterol, endocarditis, CHF, right eye blind.
PSH: right craniotomy, tracheostomy
Social History:
SOC: lives with husband, non [**Name2 (NI) 1818**], no etoh
Family History:
not obtained
Physical Exam:
PE: 121/66, 86, 17, 98% Afebrile
GEN: Rolling in bed to get comfortable, eyes closed
Neuro: With prompting, opens eyes, Oriented x 3, able to spell
name, speech clear, no obvious facial, tongue ML, unable to
assess drift secondary to poor cooperation, good grip strengths
(need to encourage Left side- seems to ? neglect). PERRL, EOMI,
sensation intact.
Chest: bibasilar crackles
Abd; Softly obese
Ext. No edema
Pertinent Results:
[**2180-7-22**] 12:15AM URINE AMORPH-MANY
[**2180-7-22**] 12:15AM URINE RBC-[**4-28**]* WBC-[**1-22**] BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2180-7-22**] 12:15AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2180-7-22**] 12:15AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2180-7-22**] 12:15AM PT-14.6* PTT-30.7 INR(PT)-1.4
[**2180-7-22**] 12:15AM PLT COUNT-121*
[**2180-7-22**] 12:15AM HYPOCHROM-1+ ANISOCYT-1+ MICROCYT-1+
[**2180-7-22**] 12:15AM NEUTS-82.0* LYMPHS-12.7* MONOS-4.9 EOS-0.3
BASOS-0.2
[**2180-7-22**] 12:15AM WBC-8.0 RBC-4.38 HGB-11.5* HCT-35.7* MCV-82
MCH-26.2* MCHC-32.1 RDW-16.1*
[**2180-7-22**] 12:15AM CALCIUM-9.8 PHOSPHATE-3.8 MAGNESIUM-1.8
[**2180-7-22**] 12:15AM GLUCOSE-119* UREA N-12 CREAT-0.8 SODIUM-143
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
Brief Hospital Course:
This 74 y/o white female was admitted 0n [**2180-7-22**] through the
emergency room after a 2 week history of headache and declining
mental status. She was on coumadin at home for her atrial
fibrillation. Hisotry at that time was obtained from her husband
and he reported that she had had episodes of incontinence
secondary to not being able to make it to the bathroom in time
secondary to ataxia. CT scan was originally done at [**Hospital1 **] and then patient was transferred to [**Hospital1 18**] after
SDH was noted. The repeat CT at [**Hospital1 18**] was unchanged as the
collection was acute with the majority of the collection being
chronic. There was 1 cm of MLS at that time.
The patient was taken to the operating room on [**2180-7-22**] shorlty
after her admission for evacuation of the SD collection as her
mental status was continuing to decline. She was given FFPx2
units to futher correct the INR which was originally 3.9 (she
recieved 4 units FFP at [**Last Name (un) 1724**]). She was also started on Dilatin.
Postoperatively she was unable to be extubated (she has had a
history of difficulty with extubation in the past per her
husband). She remained vented and was eventually trached on
[**2180-8-1**]. Her postoperative [**Last Name (un) 30640**] exams have been stable with
slow progression. She has mostly been purposeful with the right
upper extremity. Her lower extremeties are active. and the Left
upper extremity is purposeful however slightly weaker than the
right. She localizes briskly with the RUE and today on [**2180-8-9**]
has had some eye opening to noxious however still not following
commands. She did however shake her head NO when asked if she
could show her thumb. Her incision for the craniotomy has
healed completely.
On hospital day#1 she was started on levaquin and flagyl for ?
aspiration pneumonia. She was kept NPO and PPI's were started -
she was started on sub-q heparin on post op day number [**11-21**]. Her
CT scan on [**2180-7-23**] of the brain showed a right temporal
hemorrhage which was felt to be a reperfusion injury - there
were and are no infarcts. This hemorrhage was not evacuated.
Tube feeds were started on [**2180-7-24**] -She was seen and evaluated by
Inpatient Nutritional services on [**2180-7-25**] - Their recommmendation
was that she start promote with fiber at 60 cc hr - she
ultimately met her goal at 80cc / fr. (1920kcal, 120 g protien)
- (however TF goal while on propofol which provides caloric
intake was to be at 60cc/hr)
Ventilation weaning attempted on multiple occassions. As of
HD#6 [**2180-7-27**] she was not able to be weaned and the tracheostomy
was scheduled. At times her dilantin level had dropped and she
was given boluses. Ultimately her dilantin was stopped on
[**2180-8-8**] and Keppra was started.
On [**2180-8-1**] she had a Tmax of 104.2 - fever w/u was intiated by
SICU team. sputum with gm + cocci in pairs and clusters - urine
culture was neg. MRSA in sputum on [**2180-8-2**] - antibiotics were
started, she received 14 days of Vancomycin
MRI was done on [**2180-8-4**] because of slow neurological progression
although CT scans have all remained stable with postoperative
changes and the reperfusion injury. FINDINGS: Diffusion images
demonstrate no evidence of acute infarct. There is subdural
hematoma seen from the right frontal to occipital region
extending to the interhemispheric fissure. The maximum width of
the subdural is 8 mm in the right parietal region. The subdural
measures approximately 9 mm along the falx. A small left-sided
subdural hematoma is also seen in the parietal region, the
maximal width of 4 mm. There is additionally, a right temporal
intraparenchymal hematoma identified. There is mild surrounding
brain edema seen. There is effacement of the sulci along the
right cerebral hemisphere without midline shift. An area of low
signal on susceptibility-weighted images in the right occipital
region indicate chronic blood products from previous hemorrhage.
The basal cisterns are patent. There is no evidence of
transtentorial or transforamen magnum herniation seen. Following
gadolinium administration, there is some enhancement of the
meninges seen but there is no evidence of abnormal parenchymal
enhancement identified adjacent to the intraparenchymal
hematoma. No other areas of abnormal intraparenchymal
enhancement noted. Postoperative changes are seen in the right
frontal region.
IMPRESSION: Bilateral subdural hematoma with right-sided
hematoma extending to the interhemispheric fissure with
measurements as described above. Right temporal intraaxial
hematoma with surrounding edema. No midline shift or herniation.
Mild mass effect on the right cerebral hemisphere. No evidence
of acute infarct.
Pt was also seen and evaluated by PT and OT services during her
ICU stay.
She had a PEG placed on [**8-10**] under interventional radiology, her
tube feeds are Promote with fiber @80hr now at goal.
She continued to have difficulty being weaned from vent despite
numerous trials, though seems to be more successful as she is
being moved out of bed to chair and now more awake. Her current
vent settings at this writing CPAP + PS with R 12, TV 500 and
50% FiO2, PEEP of 5
On [**8-13**] her neuroexam appeared much improved she opened her eyes
spontaneously, shook her head yes/no and followed simple
commands. She was started on Baby ASA also for her hx of afib.
On [**8-14**] a noncontrast head CT was performed revealing minimal
change from prior CT on [**2180-8-8**]. The patient was later
discharged to rehab in stable condition with a 2 day course of
levaquin.
Medications on Admission:
Meds: Liptor 20, Sotalol 120, Lasix 60, Coumadin 4mg/3mg,
zoloft
75, meclizine 25.
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: [**11-21**] PO Q4-6H (every
4 to 6 hours) as needed.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
6. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-21**]
Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule,
Delayed Release(E.C.)(s)
12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 36730**] [**Hospital 4094**] Hospital - [**Hospital1 **]
Discharge Diagnosis:
Subdural hematoma
s/p SDH evacuation / Right sided. with right temporal
reperfusion intraparenchymal hemorrhage. Respiratory Failure.
History of Constrictive, A-Fib,CHF, hypercholesterolemia, blind
in R eye.
Discharge Condition:
Neurologically stable - opens eyes, follows commands, nods
yes/no Slight left hemiparesis,
Discharge Instructions:
return to [**Hospital1 18**] if there are any neurological chnges or
decreased level of consciousness.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 739**] in one month from discharge
with a noncontrast head CT [**Telephone/Fax (1) **]
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2180-8-14**]
|
[
"272.0",
"482.41",
"428.0",
"369.60",
"423.2",
"518.5",
"432.1",
"790.92",
"276.1",
"V09.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"01.31",
"31.1",
"44.32",
"96.72",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9846, 9941
|
2795, 8428
|
328, 394
|
10193, 10285
|
1886, 2772
|
10436, 10691
|
1424, 1438
|
8563, 9823
|
9962, 10172
|
8454, 8540
|
10309, 10413
|
1453, 1867
|
280, 290
|
422, 1206
|
1228, 1330
|
1346, 1408
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,015
| 178,415
|
1504
|
Discharge summary
|
report
|
Admission Date: [**2192-7-3**] Discharge Date: [**2192-7-9**]
Date of Birth: [**2116-2-6**] Sex: F
Service: [**Hospital1 139**] B Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
female who was found at nursing home on the morning of
admission having vomited a large amount of coffee ground
emesis which was reportedly guaiac positive. The patient
also was very congested with decreased O2 saturations to the
low 80s on room air. The patient was started on supplemental
O2 with no increase in her O2 saturations. The patient's
primary care provider was notified and the patient was given
levofloxacin 500 po x1. The patient was then noted to have a
sudden decrease level of consciousness with a heart rate on
the pulse oximeter noted to be down to 44. After about 30
seconds, the patient's heart rate improved to 98. The
patient was then transported to [**Hospital6 2018**] Emergency Room. In the Emergency Room, the patient
was alert and oriented x1 with bilateral rales and positive
coffee ground emesis x2. Furthermore, the patient also had a
few more episodes of decreased responsiveness with heart
rates in the 40s and systolic blood pressures to the 80s.
The electrocardiogram obtained at that time showed that the
patient was bradycardic secondary to Mobitz type I AV block
as well as ST depressions in V1 and AVL. The patient's chest
x-ray at this time was negative for any acute process.
PAST MEDICAL HISTORY:
1. Hypothyroidism
2. Seizure disorder
3. Schizo-affective disorder
4. Chronic obstructive pulmonary disease
5. Depression
6. Duodenal ulcer
7. Gastroesophageal reflux disease
8. Esophagitis
9. Dementia with dependent ADLs
ADMISSION MEDICATIONS:
1. Vitamin C 500 mg [**Hospital1 **]
2. Cogentin 1 mg [**Hospital1 **]
3. CaCO3 500 mg tid
4. Synthroid 0.1 mg qd
5. Miacalcin nasal spray
6. Risperdal 2 mg [**Hospital1 **]
7. Valproic acid 500 mg [**Hospital1 **] and 750 mg q hs
8. Zinc 220 mg qd
9. Vitamin D 400 mg [**Hospital1 **]
ALLERGIES: No known drug allergies.
VITAL SIGNS: Temperature was 98??????. Pulse was 109. Blood
pressure 121/48 and O2 saturation was 97% on 4 liters.
GENERAL: The patient was in no apparent distress lying in
bed.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light. Extraocular muscles are intact. Moist
mucous membranes.
CHEST: Rancorous breath sounds bilaterally.
CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2, no
murmurs, rubs or gallops.
ABDOMEN: Soft, nondistended, nontender and positive bowel
sounds.
EXTREMITIES: There was no cyanosis or clubbing. The patient
has 1+ edema bilaterally in her lower extremities.
RECTAL: Guaiac positive in the Emergency Department.
NEUROLOGIC: The patient was alert and oriented x1.
ADMISSION LABS: CBC: White blood count was 6.0, hematocrit
42.1, platelets 158. CK was 32. Troponin was 0.4.
Electrolytes: Sodium 138, potassium 4.5, chloride 99,
bicarbonate 30, BUN 18, creatinine 0.5, glucose 187.
HOSPITAL COURSE: The day of admission the patient was
admitted to the Medical Intensive Care Unit due to the
episodes of coffee ground emesis as well as the episodes of
bradycardia and unresponsiveness with hypotension.
1. CARDIAC: An echocardiogram was obtained on the date of
admission which showed preserved biventricular systolic
function as well as aortic sclerosis. Left ventricular
ejection fraction was greater than 55%. Cardiology and EP
was consulted to evaluate the patient for a pacemaker based
on her new cardiac conduction abnormality. Due to the
patient's long history of dementia, the primary care
physician had discussion with health care proxy and decided
that the pacemaker placement would not occur. Cardiology and
primary care provider agreed that this will not significantly
change the patient's quality of life at this time. The
patient failed to have any more bradycardic episodes
throughout her stay.
2. GASTROINTESTINAL/FLUIDS, ELECTROLYTES AND NUTRITION: The
patient had coffee ground emesis on admission and as well in
the Emergency Room. The patient had no further episodes
throughout her stay. The patient's hematocrit remained
stable. The patient had nasogastric lavage which was
negative. The patient was begun on tube feeds on [**7-4**] and
progressed to goal without difficulty. Subsequently, after
the patient was transferred to the floor, speech and swallow
evaluation was performed on [**2192-7-6**] which the patient failed.
Her baseline diet consisted of nectar thick liquids as well
as pureed solids. Due to the patient's upper airway
congestion and phlegm production, it is believed that she was
unable to take appropriate swallows. This will be repeated
on the date of discharge and recommendations will be made.
The nasogastric tube will be pulled prior to the patient
returning to the nursing home. The patient's electrolytes
were checked q day and repleted as necessary.
3. PULMONARY: On the day after admission, the patient had a
follow up chest x-ray which showed interval development of a
left lower lobe consolidation and collapse as well as
possibly a small left pleural effusion. Given the rapid
change from her unremarkable chest x-ray on admission, this
is likely aspiration pneumonia as related to her emesis. The
patient was begun on levofloxacin, Flagyl intravenous. The
patient is unable to give a strong cough in order to produce
a good sputum culture. The culture which was obtained was
contaminated was oropharyngeal flora. The patient's O2
saturations improved throughout her stay and the patient
requires some suctioning in order to clear the phlegm in the
back of her throat. In addition, the patient's white blood
cell count spiked to 32.9 and subsequently has come down
throughout her stay to a normal white blood count of 7.1.
4. ENDOCRINE: The patient has hypothyroidism and her TSH
was checked and was within normal limits at 0.77. Therefore,
her current dose of Synthroid will be continued.
5. CODE STATUS: DNR/DNI
DISCHARGE CONDITION: Improved, stable
DISCHARGE STATUS: The patient is to be discharged back to
the [**Hospital3 6560**] Home facility.
DISCHARGE DIAGNOSES:
1. Resolved upper gastrointestinal bleed
2. Aspiration pneumonia
3. Newly diagnosed cardiac conduction abnormality - type 1
AV block
DISCHARGE MEDICATIONS:
1. Albuterol nebulizer solution 1 nebulizer q6h prn wheezing
2. Ipratropium bromide nebulizer 1 nebulizer q6h wheezing
3. Levothyroxine sodium 100 mcg po qd
4. Valproic acid 500 mg po bid and 750 mg po q hs
5. Flagyl 500 mg po q8h x8 days
6. Levofloxacin 500 mg po qd x8 days
7. Colace 100 mg po bid
8. Senna 1 tablet po bid prn constipation
9. Protonix 400 mg po bid
10. Risperdal 2 mg [**Hospital1 **]
11. Cogentin 1 mg [**Hospital1 **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8829**], M.D. [**MD Number(1) 8830**]
Dictated By:[**Last Name (NamePattern1) 8831**]
MEDQUIST36
D: [**2192-7-7**] 12:27
T: [**2192-7-7**] 13:15
JOB#: [**Job Number 8832**]
cc:[**Hospital3 8833**]
|
[
"426.11",
"507.0",
"578.0",
"294.8",
"427.89",
"244.9",
"780.09",
"792.1",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6058, 6176
|
6197, 6334
|
6357, 7106
|
3034, 6036
|
1723, 2794
|
189, 1446
|
2811, 3016
|
1468, 1700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,064
| 182,461
|
43375+43376+43377
|
Discharge summary
|
report+report+report
|
O
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 93367**]
Admission Date: [**2139-10-31**] Discharge Date:
Date of Birth: [**2093-5-6**] Sex: M
NO DICTATION FOR THIS REPORT
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] P. 12-948
Dictated By:[**Dictator Info **]
D: [**2139-11-4**] 18:20
T: [**2139-11-4**] 19:27
JOB#: [**Job Number **]
Admission Date: [**2139-10-31**] Discharge Date:
Date of Birth: [**2093-5-6**] Sex: M
Service:
No Dictation for this report
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] P. 12-948
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2139-11-4**] 18:21
T: [**2139-11-4**] 19:28
JOB#: [**Job Number 93368**]
1
1
1
R
Admission Date: [**2139-10-31**] Discharge Date: [**2139-11-5**]
Date of Birth: [**2093-5-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 46-year-old man who is
well known to the [**Hospital1 69**] who
was admitted to the medical Intensive Care Unit after he lost
his hemodialysis access. He was admitted to the ICU because
he was chronically ventilated and is a current resident at
the [**Hospital3 672**] Hospital. The patient was having
hemodialysis on [**2139-10-29**]. He was found in the hallway,
sliding out of bed. He was pulled up by a five man lift. In
the process his right subclavian vascular cath was
accidentally removed. Hemodialysis was discontinued. Vitals
at the time were afebrile, 97.5, heart rate 75, respiratory
rate 16, blood pressure 128/89, 99% O2. Vent settings this
a.m. 4 and 40%, total volume 700, PEEP 5. He was transferred
to the [**Hospital1 69**] on [**2139-10-31**] after
it was felt that he would need admission given his
complicating factors of chronic trach and was admitted for
temporary dialysis plan for resumption of permanent line
during this admission.
PAST MEDICAL HISTORY: Significant for obesity, OSA, status
post tracheostomy, hypertension, pulmonary hypertension,
COPD, cor pulmonale, chronic renal insufficiency and
hemodialysis, lower extremity venous ulcers, dilated right
ventricle and right heart failure, status post GI bleed,
lower extremity edema and elephantiasis, status post
enterococcal bacteremia, herpes zoster, gastric ulcer.
ALLERGIES: Allergic to Keflex and Oxacillin.
FAMILY HISTORY: Has a history of CVA in his brothers and
sisters.
SOCIAL HISTORY: He has a history of remote Cocaine and
Marijuana, quit 10 years ago. The patient also is a 15 pack
year tobacco user. Married and lives with his wife who is
also a resident of the chronic care facility.
LABORATORY DATA: On admission, sodium 138, potassium 5.8,
chloride 103, CO2 25, BUN 45, creatinine 6.3, glucose 94,
white count of 3, hematocrit 26.8, platelet count 171,000.
HOSPITAL COURSE: The patient at the time of admission had no
indications for emergent dialysis. On [**2139-11-1**] he was
evaluated by the renal service and had a temporary right
femoral Quinton catheter placed and underwent hemodialysis
and plans were initiated to try to arrange for permanent
hemodialysis tunnel catheter placement. His ventilator
status was maintained for the most part on pressure support
ventilation which he tolerated well. Attempts to wean him to
trach mask failed because of diaphoresis and rapid
respiratory rate with small total volumes of unclear etiology
given his relatively level of comfort on very low pressure
support ventilation. The patient was stable on [**11-1**] and
[**2139-11-2**]. He spiked a temperature however, to 101 on [**11-1**] and
blood cultures were drawn which ultimately grew out [**5-6**] gram
positive cocci which were identified as Oxacillin resistant
staph. Because of this, he was started on IV Vancomycin on
[**2139-11-2**] and plans were aborted for inserting a tunnel
catheter. He underwent placement of a left subclavian
temporary Quinton catheter under interventional radiology
guidance on [**2139-11-4**] and underwent hemodialysis successfully.
Plan at the time of discharge will be to treat for 3-4 weeks
with IV Vancomycin, cultures should be followed periodically
and with plans for likely placement of a tunnel catheter in
approximately 2 weeks to be arranged through his [**Hospital6 **] facility. At time of discharge,
[**2139-11-5**], the patient is awake, alert, hemodynamically stable,
maintained on pressure support ventilation, has a left
Quinton IJ hemodialysis access placed.
DISCHARGE MEDICATIONS: Hydralazine 50 mg po qid, Isordil 20
mg po tid, Clonidine 0.2 mg po tid, Lasix 80 mg po q d and
Lasix 40 mg po q d in addition on hemodialysis days, Monday,
Wednesday, Friday, Prevacid 30 mg po q d, Heparin 5,000 subcu
tid, Prozac 10 mg po q d, Nitroglycerin 0.4 mg sublingual
times three prn for chest pain, Vioxx 25 mg po q d, Colace
100 mg po bid, Senna three tablets po q d, Nephrocaps one po
q d, Albuterol MDI four puffs trach q 4 hours, Flovent 220
mcg two puffs via trach [**Hospital1 **], Aspirin 325 mg po q d, TUMS 1 po
with each meal, Nepro one can with each meal, Vancomycin 1 gm
IV to be dosed according to levels and redosed for levels
less than 15.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: The patient will be returned to
[**Hospital3 672**] Hospital with plans to be arranged for
placement of a tunnel hemodialysis catheter in approximately
two weeks pending negative cultures with anticipated [**4-5**] week
total course of IV Vancomycin for his presumed line sepsis.
Phone number for Interventional Radiology is [**Telephone/Fax (1) 93369**].
Treatment and frequency regular tracheostomy section at least
every two hours and more frequently if necessary.
Respiratory therapy, physical therapy. Diet, renal diet and
Nepro with each meal. Hemodialysis to be continued as
scheduled.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] M. 11-685
Dictated By:[**Name8 (MD) 37298**]
MEDQUIST36
D: [**2139-11-5**] 11:12
T: [**2139-11-5**] 11:38
JOB#: [**Job Number 32270**]
|
[
"518.81",
"E878.1",
"996.62",
"038.10",
"416.8",
"403.91",
"V44.0",
"496",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"96.72",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
2425, 2476
|
4563, 5229
|
2894, 4539
|
5288, 6110
|
988, 1966
|
1989, 2408
|
2493, 2876
|
5254, 5263
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,104
| 118,610
|
18407
|
Discharge summary
|
report
|
Admission Date: [**2108-8-8**] Discharge Date: [**2108-8-13**]
Date of Birth: [**2064-5-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2108-8-8**] Aortic valve replacement with a [**Street Address(2) 11688**]. [**Hospital 923**] Medical
Biocor tissue valve. Xenograft reconstruction of pericardium
with core matrix patch.
History of Present Illness:
44 year old male with history of MSSA aortic valve enodcarditis.
He completed his 6 week course of IV Oxacillin in [**2108-4-6**].
Follow up echocardiogram showed mod-severe aortic stenosis with
mild aortic insufficiency. His aortic valve is likely bicuspid
and findings showed a 2-4mm vegetation on the posterior AV
leaflet in [**2108-4-6**]. In preperation for aortic valve
replacement, he underwent cardiac catheterization which revealed
single vessel coronary artery disease of the right coronary/PDA.
He was evaluated by Dr. [**Last Name (STitle) **] in [**Month (only) **] for surgery and returns
today for surgery.
Past Medical History:
Aortic valve enodcarditis, Aortic stenosis and insufficiency,
probable bicuspid AV
Coronary Artery Disease with evidence of prior MI
Congestive Heart Failure
History of MRSA Hand Infection, [**2107-11-7**]
Diabetes Mellitus, on Insulin Pump
TIA
Obesity
ADHD
Asthma
Acute renal failure [**1-16**]
Bipolar Disorder
Chronic low back pain
History of Kidney Infections
Psoriasis
Gastroesophageal reflux disease
Past Surgical History:
Left Hand Surgery x 2
Vasectomy
Adenoidectomy
Social History:
Occupation: still disabled
Lives with: friends ([**Name2 (NI) **]), he is divorced with 3 kids
Tobacco: 30PYH, smokes 4 cigs/day currently
ETOH: 2 drinks per week
Family History:
noncontributory
Physical Exam:
Pulse: 76 SR Resp: 14
B/P Right: 118/80 Left: 106/70
Height: 72 inches Weight: 265 lbs
General: WDWN in NAD
Skin: Dry [X] intact [X] no C/C/E. Multiple areas of psoriasis.
?ringworm on back.
HEENT: PERRLA [X] EOMI [X] OP benign
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, III/VI SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Pt has fungal infection in both groins (left much worse than
right)
Varicosities: None []
Neuro: Grossly intact
Pulses:
Femoral Right: 1 Left: 1
DP Right: trace Left: trace
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Murmur radiates to (B) carotids
Pertinent Results:
[**2108-8-8**] Echo: Pre bypass: The left atrium is elongated. No
spontaneous echo contrast is seen in the body of the left
atrium. There are focal calcifications in the aortic arch. There
are simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets, although the right and non coronary
cusps appear partially fused. There is a large mass on the non
coronary cusp with some mobile components. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. There is
no pericardial effusion.
Post bypass: preserved biventricular function LVEF 55%. A
bioprosthetic aortic valve is insitu with no AI or perivalvular
leaks. Peak graident 19, mean 11 mm hg. Aortic contours intact.
Remainging exam is unchanged. All findings discussed surgeons at
the time of the exam.
[**2108-8-11**] 05:40AM BLOOD WBC-5.9 RBC-3.09* Hgb-9.5* Hct-28.2*
MCV-91 MCH-30.6 MCHC-33.6 RDW-13.3 Plt Ct-113*
[**2108-8-8**] 09:15AM BLOOD WBC-6.9 RBC-5.13 Hgb-15.8 Hct-44.5 MCV-87
MCH-30.8 MCHC-35.6* RDW-13.5 Plt Ct-212
[**2108-8-13**] 04:40AM BLOOD Plt Ct-156
[**2108-8-11**] 05:40AM BLOOD PT-11.8 PTT-23.6 INR(PT)-1.0
[**2108-8-8**] 01:07PM BLOOD PT-13.3 PTT-23.3 INR(PT)-1.1
[**2108-8-8**] 09:15AM BLOOD Plt Ct-212
[**2108-8-13**] 10:35AM BLOOD K-5.1
[**2108-8-13**] 04:40AM BLOOD Glucose-162* UreaN-27* Creat-1.2 Na-141
K-5.2* Cl-104 HCO3-29 AnGap-13
[**2108-8-8**] 09:15AM BLOOD Glucose-150* UreaN-20 Creat-1.0 Na-134
K-3.8 Cl-97 HCO3-25 AnGap-16
[**2108-8-13**] 04:40AM BLOOD Calcium-8.3* Phos-5.1* Mg-2.3
]
[**2108-8-8**] 11:30 am TISSUE AORTIC VALVE.
GRAM STAIN (Final [**2108-8-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2108-8-11**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
Admitted same day surgery and brought directly to the operating
room where he underwent a aortic valve replacement. Please see
operative report for surgical details. He received cefazolin for
perioperative antibiotics. Postoperatively he was transferred
to the intensive care unit for hemodynamic management. In the
first twenty four hours he was weaned from sedation, awoke
neurologically intact and was extubated without complications.
He was noted for apnea and was placed on autoCPAP and sleep was
consulted ith plan for him to follow up in sleep clinic. [**Last Name (un) **]
was consulted due to elevated hgba1c on insulin pump, insulin
was adjusted and he was started on lantus. He remained in the
intensive care unit an extra day to manage his blood glucose.
Post operative day two he was transferred to the floor for the
remainder of his care. Physical therapy worked with him on
strength and mobility. Psychiatry was consulted in relation to
his medications due to him stopping lithium preoperatively.
Plan for follow up with outpatient psychiatrist and do not
restart lithium at this time. He was ready for discharge to
rehab on postoperative day five.
Medications on Admission:
Humalog Insulin Pump
Lipitor 80 mg QHS
Protonix 40mg Daily
Lithium 300mg three times day Currently weaning off and has not
taken in >1 week.
Adderall 30mg daily
Neurontin 600mg three times daily
Seroquel 100mg daily
Cymbalta 90mg daily
Aspirin 325mg daily
Xanax 2mg twice daily
Colace 100mg twice daily
Advair 500/50 twice daily
Albuterol 2 puffs twice daily
Vicodin 10mg three times daily
Fish oil l1200mg daily
Vitamin B complex daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
4. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Insulin Glargine 100 unit/mL Solution Sig: One Hundred (100)
units Subcutaneous once a day.
12. insulin sliding scale
Humalog sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
0-65 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
66-80 mg/dL 0 Units 0 Units 0 Units 0 Units
81-160 mg/dL 10 Units 10 Units 10 Units 0 Units
161-280 mg/dL 22 Units 22 Units 22 Units 6 Units
281-319 mg/dL 26 Units 26 Units 26 Units 7 Units
320-359 mg/dL 28 Units 28 Units 28 Units 8 Units
360-400 mg/dL 30 Units 30 Units 30 Units 10 Units
Instructons for NPO Patients: use bedtime scale when NPO
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] healthcare center
Discharge Diagnosis:
Aortic stenosis and insufficiency s/p Aortic Valve Replacement
AV Endocarditis(MSSA)- probable bicuspid AV
Coronary Artery Disease with evidence of prior MI
History of MRSA Hand Infection [**2107-11-7**]
Diabetes Mellitus
TIA
Obesity
ADHD
Asthma
Acute renal failure [**1-16**]
Bipolar Disorder
Chronic low back pain
History of Kidney Infections
Psoriasis
Gastroesophageal reflux disease
Past Surgical History:
Left Hand Surgery x 2
Vasectomy
Adenoidectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please report any and all wound
issues to your surgeon 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) Please wash incision with soap and water daily and gently pat
dry. No lotions, creams or powders to incisions until they have
healed. No bathing or submerging incisions for 1 month.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month.
7) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
8) Please follow up with outpatient psychiatrist
9) Please continue with sliding scale insulin and lantus no
further insulin pump [**First Name8 (NamePattern2) **] [**Last Name (un) **] diabetes recommendations
10) Autocpap for apnea - follow up with sleep clinic
Followup Instructions:
Please call to schedule appointments
Sleep clinic in [**12-9**] weeks ([**Telephone/Fax (1) 9525**]
Dr. [**Last Name (STitle) **] in [**1-10**] weeks at [**Hospital1 **] heart center [**Telephone/Fax (2) 6256**]
Dr. [**Last Name (STitle) 14334**] after discharge from rehab [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 50679**]
Please follow up with outpatient psychiatrist
Completed by:[**2108-8-13**]
|
[
"305.1",
"746.4",
"530.81",
"250.01",
"414.01",
"293.0",
"278.00",
"428.30",
"V45.85",
"696.1",
"327.23",
"424.1",
"296.80",
"314.01",
"110.3",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.77",
"35.21",
"38.93",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7917, 7986
|
4623, 5795
|
340, 531
|
8486, 8492
|
2695, 4551
|
9457, 9924
|
1879, 1896
|
6282, 7894
|
8007, 8394
|
5821, 6259
|
8516, 9434
|
8417, 8465
|
1911, 2676
|
281, 302
|
559, 1182
|
4587, 4600
|
1204, 1610
|
1696, 1863
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,008
| 137,638
|
54383
|
Discharge summary
|
report
|
Admission Date: [**2199-6-30**] Discharge Date: [**2199-7-1**]
Service: MEDICINE
Allergies:
Ciprofloxacin / Celebrex / Sulfa (Sulfonamide Antibiotics) /
Cephalexin / Vancomycin
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Mrs [**Known lastname 111329**] is a pleasant [**Age over 90 **] yo woman
with hx HTN, CAD, DM, Afib s/p pacemaker implantation who
presents today from her nursing facility after feeling
lethargic. Per her daughter, she became concerned when visiting
after finding her mother to be lethargic and more confused than
usual. Of note, pt was treated for a UTI at her last admission
earlier this month, and also finished a course of ertapenem for
cellulitis at her nursing home two days ago. En route from the
nursing facility, pt was hypotensive to the 70s.
.
In the ED she recieved 600 ccs of fluid and was started on
levophed through her midline PICC, with improvement in her
pressures to the 100s systolic. Vitals on transfer were 99.6 74
104/55 120 100 2L.
.
On arrival to the floor pt interviewed through the interpreter
and denies recent fevers, cough, chest pain or shortness of
breath. Daughter states that she fell a week ago and did hit
her head but had no LOC. Her daughter also is concerned about
swelling in her LUE. Endorses decreased PO intake over the past
several days.
Past Medical History:
- peripheral artery disease 100% occlusion R. SFA cath in [**Month (only) 116**])
- HTN
- CAD w/ NSTEMI [**2190**], stent placed
- Diabetes with neuropathy
- Hyperlipidemia
- AFIB s/p PPM
- CVA/TIA
- CKD baseline creatinine of 1.2.
- diuastolic and systolic CHF
- COPD
- BCC
- Lumbar psinal stensosis
- OA
- ? Venous thromboembolism
- Mast cell ttumor
- Gastric ulcer
Social History:
- comes from [**Hospital **] rehab
- no current tobacco
- no current ETOH
Family History:
non-contributory
Physical Exam:
Vitals: T:96 BP:101/38 P:74 R:11 O2:100%
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP <7 cm, no LAD
Lungs: Clear to auscultation bilaterally, however poor insp
effort
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, mildly ttp, 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. Clean base heel ulcer on LLE, also 1 inch ulcer on head
of first metatarsal.
Pertinent Results:
[**2199-6-30**] 11:30PM URINE HOURS-RANDOM CREAT-136 SODIUM-LESS THAN
POTASSIUM-55 CHLORIDE-LESS THAN
[**2199-6-30**] 11:30PM URINE OSMOLAL-296
[**2199-6-30**] 03:45PM LACTATE-3.5*
[**2199-6-30**] 03:30PM GLUCOSE-133* UREA N-37* CREAT-2.1*
SODIUM-128* POTASSIUM-3.7 CHLORIDE-89* TOTAL CO2-27 ANION GAP-16
[**2199-6-30**] 03:30PM CALCIUM-8.1* PHOSPHATE-4.7* MAGNESIUM-2.2
[**2199-6-30**] 03:30PM OSMOLAL-284
[**2199-6-30**] 02:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2199-6-30**] 02:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
Cultures:
Urine: Enterococcus: 10,000 - 100,000 CFU
C. Diff: FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Imaging:
CT Head:
IMPRESSION: No acute intracranial process.
CXR:
IMPRESSION: Small left pleural effusion with left basilar
atelectasis --
cannot exclude pneumonia. Consider lateral view to better
assess.
LUE US:
FINDINGS: Suboptimal and inconclusive study. The patient is
weak,
uncomfortable and difficult to cooperate with arm positioning.
There is normal compressibility in the left internal jugular
vein, axillary vein, and brachial veins. Unable to obtain
diagnostic images of the subclavian vein due to arm positioning.
Unable to see the cephalic and basilic vein. There is moderate
soft tissue edema in the left arm.
Discussed with Dr. [**First Name (STitle) **] [**Name (STitle) **] while on the floor during the
portable
ultrasound; study can be repeated in the morning if patient able
to cooperate with arm positioning.
Additional labs:
[**2199-7-1**] 06:44AM BLOOD WBC-29.1* RBC-3.78*# Hgb-10.2*#
Hct-34.4*# MCV-91 MCH-26.8* MCHC-29.5* RDW-21.1* Plt Ct-425
[**2199-7-1**] 03:50AM BLOOD Neuts-93* Bands-4 Lymphs-2* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2199-7-1**] 06:44AM BLOOD Glucose-136* UreaN-39* Creat-2.1* Na-129*
K-3.3 Cl-92* HCO3-25 AnGap-15
Brief Hospital Course:
Assessment and Plan: Pleasant [**Age over 90 **] yo woman with MMP, now admitted
for hypotension in the setting of bilateral LE ulcers, new
consolidation on CXR, and positive C. Diff assay.
.
1. Hypotension: There was concern for septic shock given her
history of infection, positive C. Diff assay, LE ulcers, and new
consolidation on CXR. The patient, however had no fever, cough,
or sputum production, which made PNA less likey. Given her
cardiac history, there was concern for cardiogenic shock,
however there were no sxs to suggest recent MI, EKG is unchanged
and no edema on CXR. There was a low suspicion for PE, however
if with UE edema some concern for clot which may have
propogated. The patient patient was confirmed DNR/DNI, and no
additional lines were placed. She was given IVF in addition to
antibiotic coverage for presumed sepsis, but she remained
persistently hypotensive. The family was notified that she
would require additional access for IV fluids. The family
reiterated there request for no additional lines, and she was
placed on comfort measures. The patient passed comfortably just
before midnight at approximately 11:56 on [**2199-7-1**].
.
# ARF: Her creatinine was elevated in the setting of a urine
sodium of less than 10. She was most likely pre-renal in the
setting hypotension. She was given fluids, through her lines,
but remained persistently hypotensive.
.
# Abd pain: She had mild pain, with mild distension. Her white
count was elevated and her c. diff was positive, which was the
most likely etiology for her pain and clinical presentation of
sepsis.
.
# LE ulcers: A small 1 cm circumscribed ucler was noted on the
foot which expressed small amounts of puss. Foot x-rays were
not suggestive of osteo.
.
# Hyponatremia: Her low sodium was liklely secondary to poor PO
intake, and she appeared dry on admission. Fluids were started
as soon as she arrived.
.
# LUE edema: concerning for DVT vs thrombophlebitis, however no
hx of recent line in the LUE. A LUE US was inconclusive.
.
# GERD: She was placed on an H2 blocker since she was also
taking plavix.
Medications on Admission:
Medications:
-Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
-Nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One (1) Transdermal
once a day.
-Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Transdermal
once a day.
-MS Contin 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
-Morphine 15 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
-Humalog 100 unit/mL Solution Subcutaneous
-Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection every eight (8) hours.
-Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain.
-Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
-Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
-Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
-Senokot 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
-Ambien 2.5 q day
-Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
-Colchicine 0.3 mg Tablet Sig: One (1) Tablet PO once a day.
-Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
-Acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO three
times a day.
-Pantoprazole 40 mg q day
Disp:*30 Tablet(s)* Refills:*2*
Disp:*6 Tablet(s)* Refills:*0*
-Bisacodyl PRN
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Sepsis
Secondary diagnosis:
Hypotension
C. Diff
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2199-7-3**]
|
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"357.2",
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"707.07",
"403.90",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8075, 8084
|
4529, 6633
|
303, 309
|
8195, 8204
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2583, 3339
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1989, 2564
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252, 265
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365, 1456
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3348, 4506
|
8153, 8174
|
8124, 8132
|
1478, 1848
|
1864, 1940
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,073
| 124,800
|
48050
|
Discharge summary
|
report
|
Admission Date: [**2110-3-5**] Discharge Date: [**2110-3-20**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
The pt is a 85 y/o M with a PMH of PUD, aflutter, Heart block
s/p PPM, CHF, CRI, AAA with endovascular repair and recent [**Hospital 11091**]
transferred from nuring home with BRBPR and chest pain. Pt had
been on azithromycin and prednisone taper for PNA and COPD
exacerbation. He then developed BRBPR and hypotension with an
initial HCT in ED of 23. OG lavage was negative.
Given history of endovascular repair concern for aorto-enteric
fistula prompted a non-contrast CT which did not show a fistula,
however did demonstrate an existing infrarenal AAA and a high
density intraluminal material within right colon (? blood). GI,
surgery and IR were consulted. The pt. had a negative tagged-RBC
scan. Surgery did not feel there was an acute indication for
surgerical intervention. Pt received 8U PRBCs in total prior to
ICU transfer. The patient was briefly intubated for airway
protection, extubated [**3-7**]. He remained HD stable through MICU
stay and is transferred to the floor with planned colonscopy for
Monday.
Past Medical History:
PUD
DM2
CHF
A. flutter
AAA s/p endovascular repair
Heart Block s/p PPM
squamous cell ca n
Bladder malignancies
Social History:
widowed, retired (from restaurant industry), former smoker, no
ETOH
Family History:
non-contributory
Physical Exam:
PE: Vitals: T 98.1, BP 135/63, HR 60, RR 18, O2 sat 100% 3L NC
Gen: alert and oriented, speech spontaneous and fluent, poor
historian
HEENT: NC/AT, PERRLA, EOMI, Dry MM
CV: RRR, nl S1/s2, no M/R/G, flat JVP
Resp: clear anteriorly, decreased BS at bases w/ dullness to
percussion
Abd: obese, mildly distended, NABS, non-tender, no
rebound/guarding
Ext: 1+ edema LE b/l
Skin: scattered hypersegmented lesions on face and neck
Neuro: moving all extremities, non-focal
Pertinent Results:
[**2110-3-5**] 09:00AM WBC-18.1* RBC-2.25* HGB-7.7* HCT-23.3*
MCV-104* MCH-34.1* MCHC-32.9 RDW-14.8
[**2110-3-5**] 09:00AM NEUTS-76.9* LYMPHS-17.7* MONOS-4.5 EOS-0.7
BASOS-0.2
[**2110-3-5**] 09:00AM PLT COUNT-157
[**2110-3-5**] 09:00AM CK(CPK)-55
[**2110-3-5**] 09:00AM cTropnT-0.12*
[**2110-3-5**] 09:00AM GLUCOSE-91 UREA N-60* CREAT-2.7* SODIUM-142
POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-27 ANION GAP-13
[**2110-3-5**] 04:24PM CK(CPK)-45
[**2110-3-5**] 04:24PM cTropnT-0.10*
[**2110-3-5**] 06:50PM PT-15.5* PTT-38.1* INR(PT)-1.4*
[**2110-3-5**] 06:50PM WBC-14.9* RBC-3.30*# HGB-10.3*# HCT-30.2*#
MCV-92# MCH-31.2 MCHC-34.0 RDW-15.9*
[**2110-3-5**] 06:50PM NEUTS-86.3* BANDS-0 LYMPHS-7.3* MONOS-6.1
EOS-0.3 BASOS-0
[**2110-3-5**] 06:57PM HGB-10.4* calcHCT-31
[**2110-3-5**] 11:40PM PT-13.0 PTT-28.5 INR(PT)-1.1
[**2110-3-5**] 11:40PM PLT COUNT-41*
[**2110-3-5**] 11:40PM WBC-19.1* RBC-5.31# HGB-16.5# HCT-45.9#
MCV-87 MCH-31.1 MCHC-36.0* RDW-16.2*
[**2110-3-5**] 11:40PM NEUTS-80.7* LYMPHS-12.9* MONOS-5.8 EOS-0.2
BASOS-0.4
[**2110-3-5**] 11:40PM CALCIUM-6.6* PHOSPHATE-5.5* MAGNESIUM-2.1
[**2110-3-5**] 11:40PM CK-MB-NotDone cTropnT-0.08*
[**2110-3-5**] 11:40PM CK(CPK)-65
[**2110-3-5**] 11:40PM GLUCOSE-271* UREA N-56* CREAT-2.3* SODIUM-140
POTASSIUM-5.4* CHLORIDE-110* TOTAL CO2-21* ANION GAP-14
.
[**2110-3-9**] HIT Negative
.
[**2110-3-5**] GI BLEEDING STUDY
IMPRESSION:
No GI bleeding noted in the 100 minutes of the study.
.
[**2110-3-6**] CT ABD& PELVIS
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are small bilateral
pleural effusions and dependent atelectasis. Evaluation of the
solid organs is limited without IV contrast. Non-contrast view
of the liver, spleen, pancreas, adrenal glands are unremarkable.
There are a few gallstones but no CT evidence of acute
cholecystitis. Both kidneys are atrophic. Nasogastric tube
terminates in the stomach. There is no free intraperitoneal gas
or fluid. Soft tissue contusion is noted of the subcutaneous
tissues of the left flank. There are atherosclerotic
calcifications of the abdominal aorta and abdominal arteries.
Patient is status post endograft repair of an infrarenal
abdominal aortic aneurysm with graft material extending from
below the takeoff of the renal arteries into both common iliac
arteries. The AAA measures 5.8 AP x 5.5 TV x 7.2 CC cm in size.
No prior studies available to assess change. There is no
retroperitoneal hematoma. High density material within the right
colon may have been ingested but could represent intraluminal
blood given patient history.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is a Foley catheter
within the decompressed urinary bladder. There are a few
scattered colonic diverticula but no evidence of acute
diverticulitis. Prostate and seminal vesicles are unremarkable.
A left inguinal hernia contains fat. The appendix is visualized
and is normal in caliber and filled with gas.
BONE WINDOWS: Wedge compression deformity of L3 is age
indeterminate but sclerotic appearance suggests that it is
chronic.
IMPRESSION:
1. Contusion of the subcutaneous soft tissues of the left flank,
but no evidence of rib fracture or intra-abdominal injury.
2. High density intraluminal material within right colon may
have been ingested but could represent blood given patient
history.
3. Status post endograft repair of large infrarenal abdominal
aortic aneurysm which measures 5.8 cm maximal diameter.
4. Simple cholelithiasis.
5. Atrophic appearance of the kidneys.
6. Wedge deformity of L3 is age indeterminate but given
sclerotic appearance is probably chronic.
.
[**3-10**] EGD
Findings: Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
.
[**3-10**] Colonscopy
Edema and friability with contact bleeding were noted in the
splenic flexure at ~45cm. These findings are compatible with
ischemic colitis. Cold forceps biopsies were performed for
histology at the splenic flexure.
Impression: Edema and friability in the splenic flexure at ~45cm
compatible with ischemic colitis (biopsy)
Additional notes: No obvious source of bleeding identified and
no diverticuli seen. Splenic flexure edema likely represents
ischemic colitis. Consider vascular surgery eval
re:aorto-enteric herald bleed +/- capsule endoscopy.
.
[**2110-3-10**] Path
Procedure date Tissue received Report Date Diagnosed
by
[**2110-3-10**] [**2110-3-10**] [**2110-3-12**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/lo??????
DIAGNOSIS:
Splenic flexure mucosal biopsy:
1. Ulceration with granulation tissue.
2. No viral inclusions or tumor
.
[**2110-3-11**] Capsule Endoscopy Report
1. Normal exam up to 3 hr and 20 min of the study, likely when
the capsule was in the mid to distal small bowel.
2. Starting from 3 hr and 20 min until the end of the study at 8
hr, the lumen was filled with blood. The mucosa could not be
visualized due to the blood, and no active bleeding lesion could
be identified. It appeared that the capsule passed into the
colon, but it was unclear when it occurred.
Summary & recommendations:
Summary:
1. 1. Normal exam up to 3 hr and 20 min of the study, likely
when
the capsule was in the mid to distal small bowel.
2. Starting from 3 hr and 20 min until the end of the study at 8
hr, the lumen was filled with blood. The mucosa could not be
visualized due to the blood, and no active bleeding lesion could
be identified. It appeared that the capsule passed into the
colon, but it was unclear when it occurred.
.
[**2110-3-12**] TTE
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler. Normal IVC diameter
(<2.1cm) with <35% decrease during respiration (estimated RAP
(indeterminate).
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV
systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The right atrial pressure is indeterminate.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
There is no ventricular septal defect. The right ventricular
cavity is mildly dilated with borderline normal free wall
function. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Preserved LVEF. Pulmonary hypertension. Elevated
PCWP. These findings are suggestive of significant diastolic
dysfunction.
.
[**2110-3-14**] Meckel's Scan - negative
.
[**2110-3-15**] ABD US
FINDINGS: Patient is status post endograft repair of an
abdominal aortic aneurysm, and although evaluation is limited,
there appears to be wall- to- wall flow within the aortic lumen
without flow noted in the excluded thrombosed aneurysm.
Waveforms within the aorta are not reliable though the right and
left internal iliac veins demonstrate normal flow and waveforms.
Overall, the aneurysm sac measures up to approximately 5.6 cm in
maximal axial diameter, which is slightly smaller than on the CT
abdomen from [**2110-3-5**].
Normal renal arterial waveforms are demonstrated bilaterally
however interrogation of the superior mesenteric artery was
limited. The right kidney measures 9.5 cm. The left kidney
measures 9.9 cm. No hydronephrosis or renal stone is identified.
IMPRESSION:
Wall-to-wall flow within the aorta status post aneurysm repair
with slightly smaller size of aneurysmal sac compared to prior
CT torso. Normal renal arterial waveforms bilaterally.
.
SBFT [**3-18**]
FINDINGS: An initial scout image of the abdomen demonstrates the
outline of several aortic and iliac stents. Mild degenerative
disease of the lumbar spine and hip joints bilaterally is
incidentally noted.
Following the administration of oral thin barium overhead and
fluoroscopic spot images of the small bowel were obtained. These
images demonstrate a small-medium sized duodenal diverticulum at
the level of the third portion of the duodenum. A second
medium-sized diverticulum is noted of the proximal jejunum.
Otherwise, the small bowel is normal in caliber and contour. The
transit time to the colon is approximately three hours.
Evaluation of the terminal ileum demonstrates no focal
abnormality.
IMPRESSION: No evidence of small bowel masses or irregularities.
Incidentally noted duodenal and jejunal diverticula.
.
Brief Hospital Course:
# GI Bleed - Pt was admitted BRBPR and became hypotensive in the
ED. Initial HCT was 23. OG lavage was performed to rule out
upper GI source and was negative. The patient was given a total
of 8U PRBC and was transferred to the MICU. He underwent a
tagged RBC scan which was negative for source of bleed. GI,
general surgery and IR were consulted. Surgery felt no
indication for acute surgical intervention as the patient
stabalized with transfusion. He was given 1 bag plts on [**3-6**] for
plt count 30. He remained stable throughout his MICU stay and
was transferred to the floor.
The patient underwent EGD and colonscopy which were negative for
source of bleeding. He was found to have ischemic colities of
splenic flexure however this was thought to be secondary to his
bleed and hypotension, rather than the cause. Given history of
endovascular repair concern for aorto-enteric fistula prompted a
non-contrast CT which did not show a fistula, however did
demonstrate an existing infrarenal AAA and a high density
intraluminal material within right colon. Vascular surgery was
consulted for question of aorto-enteric fistula. The patient
underwent capsule endoscopy to evaluate for bleeding of small
bowel and was found to have active bleeding in distal small
bowel. Unable to localize well enough for possible surgical
intervention. Given distal bleed, very unlikely to be
aorto-enteric fisutla. Pt also had a negative adominal
ultrasound. Further evaluation for potential mass/diverticulum
in small bowel was negative, including Meckel's scan and small
bowel follow through. His HCT has remained stable, received
transfsion on [**3-14**] and [**3-16**] for slowly trending down HCT. Per GI
recommendations, the patient should undergo repeat capsule
endoscopy as an outpatient further evaluate small bowel. He will
continue on pantoprazole. His asprin was discontinued due to his
risk of bleed with low platelet counts.
.
# Thrombocytopenia - Pt has history of thrombocytopenia over
approx. 2 years of unclear etiology. On admission, initially
felt to be dilutional given large volume transfusions. He had a
plt count of 157 on arrival, followed by a decrease to 30
following multiple transfusions. The pt bumped appropriately
with plt transfusion. HIT negative. He was evalauted by
hematology for thrombocytopenia, felt possible the patient has
myelodysplastic syndrome as a cause for thrombocytopenia. He
will follow up in hematology clinic for further evaluation on
[**2110-3-28**].
.
# Demand Ischemia - Pt presented with chest pain and elevated
troponin in the setting of active GI bleed. No significant ECG
changes noted however the pt is v-paced. His cardiac enzymes
trending down appropriately (0.12 to 0.08). His aspirin should
be discontinued due to his history of thrombocytopenia and GI
bleed.
.
# Diastolic CHF - Pt underwent TTE on [**3-12**] and was found to have
significant diastolic dysfunction. EF >55%, moderate pulm HTN.
1+ AR, 1+MR, 2+ TR. He was restarted on his home dose lasix 20mg
daily once HD stabilized. He should continue on losartan 25mg
daily.
.
# CRI - baseline (2.4-2.8) Pt remained at his baseline
.
# DM - The patient was maintained on SSI and NPH. His home dose
of NPH, 32U QAM and 5U QPM was decreased to 27U QAM and
discontinued in the evening due to low fingersticks in the
morning. He should continue on NPH with titration of dose as
needed.
.
# COPD - The patient was recently treated for exacerbation and
PNA. Per records he finished a course of azithromycin. His
prednisone was discontinued as it was felt it may contribute to
GI bleeding. He was briefly intubated in the MICU for airway
protection but quickly extubated and weaned off O2. He was
continued on nebulizers as needed.
.
# Hyperlipidemia - continue statin
.
# Code - Full code - discussed with patient on [**2110-3-14**]
Medications on Admission:
insulin NPH 32 qAM/5 qPM
SSI
ambien 5mg prn
ambien cr 6.25mg qhs
tylenol 1000mg prn
mvi
asa 325mg qdaily
colace 100mg qdaily
lidodern 5% patch qdaily
douneb qdaily
mucinex 600mg [**Hospital1 **]
flonase 50mcg 2 sprays [**Hospital1 **]
bismuth subsalicylate 262mg prn
simvastatin qdaily
amlodipine 2.5mg qdaily
omeprazole
simethacone q cap qdaily
lactulose 20g qdaily
cetylpuridinium lozenges
losartan 25mg qdaily
metacmucil
lasix 20mg qdaily
calcium 500mg qdaily
prednisone taper (currently 10mg)
recently completed azithromycin course
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Seven (27) Subcutaneous QAM.
11. Insulin Lispro 100 unit/mL Cartridge Sig: Per sliding scale
Subcutaneous four times a day: Use per sliding scale.
12. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
13. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a
day.
14. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Nasal twice a day.
15. Metamucil Powder Sig: One (1) PO once a day as needed
for constipation.
16. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day.
17. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
18. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for PRN constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
1. Lower GI bleed
2. Thrombocytopenia
3. Demand Ischemia
4. Diabetes Mellitus
Secondary:
1. Chronic Obstructive Pulmonary Disesae
2. Hypertension
3. Coronary Artery Disease
Discharge Condition:
Clinically improved, discharged to [**Hospital1 1501**].
Discharge Instructions:
You were admitted with bleeding from your gastrointestinal tract
and required multiple blood transfusion because of your large
amount of bleeding. Your EGD and colonscopy were negative for
bleeding. Your small bowel capsule endoscopy found bleeding from
your small bowel but this was unable to be further localized by
additional testing. Your blood counts have been stable and there
is no signs of continued bleeding. You will follow up in
[**Hospital **] clinic to repeat your capsule endoscopy.
.
You were also found to have a low platelet level. Your
medication aspirin has been stopped as it may increase your risk
of bleeding. You are scheduled to follow up in [**Hospital **] Clinic
for further workup.
.
Your medication NPH has been decreased to 27Units in the morning
and no NPH in the evening as you have had low night time blood
sugars. Please continue to monitor your blood sugar and follow
up with Dr. [**First Name (STitle) **] for further management of your diabetes.
.
Please continue to take the remainder of your medications as
directed.
.
Please return if you notice more bleeding in your stools. You
should also return or call your primary care physician if you
experience chest pain, shortness of breath or fevers.
Followup Instructions:
Please maintain your scheduled follow up listed below:
.
You should follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 1-2 weeks after your
discharge from rehab. Please call ([**Telephone/Fax (1) 72966**] to schedule an
appointment.
.
Please follow up with Gastroenterolgy as scheduled. You are
scheduled to follow up with Dr. [**First Name4 (NamePattern1) 2795**] [**Last Name (NamePattern1) 908**] on [**2110-3-26**] at
3:00pm. You should have a capsule endoscopy to evaluate your
small bowel for evidence of bleeding.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2110-3-26**] 3:00
.
Please follow up with Hematology as scheduled for further workup
of your low platelet counts.
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 17488**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2110-3-28**] 4:00
Provider: [**Name10 (NameIs) **] HEMATOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2110-3-28**] 4:00
|
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"411.89",
"496",
"V45.01",
"584.9",
"287.5",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"99.04",
"96.04",
"99.05",
"45.13",
"45.25"
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icd9pcs
|
[
[
[]
]
] |
17593, 17665
|
11608, 15442
|
230, 247
|
17891, 17950
|
2050, 11585
|
19233, 20300
|
1532, 1550
|
16029, 17570
|
17686, 17870
|
15468, 16006
|
17974, 19210
|
1565, 2031
|
182, 192
|
275, 1296
|
1318, 1431
|
1447, 1516
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,941
| 104,724
|
34101
|
Discharge summary
|
report
|
Admission Date: [**2148-5-5**] Discharge Date: [**2148-5-14**]
Date of Birth: [**2085-7-3**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2006**]
Chief Complaint:
Right Femur Fracture
Major Surgical or Invasive Procedure:
Femur repair
Colonic decompression
History of Present Illness:
62 yo F with severe mental retardation, afib, and Hodgkin's
disease in remission. She lives in a monitored home for the
developmentally and physically disabled. She is wheelchair-bound
and normally moved by a [**Doctor Last Name 2598**] lift. It is unclear what the
etiology of her injury is. The patient is not able to describe
what happened, and the facility reports no particular incident.
They noted on [**5-3**] that she was having right leg and knee pain.
She had x-rays which showed a right subtrochanteric right
proximal femur fracture.
.
In the ED, initial vs were:97.8 79 132/61 16 97%. On exam
patient is AO to baseline per report. UA with >182 WBC and
moderate bacteria. Urine culture obtained. Patient was given
lorazepam in order to take films. She is ordered for
ciprofloxacin for UTI. Ortho consult called. Admitted to
medicine. Vitals on Transfer: 97.5, 68, 14, 102/55, 94 RA.
.
On the floor, she is alert and conversant. She is pleasant, and
in no acute distress. She does complain of right knee pain, but
mostly when prompted.
Past Medical History:
Hodgkins Lymphoma, in remission since [**2144**]
Atrial fibrillation
Hypertension
Hypothyroid
Osteoporosis
Chronic ileus
Temporary colostomy in [**2128**] for SBO
VRE UTIs
Pericardial effusion s/p window
GERD
Social History:
Lives at [**Location 69885**] Nursing Center. She is non-ambulatory and in
a wheelchair at baseline, and incontinent of bowels and bladder.
She is able to feed herself independently and performed some
ADLs. No history of smoking, alcohol or drugs.
Family History:
Father - CAD, [**Name2 (NI) 499**] and prostate cancer, d 80s
Mother - CVA
M Aunt - ovarian and breast cancer
MGM - liver cancer
Physical Exam:
Vitals: 98.0 104/62 60 20
General: Alert, conversant and able to answer yes/no questions,
but generally agreeable, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended and tympanitic, hypoactive
bowel sounds
Ext: severe pitting edema of bilateral legs and feet, no pain on
palpation of hip or knee, unable to assess range of motion due
to contractures
Skin: warm and dry
DISCHARGE EXAM:
99.1, 138/69, 72, 20% RA
General: Alert, conversant and able to answer yes/no questions,
no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: bibasilar crackles stable from prior exams, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended and tympanitic but reduced
in size compared to several days ago, active bowel sounds
Ext: severe pitting edema of bilateral legs and feet, stable;
thigh incision healing well with no erythema or drainage
Pertinent Results:
ADMISSION LABS:
[**2148-5-5**] 12:40AM BLOOD WBC-5.7 RBC-3.36* Hgb-10.8* Hct-34.5*
MCV-103*# MCH-32.1* MCHC-31.3# RDW-12.9 Plt Ct-188
[**2148-5-5**] 12:40AM BLOOD Neuts-76.1* Lymphs-14.5* Monos-5.2
Eos-3.5 Baso-0.7
[**2148-5-5**] 12:40AM BLOOD PT-12.7* PTT-30.3 INR(PT)-1.2*
[**2148-5-6**] 05:37AM BLOOD ESR-55*
[**2148-5-5**] 12:40AM BLOOD Glucose-129* UreaN-20 Creat-0.6 Na-140
K-4.4 Cl-107 HCO3-28 AnGap-9
[**2148-5-5**] 12:40AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.2
[**2148-5-8**] 05:30AM BLOOD VitB12-369
[**2148-5-6**] 05:37AM BLOOD CRP-76.2*
DISCHARGE LABS:
[**2148-5-14**] 06:16AM BLOOD WBC-4.8 RBC-3.13* Hgb-9.7* Hct-31.1*
MCV-100* MCH-31.2 MCHC-31.3 RDW-17.5* Plt Ct-167
[**2148-5-14**] 06:16AM BLOOD Glucose-113* UreaN-14 Creat-0.3* Na-143
K-3.7 Cl-109* HCO3-30 AnGap-8
[**2148-5-14**] 06:16AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1
[**2148-5-8**] 05:30AM BLOOD VitB12-369
[**2148-5-9**] 10:40AM BLOOD Lactate-1.5
[**2148-5-9**] 10:40AM BLOOD freeCa-1.15
IMAGING:
CT ABD/Pelv/Thighs Non-Con:
.
FEMUR AP/LAT: Displaced and overriding right femoral
subtrochanteric fracture
.
PELVIS AP: Right-sided subtrochanteric femoral fracture
.
CT LE: Comminuted, markedly angulated and displaced fracture of
the
subtrochanteric femur with involvement of the lesser trochanter.
.
KUB: Chronic, marked colonic dilatation slightly increased from
[**2146-8-9**]. No free air is detected.
.
FEMUR AP/LAT: Multiple views of the right hip and proximal
femur. Status post ORIF of the right proximal femur including
the femoral neck with hooks, plate and screws. The hardware
appears intact. Improved alignment of the comminuted fracture.
No dislocation. Total intraoperative fluoroscopic imaging time
90.8 seconds. Please see operative report for further details.
.
CT A/P: IMPRESSION:
1. In this patient status post right femur fixation surgery,
there are
expected surgical changes and moderate soft tissue edema. No
large hematoma
in the surgical site or retroperitoneal bleed to explain the
patient's
symptoms.
2. Diffuse dilation of the [**Month/Day/Year 499**] measuring up to 16 cm, likely
is ileus.
Recommend correlation with clinical symptoms because there is an
increased
risk of perforation.
.
ABD SUPINE/ERECT: In comparison with the CT scout of [**5-10**],
there is continued and possibly even more prominent extreme
dilatation of a gas-filled [**Date Range 499**]. Although this probably
represents severe post-operative ileus with colonic dilatation
as suggested in the clinical history, the possibility of a
distal obstruction cannot be excluded radiographically.
.
KUB [**2148-5-12**]: In comparison with the study of [**5-11**], there is
again extreme
distention of the visualized loops of bowel. This most likely
represents a
profound adynamic ileus.
.
KUB [**2148-5-12**]: Chronic, marked colonic dilatation is unchanged from
the
preceding radiograph and also seen as far back as CT of [**2146-8-9**].
Brief Hospital Course:
62 yo F with severe mental retardation, afib, and history of
Hodgkin's, admitted with a displaced right proximal femur
fracture.
# Acute Blood Loss Anemia/Hypotension: On post-op day 2 pt was
found to have BP 80/50 on 8 AM vitals with HR in 120s. On
recheck SBP was in 70s. Previous vitals overnight had been
stable with SBP in 120s and HR 70s. Other notable values at the
time were low UOP (220 since midnight) and Hct drop from 31.4 to
26.8 (verified by recheck). EKG was rapid and regular with poor
baseline - either sinus tach or aflutter. No ischemia. Pt was
asymptomatic but had lip pallor. 1L NS was hung wide open and
ortho was asked to evaluate post-op site for internal bleeding.
Ortho did not feel there was high concern for bleeding into
thigh. No other e/o bleeding, such as bloody stool or flank
ecchymosis. BP improved to SBP 90s with fluids but PIV
infiltrated after only a couple hundred mL NS and no other
access could be obtained. Pressures remained in 90s and HR had
increased to 140s so transfer to MICU was initiated. Pt remained
asymptomatic during this period and was alert and talkative. In
the MICU, the patient required 3 units of pRBC's and she had a
non-contrast CT scan of her abdomen and pelvis which extended
into her thighs which did not show any active bleed. Following
her transfusions her crits remained stable and she was called
out to the floor for further management. Her Hct trended up
throughout the rest of admission. There was no evidence of
bleeding from GI tract.
# Right femur fracture s/p ORIF: Found to have right leg pain
with xrays showing a displaced proximal femur fracture. No
mechanism of injury identified by the nursing home, raising
concerns for a pathological fracture, especially in light of
history of Hodgkin's lymphoma. Ortho consulted in the ED and
recommended CT scan then surgery. She was taken for repair on
[**2148-5-7**] which was complicated only by 500mL blood loss
necessitating 2 unit PRBC transfusion for Hct drop from 29 to 24
post-op. Hct subsequently stabilized. Pain well-controlled with
tylenol and pt resting comfortably and denying pain. Biopsy was
taken at the time of surgery to evaluate for malignancy but was
pending at the time of discharge. Pt started on lovenox 40mg
subcutaneous qHS after surgery and should continue this for 1
month. She was started on calcium and vitamin D and is
recommended to start a bisphosphonate after at least month from
surgery.
# UTI: Found to have UTI on admission with pyuria and moderate
bacteria on u/a. Her similar presentation in [**2144**] grew an E coli
sensitive to bactrim, but prior cultures have shown VRE. Started
on bactrim for 7 days. cultures subsequently grew pansensitive
E. coli, including to bactrim. Also grew 10-100K Strep bovis.
Following her hypotension as above, she was broadened to
vanc/cefepime but was switched back to ceftriaxone prior to
call-out to the floor. On floor, CTX was continued for duration
of UTI course, last day [**2148-5-13**].
# S. bovis: organism seen most commonly in pathologic states in
[**Month/Day/Year 499**], such as malignancy or fistula per GI (consulting) and ID
(curbside) but can also be part of normal colonic flora. Pt had
CT A/P which showed no masses that would be concerning for
malignancy. It also showed no evidence of inflammation/conduit
to bladder that would be concerning for fistula. While pt had
bleeding leading to MICU, she never had rectal bleeding that
would be concerning for colonic malignancy and she had a more
likely source of bleeding, which was the recent thigh operation
in which she lost 700cc of blood intraop. suspect that
pathologic state of chronic ileus could be what had led to s.
bovis colonization. If family concerned or new sx develop, can
pursue colonoscopy as outpatient, however, this was not
indicated based on the existing data.
# Atrial Fibrillation: Thought to be related to pericardial and
pleural effusion that occurred in the setting of chemotherapy,
requiring a pericardial window. Was in normal sinus with good
control. Continued amiodarone 100mg [**Hospital1 **] and continued metoprolol
100mg daily.
# Chronic Ileus: This has been an ongoing problem all of her
life, and in the past required a temporary colostomy. She was
controlled on an aggressive bowel regimen at the nursing home,
often turned side to side to relief the gas, and occasionally
rectal tube has been needed. Continued senna, miralax, and
bisacodyl PR in house and added docusate. Having regular BM in
house but abdomen markedly distended (denied pain) so KUB
ordered after surgery in PACU to eval but was mostly unchanged
from prior imaging and shows no free air. CT abdomen and pelvis
showed severely dilated loops of bowel to as large as 16cm yet
patient was without abdominal pain, fevers, white count, or HD
compromise to suggest colitis or megacolon. Patient having bowel
movements. GI performed a colonic decompression by sigmoidoscopy
and temporary placement of rectal tube with frequent
repositioning to help relieve gas. Rectal tube removed after
about 24 hours because pt was stooling around tube (?blockage in
tube), and she continued having BM after removal of tube. Her
abdominal distension improved and she had no abd pain so she was
discharged on a generous bowel regimen. Per GI she can continue
use of rectal prn with frequent positioning at the nursing home
if needed, which was her regimen prior to admission as well.
# Mental Retardation: Appeared at her baseline per her family.
Continued 1:1 sitter from nursing home.
TRANSITIONAL ISSUES:
1. follow up bone biopsy
2. rectal tube prn ileus
3. f/u with ortho in 2 weeks
4. lovenox for one month
5. start bisphosphonate therapy after 1 month post-surgery
Medications on Admission:
Alprazolam 0.25mg TID
Amiodarone 100mg [**Hospital1 **]
Cholecalciferol 1000 units daily
Levothyroxine 75mcg daily
Magnesium 400mg [**Hospital1 **]
Metoprolol 100mg daily
Omeprazole 20mg daily
Potassium chloride ER 20meq, 2 tabs [**Hospital1 **]
Senna 2 tabs qHS
Miralax 17g [**Hospital1 **]
Bisacodyl PR daily
Discharge Medications:
1. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO twice a day.
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO BID (2 times a day).
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
12. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous QPM (once a day (in the evening)).
Disp:*30 syringes* Refills:*0*
13. amiodarone 100 mg Tablet Sig: One (1) Tablet PO twice a day.
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day for 7 days: take standing for 7 days, then OK to use
TID:PRN pain.
Disp:*120 Tablet(s)* Refills:*0*
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
16. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 69885**] Center
Discharge Diagnosis:
Primary Diagnosis:
Right subtrochanteric displaced proximal femur fracture
Urinary tract infection
Chronic ileus
Secondary Diagnoses:
osteoporosis
Hodgkins Lymphoma
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital because you had a fracture in your
femur. You had surgical repair of your femur and a biopsy was
taken to help identify the cause of the fracture. You received a
blood transfusion after surgery due to blood loss. You were
found to have a urinary tract infection while you were here so
you were treated with antibiotics for this. Your abdomen also
became very distended with gas and stool, so a
gastroenterologist was consulted and they performed
decompression of your [**Last Name (un) 499**]. Your distension improved so you
were sent home. Your blood counts were improved at the time of
discharge. You were also found to have low Vitamin B12 so you
were started on a supplement for this.
The following changes were made to your medications:
STARTED:
calcium carbonate 200 mg calcium (500 mg) Tablet twice a day
enoxaparin 40 mg/0.4 mL Syringe One (1) syringe Subcutaneous
every night for one month (last dose [**2148-6-7**])
acetaminophen 500 mg Tablet Two (2) Tablets three times a day
for 7 days, then as needed for pain after that
docusate sodium 100 mg Capsule One (1) Capsule 2 times a day
cyanocobalamin (vitamin B-12) 250 mcg Tablet One (1) Tablet
DAILY
Followup Instructions:
Follow up with your primary care doctor in one week.
**Consider starting bisphosphonate therapy at least month after
fracture repair heals.
Department: ORTHOPEDICS
When: THURSDAY [**2148-5-23**] at 2:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2148-5-23**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
GASTROENTEROLOGY
[**2148-6-19**]
01:30p
[**First Name9 (NamePattern2) 2606**] [**Doctor Last Name 2607**]
RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
|
[
"041.49",
"V85.39",
"244.9",
"733.96",
"278.00",
"E928.9",
"285.1",
"595.9",
"560.1",
"427.89",
"780.62",
"041.09",
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"V46.3",
"458.29",
"201.90",
"318.1",
"427.31",
"284.19",
"530.81",
"V49.86",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.09",
"79.35",
"45.23",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
13942, 14002
|
6153, 11697
|
323, 359
|
14212, 14259
|
3214, 3214
|
15605, 16534
|
1950, 2081
|
12245, 13919
|
14023, 14023
|
11909, 12222
|
14387, 15582
|
3776, 6130
|
2096, 2650
|
14158, 14191
|
2666, 3195
|
11718, 11883
|
263, 285
|
387, 1436
|
3230, 3760
|
14042, 14137
|
14274, 14363
|
1458, 1668
|
1684, 1934
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,799
| 107,198
|
30417
|
Discharge summary
|
report
|
Admission Date: [**2133-3-25**] Discharge Date: [**2133-4-3**]
Date of Birth: [**2064-1-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
[**2133-3-26**] Cardiac Catheterization
[**2133-3-27**] Six Vessel Coronary Artery Bypass Grafting(left internal
mammary to ramus, vein grafts to left anterior descending, first
obtuse marginal, second obtuse marginal, acute marginal and
right coronary artery)
History of Present Illness:
69 year old male without medical follow up since childhood
presented to new PCP with new complaint of palpitations on
[**2133-3-12**] - no CP, no SOB. At that time exam was notable for HTN
(SBP to 151), tachycardia (104) and hepatomegaly of uncertain
etiology - lungs clear, no JVD, no peripheral edema. EKG on [**3-14**]
showed sinus at 90 with T-wave inversions in the inferior leads,
possible Q-s in the anteroseptal leads, and LVH with ST
elevations in V1-V5. No delta waves or abnormal intervals. PCP
started ASA and Metoprolol which eliminated the patient's
symptoms. Saw patient again on [**3-14**] and the patient was
hypertensive so the Metoprolol was increased to 100 [**Hospital1 **] and
Simvastatin was added for elevated cholesterol. Patient went for
a stress test on [**3-25**] and was found to have a large fixed defect
in the LAD territory. In ED patient was given ASA and metoprolol
Patient admitted for ROMI and evaluation.
Past Medical History:
Hypertension
Hyperlipidemia
Hepatomegaly
Social History:
Social history is significant for remote tobacco use. There is
no history of alcohol abuse, though the patient reports a couple
of beers per week.
Family History:
There is no clear family history of premature coronary artery
disease or sudden death. The patient reports that his father
died of the effects of alcohol abuse on the heart at age 65.
Physical Exam:
Blood pressure was 149/88 mm Hg while seated. Pulse was 84
beats/min and regular, respiratory rate was 20 breaths/min
saturating at 98% on RA.
Generally the patient was thin and and well groomed. The patient
was oriented to person, place and time. The patient's mood and
affect were not inappropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 8 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Palpation of the heart revealed a laterally displaced PMI. There
were no thrills, lifts or palpable S3 or S4. The heart sounds
revealed a 2-3/6 diastolic murmur at the apex that was audible
in the axilla. There were no rubs, clicks or gallops.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
Pulses were 2+ distally.
Pertinent Results:
[**2133-3-26**] Cardiac Catheterization:
RIGHT ATRIUM {a/v/m} 16/13/12
RIGHT VENTRICLE {s/ed} 61/12
PULMONARY ARTERY {s/d/m} 61/28/40
PULMONARY WEDGE {a/v/m} 33/34/35
LEFT VENTRICLE {s/ed} 157/39
AORTA {s/d/m} 157/86/115
CARD. OP/IND FICK {l/mn/m2} 3.03
CARD. OP/IND OTHER {l/mn/m2} 1.82
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 2720
PULMONARY VASC. RESISTANCE 132
1. Coronary angiography of this right dominant system revealed
sever
three vessel coronary artery disease with left main involvment.
The LMCA
had a mid to distal 80% eccentric stenosis. The LAD was heavily
calcified with severe dffuse disease of the first and second
diagonal
branches. The mid LAD is occluded and fills via left to left and
right
to left collaterals. The LCX is also heavily calcified with 70%
proximal
disease, diffuse disease of major OM2 branch and 50% stenosis of
the mid
AV groove CX supplying the OM3 and large LPL branch. The LCx
also
provides collaterals to the large distal RCA system. The RCA has
sever
diffuse disease with a proximal to mid total occlusion.
Competitive flow
in the distal RCA with no antegrade filling of the R-PDA and
RPL, with
collateral filling of the LAD. 2. Resting hemodyanmics revealed
severely elevated right and left sided filling pressures with
RVEDP of 15mmHg and LVEDP of 39 mmHg. There was severe pulmonary
artery systolic hypertension with PASP of 58mmHg. The cardiac
index was moderately reduced at 1.82 l/min/m2. There was
moderate systemic arterial systolic hypertension with SBP of
157mmHg. 3. Left ventriculography was deferred due to severely
elevated LVEDP. 4. Successful placement of a 7.5F 40cc IABP
under fluroscopy with good systolic unloading and diastolic
augmentation.
[**2133-3-26**] Transthoracic ECHO:
Left Atrium - Long Axis Dimension: 2.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.6 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.9 cm
Left Ventricle - Fractional Shortening: 0.30 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 20% to 30% (nl >=55%)
Aorta - Valve Level: *4.3 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aorta - Arch: 2.3 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.63
Mitral Valve - E Wave Deceleration Time: 154 msec
TR Gradient (+ RA = PASP): *28 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline
dilated LV cavity size. Severely depressed LVEF. TDI E/e' >15,
suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Focal apical hypokinesis of RV free wall.
AORTA: Moderately dilated aortic sinus. Mildly dilated ascending
aorta. Normal aortic arch diameter. No 2D or Doppler evidence of
distal arch coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or
vegetations on aortic valve. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Mild thickening of mitral valve chordae.
Calcified tips of papillary muscles. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve
supporting structures. No TS. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: Small pericardial effusion. Effusion
circumferential. No
echocardiographic signs of tamponade.
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is severely depressed (ejection fraction 20-30 percent)
secondary to severe hypokinesis of all but the basal segments of
the left ventricle. There is extensive apical akinesis with
spontaneous echocardiographic contrast indicating stasis of flow
at the apex. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. There is focal hypokinesis of the
apical free wall of the right ventricle, but overall right
ventricular contractile function appears well-preserved. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. No masses or vegetations are seen on the
aortic valve. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is a small
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of
tamponade.
CHEST (PA & LAT) [**2133-4-1**] 6:39 PM
CHEST (PA & LAT)
Reason: evaluate for hemothorax
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with HTN, h/o palpitations, p/w abnormal EKG.
REASON FOR THIS EXAMINATION:
evaluate for hemothorax
HISTORY: 69-year-old male with hypertension, history of
palpitations and abnormal EKG. Evaluate for hemothorax.
Comparison is made to prior radiograph dated [**3-31**] and [**3-28**], [**2132**].
PA AND LATERAL CHEST RADIOGRAPHS
FINDINGS: Stable appearance to left pleural effusions with
slight decrease in right effusion is noted. Probable left lower
lobe compression atelectasis is stable. The remaining lung
appears clear. No change to CABG changes and cardiomegaly. Mild
calcifications are again noted within the thoracic aorta. No
evidence of pneumothorax or pulmonary edema.
IMPRESSION:
1. Stable left effusion with slight decrease in right effusion,
otherwise unchanged.
Please note evaluation for hemothorax can be obtained with
dedicated chest CT examination.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
[**2133-4-1**] 10:15AM 9.1 3.74* 11.3* 32.3* 86 30.1 34.8 14.3
278
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2133-4-3**] 06:30AM 30.4* 3.2
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2133-4-2**] 06:35AM 31.2*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2133-3-26**] 12:45PM 66.7 28.3 3.6 0.3 1.0
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2133-4-3**] 06:30AM 30.4* 3.2*
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2133-3-29**] 03:13AM 585*#
Source: Line-arterial
HEMOLYTIC WORKUP Ret Aut
[**2133-3-29**] 03:13AM 1.4
Source: Line-arterial
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2133-4-2**] 06:35AM 104 36* 1.5* 133 4.3 97 29 11
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 20003**] in for MI based on enzymes. Given his renal
insufficiency, he was pretreated with hydration and Mucomyst
prior to catheterization. Patient was loaded with Clopidogrel
and Heparin. Cardiac catheterization demonstrated 80% left main
lesion and severe three vessel coronary artery disease. Based
on his critical anatomy, an intra-aortic balloon pump was placed
and patient was transferred to Cardiac surgery service under Dr.
[**Last Name (STitle) 914**] for surgical revascularization. In preperation for
surgery, echocardiogram was performed which showed severely
depressed left ventricular function, estimated LVEF of 20-30%.
The right ventricle had focal apical hypokinesis of the free
wall but overall right ventricular contractile function appears
well-preserved. There was only mild aortic insufficiency and
trivial mitral regurgitation. He otherwise remained pain free on
intravenous therapy and was cleared for surgery.
On [**3-27**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting. For surgical details, please see seperate dictated
operative note. Following the operation, he was brought to the
CSRU for invasive monitoring. On postoperative day one, patient
awoke neurologically intact and was extubated without incident.
He maintained stable hemodynamics and weaned from inotropic
support without difficulty. His CSRU course was notable for
paroxsymal atrial fibrillation which was treated with
Amiodarone, beta blockade and anticoagulation. ACE inhibitors
were not utilized postoperatively for hypertension given his
renal insufficiency. His creatinine peaked to 1.9 on
postoperative day three. His renal function otherwise remained
relatively stable throughout his hospital stay. He eventually
transferred to the SDU for further care and recovery. He
continued to experience paroxsymal atrial fibrillation. Just
after several doses of Warfarin, his INR increased as high as
6.9. Warfarin was therefore held for several days and Vitamin K
was administered. After several days, his prothrombin time
gradually improved. He otherwise continued to make clinical
improvements and was eventually cleared for discharge on
postoperative day 7. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] will monitor his
Warfarin as an outpatient. His goal INR should be around 2.0 for
atrial fibrillation. His INR in discharge is 3.2 and he will
receive 1 mg of coumadin today.
Medications on Admission:
Metoprolol 100 [**Hospital1 **]
Simvastatin ? dose.
ASA 325 qd
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
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:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
11. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take
I mg PO on sat. and Sun., then take as directed for INR of [**1-30**].5
.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG, Recent Myocardial
Infarction, Systolic Congestive Heart Failure, Postop Atrial
Fibrillation, Hypertension, Hyperlipidemia, Renal Insufficiency
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions. Please take Warfarin as directed. Dr.
[**Last Name (STitle) **] will monitor your Warfarin as an outpatient. Warfarin
should be adjusted for goal INR around 2.0.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2-3 weeks, call for appt
Dr. [**Last Name (STitle) 914**] 4-5 weeks, call for appt
Dr. [**Last Name (STitle) **] in [**1-31**] weeks, call for appt
Completed by:[**2133-4-3**]
|
[
"585.9",
"410.71",
"403.90",
"428.20",
"427.31",
"272.4",
"412",
"428.0",
"789.1",
"414.01",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"36.15",
"37.61",
"88.56",
"37.23",
"39.61",
"97.44"
] |
icd9pcs
|
[
[
[]
]
] |
14693, 14751
|
10689, 13170
|
331, 594
|
14974, 14981
|
3424, 8662
|
15462, 15670
|
1809, 1994
|
13283, 14670
|
8699, 8761
|
14772, 14953
|
13196, 13260
|
15005, 15439
|
2009, 3405
|
279, 293
|
8790, 10666
|
622, 1565
|
1587, 1629
|
1645, 1793
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,108
| 126,744
|
12606
|
Discharge summary
|
report
|
Admission Date: [**2138-4-4**] Discharge Date: [**2138-4-9**]
Date of Birth: [**2070-8-31**] Sex: M
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] [**Known lastname 38975**] is a 67 yo male with severe COPD, s/p recent
hospitalization for COPD exacerbation and atypical pneumonia in
[**Month (only) 547**], cancer of the layrnx who presents with shortness of
breath and productive cough. The patient finished his prednisone
taper approximately 1 week ago. His wife reports that his
breathing worsened as the steroids were tapered but that it has
been much worse since the steroids were off 1 week ago. When
his breathing is at it's best, he is able to do some household
chores and walk across the room. However, for the past few days
he has not been able to get out of his chair. He has a chronic
cough with white/[**Doctor Last Name 352**] sputum at baseline, but the sputum turned
green approximately 3 days ago. He was started on azithromycin
and levofloxacin approximately 2 days ago without improvement in
his symtoms. He denies fevers and rigors, but reports feeling
chilled and sweaty. He does not feel like he has a cold or flu.
He reports increased wheezing. His wife reports poor PO intake
and increased confusion, which is typical of his COPD
exacerbation. Patient's steroids were increased around [**3-14**] and
then quickly tapered. Of note, pt takes Bactrim for PJP PPX
while on steroids.
In the ED, initial vs were: T 98.2 HR 95 BP 151/67 RR 28 O2SAT:
90% 4L. He was tachypneic, wheezy on exam and with poor
airflow. CXR was negative for infiltrates. His EKG was
unchanged. He was hypoxic to 88% on 4L so was placed on
non-invasive ventilation with improvemetn in O2 sats to 94-95%.
Patient was given Ipratropium Bromide & Albuterol Nebs,
MethylPREDNISolone Sodium Succ 125mg IV x1, and Levofloxacin
750mg IV x1. VS prior to transfer were AF 92 133/53 25 95%
CPAP: FiO2 .35 Peep 8.
In the ICU, patient is no longer on non-invasive ventillation.
Past Medical History:
- COPD, on 4L home O2, followed by Dr. [**Last Name (STitle) **]. Pt uses CPAP at
night and has done so for a long time possibly for OSA vs night
time ventilatory support for COPD.
- Newly diagnosed T1 larynx cancer
- [**Doctor Last Name **] 8 prostate adenocarcinoma
- Depression
- H/o pyloric stenosis
- Memory loss: no formal diagnosis of dementia
Social History:
Patient lives with his wife. [**Name (NI) **] 2 grown children. Reports 4
pack per day times 35 years. Quit in [**2112**]. Served in [**Country 3992**];
history of [**Doctor Last Name 360**] [**Location (un) 2452**] exposure. No current alcohol
consumption. Denies any other illicit drug use.
Family History:
Brother died of emphysema, also was a smoker
Physical Exam:
General: Alert, pursed-lip breathing, but not tachypneic.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, dry MM, oropharynx
clear
Neck: supple, JVP 5cm, no LAD
Lungs: Poor airflow, no wheezes, rales, rhonchi
CV: Distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: + epigastric scar,soft, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Rectal: nl tone, guiaic + stool.
Ext: warm, well perfused, 2+ radial, DP & PT pulses, no
clubbing, cyanosis or edema
Neuro: A&Ox2 (person & place only), strenght [**3-26**] in UE & LE
bilat, sensation grossly intact.
Pertinent Results:
[**2138-4-4**] 06:00AM WBC-7.3 RBC-3.99* HGB-10.9* HCT-37.7* MCV-95
MCH-27.2 MCHC-28.8* RDW-15.1
[**2138-4-4**] 06:00AM NEUTS-93.7* LYMPHS-4.8* MONOS-1.2* EOS-0.3
BASOS-0.1
[**2138-4-4**] 06:00AM PLT COUNT-135*
[**2138-4-4**] 06:00AM PT-10.9 PTT-26.7 INR(PT)-0.9
[**2138-4-4**] 06:00AM calTIBC-295 VIT B12-272 FOLATE-13.8
FERRITIN-372 TRF-227
[**2138-4-4**] 06:00AM IRON-54
[**2138-4-4**] 06:00AM GLUCOSE-201* UREA N-21* CREAT-0.6 SODIUM-147*
POTASSIUM-5.1 CHLORIDE-96 TOTAL CO2-47* ANION GAP-9
[**2138-4-4**] 06:04AM LACTATE-2.7*
[**2138-4-4**] 06:19AM TYPE-ART PO2-162* PCO2-67* PH-7.36 TOTAL
CO2-39* BASE XS-9 COMMENTS-GREEN TOP
[**2138-4-4**] 01:18PM LACTATE-2.4*
[**2138-4-4**] 03:04PM FIBRINOGE-763*
[**2138-4-4**] 03:21PM LACTATE-1.3
[**2138-4-4**] 03:21PM TYPE-ART PO2-77* PCO2-82* PH-7.36 TOTAL
CO2-48* BASE XS-16
[**2138-4-4**] 07:46PM LACTATE-0.8
[**2138-4-4**] 07:46PM TYPE-ART PO2-59* PCO2-79* PH-7.38 TOTAL
CO2-49* BASE XS-16
ECHO [**4-4**]: The left atrium is mildly dilated. The right atrium
is moderately dilated. A right-to-left shunt across the
interatrial septum is seen during Valsalva maneuver release
(bubble study). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: right-to-left shunt at atrial level (note that
neither the size, nor the predominant directionality, nor the
anatomic classification of the atrail shunt can be determined on
thre basis of a positive bubble study; however, this most likely
represents either a patent foramen ovale or a small secundum
type atrial septal defect)
CXR [**4-4**]: IMPRESSION: No evidence of pneumonia.
CT chest [**4-4**] IMPRESSION:
1. Resolution of left lower lobe pulmonary nodule, consistent
with infectious or inflammatory etiology.
2. New patchy consolidations involving the left upper lobe and
lingula,
consistent with bronchopneumonia.
3. Severe emphysema and diffuse bronchial wall thickening.
4. Right renal cystic structure, incompletely characterized. If
clinically
warranted, ultrasound on a non-emergent basis could be
considered.
Brief Hospital Course:
67 y/o male with a PMHx significant for severe COPD on 4L of
home oxygen, who presented with worsening shortness of breath
and productive cough.
# Dyspnea: Likely related to COPD exacerbation. He has Gold
stage IV COPD. There was a question of an underlying pneumonia
based on CT findings; however, he was not noted to have fevers
or a leukocytosis. He was placed on BiPAP overnight and
tolerated this well. He was transitioned back to NC on th
emorning following admission. Of note, echo showed evidence of
R-to-L shunt, which could be contributing to hypoxemia. He was
placed on ipratropium and albuterol nevs. His dose of advair was
increased. He was also started on prednisone. Given concern for
possible infection, cefepime was started. He was also continued
on his previously-started 5-day course of azithromycin. he
completed the 5-day course of azithro and cefepime was
discontinued on [**4-6**] as there was low suspicion for infection.
Pulmonary recommended the following:
- Consider switching to BiPap 14/10 QHS.
- Continue high-dose Advair (500/50) on discharge.
- Slow prednisone taper on discharge with prompt outpatient
pulmonary clinic follow-up within 1 month while still on taper.
- Outpatient sleep study as soon as possible following
discharge.
- Follow up in sleep clinic following sleep study to titrate
NIPPV settings.
The patient may benefit from BiPAP. He will discuss with
primary pulmonologist or at sleep clinic appointment to get
BiPAP approved for home use. It would be more for ventilatory
failure rather than OSA. In the meantime, he will continue with
CPAP.
# Hypernatremia: On admission, it was felt that this was
hypovolemic hyponatremia in the setting of poor PO intake. Given
IVFs overnight and sodium was improved this morning.
# Anemia: Hematocrit noted to drift down during the first day of
admission. Guiaic positive on exam. Fe studies c/w borderline
ACD. Hematocrit was stable.
# Thrombocytopenia: Plt count trended down following admission,
and were also noted to be down from recent baseline.
Thrombocytopenia could possibly be secondary to PPI. Coags wnl.
Was placed on ranitidine. Thrombocytopenia improved in the end.
# Memory difficulties/delirium: The patient was A&Ox2 on
admission. The etiology is liekly multifactorial from a
combination of hypoxemia, hypercapnia, hypernatremia, and
chronic dementia. He was continued on Aricept and an outpatient
MRI of his brain should be considered. Mental status improved on
the morning following admission.
# T1 Larynx Cancer: Patient is status post radiation therapy.
There was concern about possible metastatic disease on last
Chest CT. Repeat chest CT did not show evidence of metastatic
disease
# [**Doctor Last Name **] 8 Prostate Adenocarcinoma: Patient reports worsening
urinary symptoms, increased avodart as outpatient. Continue
avodart at 1mg PO daily
# Depression: continue prozac.
Medications on Admission:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk 1 Inhalation [**Hospital1 **]
2. Donepezil 10mg PO AM
3. Avodart 1 mg PO once a day.
4. [**Hospital1 **] with HandiHaler 18 mcg Capsule, Inhalation once a
day.
5. Fluoxetine 40 mg Capsule PO DAILY
6. Ipratropium Bromide 0.02 % 1 Inhalation Q6H
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) 1 NEB Q6H PRN
8. Omeprazole 20 mg Capsule, 2 tabs PO daily
9. Albuterol Sulfate 90 mcg/Actuation HFA 1-2 puffs QID PRN
wheezing.
11. Levofloxacin 500mg PO daily for past 2 days
12. Azithromycin 500mg PO x1 day, now 250mg PO daily
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: Taper PO for 4 weeks: Take
40mg daily for 7 days; then 30mg daily for 7 days; then 20mg
daily for 7 days, then 10mg daily until otherwise advised by
your pulmonologist.
Disp:*70 Tablet(s)* Refills:*0*
2. Avodart 0.5 mg Capsule Sig: Two (2) Capsule PO daily ().
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) unit dose Inhalation Q6H (every 6
hours).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) unit dose Inhalation Q2H (every 2
hours) as needed for sob, wheeze.
5. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) unit dose
Inhalation Q6H (every 6 hours).
8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Acute exacerbation of severe chronic obstructive pulmonary
disease
- Anemia, HCT stable
- Guaiac-positive stools
- Thrombocytopenia, resolved, possibly [**12-24**] PPI
SECONDARY DIAGNOSES:
- Larynx cancer
- Prostate adenocarcinoma
- Depression
- History of pyloric stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation and management of an
exacerbation of your COPD. Your symptoms seemed to have flared
after you finished your taper of steroids. Initially, you had
some episodes of confusion likely from your ventilatory status
being so poor. You were restarted again on Prednisone and
gradually improved over the last several days with regard to
your mental status, ambulatory status, and breathing ability.
Pulmonology consultation recommends a more formal assessment of
your need for postitive pressure ventilation (i.e., CPAP or
BiPAP). A sleep clinic appointment has been arranged to assess
these needs.
[**Hospital **] rehabilitation may be very helpful for your
condition.
MEDICATION CHANGES:
1. START Prednisone taper: 40mg daily for week 1, then 30mg
daily for week 2, then 20mg daily for week 3, then 10mg
indefinitely until advised otherwise by your pulmonologist.
2. INCREASE DOSE Advair 500/50 one inhalation twice daily
(previously 250/50 twice daily)
2. STOP Levofloxacin and Azithromycin
3. If using Ipratropium nebulizer treatments, there is no need
to use your inhaler named [**Name (NI) **].
4. If using Albuterol nebulizer treatments, there is no need to
use your inhaler for Albuterol.
4. Otherwise, there were no other changes made to your
medication regimen.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2138-4-23**] at 2:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2138-4-23**] at 3:00 PM
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2138-4-23**] at 3:00 PM
With: DR. [**Last Name (STitle) 91**] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SLEEP
When: THURSDAY [**2138-5-22**] at 11:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"491.21",
"311",
"327.23",
"518.81",
"V10.46",
"V10.21",
"287.5",
"276.1",
"293.0",
"578.1",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
10736, 10807
|
6115, 9016
|
285, 292
|
11147, 11147
|
3624, 6092
|
12623, 13554
|
2880, 2926
|
9631, 10713
|
10828, 11018
|
9042, 9608
|
11298, 11997
|
2941, 3605
|
11039, 11126
|
12017, 12600
|
226, 247
|
320, 2174
|
11162, 11274
|
2196, 2548
|
2564, 2864
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,423
| 159,274
|
22696
|
Discharge summary
|
report
|
Admission Date: [**2122-5-18**] Discharge Date: [**2122-6-17**]
Date of Birth: [**2074-2-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
agitation
Major Surgical or Invasive Procedure:
Endotracheal intubation for 1 day in the MICU
History of Present Illness:
This is a 48 year old male w/ multiple CVA, a fib on coumadin,
h/o endocarditis requiring [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mitral valve replacement in
the past, ESRD on HD s/p failed renal transplant recently
admitted to OSH for accidental ativan/oxycodone overdose
requring intubation for 1 day, subsequently developed seizures
(right arm and leg seizure) and started on dilantin prophylaxis.
Had a GPC line infection treated w/ vanco/gent in the MICU in
setting of increased lethary and delerium. After transfer from
the MICU, patient continued to have waxing / [**Doctor Last Name 688**] mental
status complicated by dementia (toxic/metabolic plus chronic
multi-infarct). In conjunction with HD, neurology attempted to
titrate his anti-agitation medications to improve his delerium
status. Despite decreasing sedatives, Mr. [**Known lastname 58784**] was still
quite disoriented, and oriented only to self. Considering his
quality of life (on hemodialysis, little self-awareness, poor
orientation, frequent agitation), the decision was made to
discontinue [**Known lastname 2286**] and focus on improving quality of life in
transition to hospice.
Past Medical History:
DM type I c/b diabetic nephropathy, retinopathy and neuropathy.
ESRD s/p kidney transplant in [**2107**], now on HD [**12-26**] chronic
rejection
Mechanical mitral valve after endocarditis
Paroxysmal atrial fibrillation
Hypertension
Hypercholesterolemia
Anxiety
Chronic L ankle pain
s/p humerus fracture
Social History:
Married, lives with wife and two stepchildren. Moved to [**Location (un) 86**]
from [**Location (un) 9012**] 3y ago. Unemployed since foot fracture. Denies
tobacco, alcohol, other illicits.
Family History:
Non-contributory
Physical Exam:
VS T 98.4 P 78 BP 128/84 RR 18 O2 96 on RA
Gen: NAD, well appearing
Heent: PERRL, sclrae anicteric
Neck: Supple, no LAD
CV: RRR, no m/r/g
Resp: CTAB, nl resp effort
Abd: S, NT, ND + BS
Ext: warm, no edema, +2 distal pulses
Neuro: left pupil pinpoint (chronic), R pupil small but
reactive, alert, responsive, perseveration, agitated, follows
command occasionally, moves all ext
Pertinent Results:
Labs:
[**2122-5-18**] 09:30PM WBC-9.5 RBC-4.11* HGB-12.0* HCT-34.8* MCV-85#
MCH-29.2 MCHC-34.5# RDW-16.4*..
.
Studies:
CXR ([**5-19**] - admission)
SEMI-UPRIGHT AP CHEST: A right-sided [**Month/Year (2) 2286**] catheter tip
overlies the right atrium. The patient is post-median
sternotomy. Cardiac and mediastinal contours are unchanged.
The lung volumes are low, with persistent left hemidiaphragmatic
elevation. However, the lungs remain clear, without
consolidation or vascular congestion. No pleural effusion or
pneumothorax.
IMPRESSION: No pneumonia.
.
Neurophysiology Report EEG Study Date of [**2122-5-20**]
IMPRESSION: Abnormal EEG due to the frequent bursts of
generalized
delta slowing, occasionally more prominent on one side or the
other and
due to the irregular and mildly slow background. These findings
suggest
a widespread encephalopathy affecting both cortical and
subcortical
structures. Medications, metabolic disturbances, and infection
are
among the most common causes. There was no area of persistent
focal
slowing although encephalopathies may mask focal findings. There
were
no epileptiform features.
.
MR/MRA Brain ([**5-20**])
IMPRESSION:
1. Limited examination secondary to patient motion. No
evidence of acute infarction. Persistent T2 signal abnormality
within the periventricular and subcortical white matter
consistent with a combination of watershed infarction, chronic
small vessel disease and possible sequelae of previous
immunosuppressive therapy for transplant.
2. Nondiagnostic MRA secondary to patient motion.
.
[**Month/Year (2) **] ([**5-21**])
IMPRESSION: No valvular vegetations seen. Normal global and
regional
biventricular systolic function. Normally-functioning mechanical
mitral
prosthesis. Compared with the prior study (images reviewed) of
[**2122-4-6**], transmitral valve gradients and estimated pulmonary
pressures have normalized. The other findings are similar.
.
CT HEAD W/O CONTRAST ([**5-26**])
IMPRESSION: No short interval change. No evidence of acute
intracranial
hemorrhage. Prominent white matter disease likely relates to
chronic small vessel ischemic changes, however given this
patient's history see differential diagnosis provided on prior
studies.
Brief Hospital Course:
48 year old male w/Type II DM, ESRD on hemodialysis s/p failed
kidney transplant, history of multiple CVA, a-fib on coumadin,
endocarditis, mechanical MVR, and [**Hospital 2754**] transferred to the floor
from MICU for unresponsiveness after arriving from rehab for
agitation after hospitalization for hypoglycemia and sz in the
context of a ativan/oxycode overdose who throughout his stay,
continued to have labile sugars and mental status changes. The
decision to make the patient CMO was made [**6-10**].
.
Brief hospital course by probelem:
.
# Mental status change:
Patient carries history of chronic multi infarct dementia.
After arriving on the floor from the MICU, the patient was
delerius and neurology was consulted, and an additional
diagnosis of acute toxic metabolic encephalopathy was made. In
effort to best titrate his medicaitons to reduce encephalopathy,
neurology followed the patient. After discontinuing all
sedatives, the patient was still disoriented and delerious.
Thus, attempts to clear his sensorium were unsuccessful.
Ultimately, it was decided that the patient would not wish to
continued to live as he is currently living and that the current
quality of life would be unacceptable to the patient. As such,
his wife and health care proxy made the decision to provide
comfort measures, discontinue hemodialysis, and enter hospice.
.
#DM1/hypoglycemia: Patient is a long standing type I brittle
diabetic. He was followed by [**Last Name (un) **] and titrated w/ glargine
and regular insulin. Towards the end of his care the glargine
was switched to 6 units lantus daily and follwed w/ [**Hospital1 **]
fingersticks. All critically high sugars > 400 were treated
with 2 units of regular insulin.
.
#Infection:Patient began treatment with gent and vanc for a
presumed line infection at the OSH after one out of two bottles
grew GPC. When he was transferred from OSH to [**Hospital1 18**] he
continued antibiotics. After two days on the floor he became
severely hypoglycemic, unresponsive, and was transferred to the
MICU and intubated. In the MICU zosyn was added for new fever,
rising WBC count, and a lactate to 3.1 (returned to 1.3 with
IVF). Urine grossly positive. Defervesced on vanc/gent/zosyn
initailly, but continued spiking for 3 days. ID became involved
and recommended LP and TEE. LP was done and was negative for
bacterial infection and fungal infection. TEE attempted and
failed. Candiduria was identified and treated with a three day
course of Amphotericin B flushes. Once stabilized in the MICU
and transferred back to the floor. Vanc and gent were ended
after 4 weeks and zosyn after 7 days on [**5-27**] as this completes
treatment of the presumed line infection, he had been afebrile,
there is no leukocytosis and the high lactate level had
resolved. The patient had a recent episode of fever, during
which he was blood and urine cultured. The UA on [**2122-6-11**]
suggested a UTI but because of CMO status treatment and patient
was felt not to be in discomfort antimicrobial therapy was not
initiated.
.
# Cardio:
1.Vessels- no issues
2.Pump- The patient has had labile blood pressures due to
hypertension at baseline. While in the hospital his blood
pressure medications from home were titrated to maintain stable
blood pressures. Amlodipine, diltiazem and Imdur were used
initially, until the patient was made CMO and he is now on
amlodopine and diltiazem XR only.
3.Rhythym- Paroxysmal AFib/flutter were stable during
hospitalization. He was transitioned from heparin to coumadin
during this hospitalization and has been therapeutic. He
continues on Diltizem XR 180mg QD, coumadin 5mg.
4.Valves-Mechanical mitral valve due to endocarditis, has been
stable during this hospitalization. TEE attempted and failed and
it was decided not to treat. Anticoagulated on coumadin.
.
#ESRD: The patient continued to receive three times weekly
hemodialysis while here, the last of which was [**6-9**]. He was
followed by his nephrologist, who monitored his sevelemir and
ertythrpoeiten.
.
#PPX- Nystatin Oral Suspension 5 ml PO QID:PRN and senna
#FEN- regular diet.
#Access: [**Month/Year (2) 2286**] port still in place
#Code- DNR/DNI/CMO
Medications on Admission:
Vanco 1gm post [**Month/Year (2) 2286**]-
Gent 80 mg post [**Month/Year (2) 2286**]-
Prednisone 10 mg DAILY
Diltiazem HCl 60 mg q 6h-
Pantoprazole 40 mg Tablet q12 hrs-
Folic Acid 1 mg DAILY
Labetalol 800 mg tid -
imdur 30 daily-
norvasc 10 mg daily-
Lorazepam 0.5 mg [**Hospital1 **] + 1 mg [**Hospital1 **] prn-
Docusate Sodium 100 mg [**Hospital1 **]
Sevelamer 1600 mg TID -
Oxycodone 10 mg Tablet Sustained Release q12h
Oxycodone 5 mg q6 h prn -
Insulin Glargine 18 u qhs-
humalog SS-
Warfarin 4 mg qhs-
ambien 10 qhs
Discharge Medications:
1. Lorazepam 0.5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every four (4)
hours as needed for anxiety.
Disp:*36 Tablet(s)* Refills:*0*
2. Artificial Tears 1.4-0.6 % Drops [**Hospital1 **]: [**11-25**] Ophthalmic [**11-25**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes. .
Disp:*1 bottle* Refills:*2*
3. Nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO QID
(4 times a day) as needed for oral exudate.
Disp:*1 bottle* Refills:*0*
4. Trazodone 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*14 Tablet(s)* Refills:*0*
5. Olanzapine 5 mg Tablet, Rapid Dissolve [**Month/Day (2) **]: One (1) Tablet,
Rapid Dissolve PO QID (4 times a day) as needed for agitation.
Disp:*42 Tablet, Rapid Dissolve(s)* Refills:*0*
6. Haloperidol 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: 650mg Solutions PO
Q4H (every 4 hours) as needed for chills, sweats, fevers.
8. Insulin Glargine 100 unit/mL Solution [**Month/Day (2) **]: Five (6) units
Subcutaneous at bedtime.
9. Morphine Concentrate 20 mg/mL Solution [**Month/Day (2) **]: One (1) 5-10mg PO
q 2 hrs as needed for pain: 5-10 mg SL q 2 hr prn.
Disp:*144 mL* Refills:*0*
10. Levsin/SL 0.125 mg Tablet, Sublingual [**Month/Day (2) **]: One (1) tab
Sublingual every 4-6 hours as needed for pulmonary secretions.
Disp:*42 tabs* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis:
1. Toxic-Metabolic Encephalopathy.
2. Seizure Disorder NOS.
3. Fever NOS.
4. Candiduria.
5. Drug Withdrawal
6. 3.5-mm RLL Pulmonary Nodule.
Secondary Diagnoses:
1. Multi-infarct Dementia
2. CKD Stage V on Hemodialysis.
3. Failed Cadaveric Renal Transplant
4. Atrial Fibrillation.
5. Endocarditis s/p [**Hospital3 9642**] MVR.
6. Diabetes Mellitus Type I.
7. Hypertension
8. Hypercholesterolemia
9. Neuropathy
10. Retinopathy - Blind.
11. Frozen Shoulder
12. Chronic Left Foot Pain s/p crush injury.
13. Peptic Ulcer Disease
14. Gastroparesis
15. Cystic Pancreatic Tail Mass 3 x 4cm.
16. Narcotic and Benzodiazepine Dependence
17. Arthritis
18. Gout.
19. Anemia of CKD and Chronic Disease.
20. RLL Segmental Pulmonary Embolus
Discharge Condition:
blood sugars labile, agitation improved
Discharge Instructions:
You were in the hospital because of agitated behavior. While you
were here you received antibiotics for an infection, your blood
sugars and blood pressures were stabilized.
Followup Instructions:
None
|
[
"250.82",
"112.2",
"038.9",
"272.0",
"995.91",
"250.12",
"518.81",
"290.41",
"V43.3",
"349.82",
"250.62",
"357.2",
"V66.7",
"250.42",
"437.0",
"585.5",
"403.91",
"996.62",
"780.6",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.95",
"03.31",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11027, 11127
|
4778, 8973
|
275, 322
|
11931, 11973
|
2520, 4755
|
12194, 12201
|
2089, 2107
|
9545, 11004
|
11148, 11148
|
8999, 9522
|
11997, 12171
|
2122, 2501
|
11335, 11910
|
226, 237
|
350, 1538
|
11167, 11314
|
1560, 1865
|
1881, 2073
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,241
| 118,071
|
11498
|
Discharge summary
|
report
|
Admission Date: [**2200-12-9**] Discharge Date: [**2200-12-16**]
Date of Birth: [**2150-11-30**] Sex: F
Service: CT Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 49 year old
otherwise healthy female, on only aspirin 81 mg daily, who
comes in after a routine physical examination and her primary
care physician having heard [**Name Initial (PRE) **] murmur. Dr. [**Last Name (STitle) **], her
primary care physician, [**Name10 (NameIs) **] referred her to get an
echocardiogram, which ultimately led to a transthoracic
echocardiogram at [**Hospital6 1708**].
The transthoracic echocardiogram actually revealed a secundum
type atrial septal defect. As a consequence, her pulmonary
artery pressures were measured accordingly. It was noted
that she did have pulmonary pressure of 27/5, right
ventricular pressure of 27/7, central venous pressure of 6,
wedge pressure of 7, left ventricular pressure 126/10, aortic
root pressure 126/73, and left ventricular ejection fraction
60%. There was a positive atrial septal defect seen.
Th[**Last Name (STitle) 1050**] was therefore referred to Dr. [**Last Name (Prefixes) **] at
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] due the fact that she
had evidence of some right ventricular hypertrophy and some
early onset pulmonary hypertension, but no reversal of shunt
was present. She was therefore referred to operative repair.
Th[**Last Name (STitle) 36678**]mally invasive approach was ultimately utilized, a
VAT procedure with Dr. [**Last Name (Prefixes) **]. The patient presented to
the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2200-12-9**].
PAST MEDICAL HISTORY: Negative.
PAST SURGICAL HISTORY: Tonsillectomy and adenoidectomy.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
REVIEW OF SYSTEMS: Completely benign.
LABORATORY DATA: Admission hematocrit was 38, platelet count
307,000, BUN 20 and creatinine 0.9.
HOSPITAL COURSE: On [**2200-12-9**], the patient went to
the Operating Room and, under general anesthesia, she
underwent a video assisted thoracic procedure to have
minimally invasive repair of her atrial septal defect. She
was sent to the Post Anesthesia Care Unit and then ultimately
to the Cardiac Intensive Care Unit postoperatively. She was
maintained on epinephrine, Neo-Synephrine and propofol.
The patient was extubated on the night of surgery. She did
ultimately get six units of packed cells, one set of
platelets and six units of fresh frozen plasma in her initial
resuscitation. Once she was weaned from extubation, her
laboratory values revealed a hematocrit of 27, down from 38,
for which she was transfused with the above mentioned blood
products. Prothrombin time and INR were 12 and 1.1,
fibrinogen 137, BUN 14 and creatinine 0.9. A chest x-ray
just showed a large opacification across the right middle and
lower lobes, thought to be secondary to a possible
parenchymal hemorrhage due to the nature of the surgery and
its right thoracic approach.
Once the patient was extubated, she was alert and oriented.
Her pain control was adequate on Percocet. She was advanced
to a cardiac diet. She was put on Lasix for diuresis. She
was given three doses of perioperative Ancef as well. Her
epinephrine and Neo-Synephrine drips were quickly weaned.
Her Swan-Ganz catheter was changed to a triple lumen
catheter.
By postoperative day number two, the patient was again
hemodynamically stable. Her hematocrit was 26. Her chest
x-ray just showed right middle lobe consolidation, again
thought to be secondary to pulmonary hemorrhage, which was
stable. She was placed on Lasix and aspirin and discharged
to the floor.
It should be noted that, on postoperative day number two, the
patient was in a junctional rhythm in the 50s and was
therefore not placed on any beta blockade. While on the
floor on postoperative day number three, she was noted to go
into atrial fibrillation with a rapid ventricular response to
the 170s. Her blood pressure was in the 140s.
Symptomatically, she was just experiencing chest flutter and
some lightheadedness. She was therefore given intravenous
Lopressor 5 mg times two as well as 25 mg of oral Lopressor,
which quickly brought her out of her rate and into the 50s
and 60s, sinus rhythm and sinus bradycardia.
By the morning of postoperative day number four, the patient
was noted to be in and out of a junctional and a bradycardiac
arrhythmic rhythm and was therefore continued on her
medications. However, she ultimately began having
intermittent episodes of rapid atrial fibrillation into the
130s. This was then treated with amiodarone, but
subsequently caused the patient to have two intermittent
pauses of greater than five seconds, causing syncope.
Due to the fact that the patient was given beta blockade and
the amiodarone simultaneously, she now had symptomatic
syncope with evidence of heart block. All medications were
discontinued and an electrophysiology consultation was then
obtained.
The electrophysiology service reviewed all of the patient's
rhythm strips over her postoperative course, noting that she
had gone from a junctional rhythm to rapid atrial
fibrillation and now was in and out of a junctional rhythm,
rapid atrial fibrillation and then subsequently to sinus
bradycardia. The frequent flipping in and out multiple
rhythms, they thought was due to sinoatrial node dysfunction
and also due to atrial dynamics with a change in the pressure
dynamics after a septal defect repair. Certainly the volume
status of the atria is now significantly changed and with any
type of volume change, whether it be with Valsalva or
hormonal influences that may change the filling pressure and,
therefore, distention of the atrial wall, this would perhaps
cause the overall irritability of her atria.
Ultimately, the patient was placed back on 12.5 mg of
Lopressor and was maintained in a junctional or sinus
bradycardiac rhythm in the 60s and 50s. She only had
intermittent episodes of bursts into the 130s of rapid atrial
fibrillation, but much less frequent than previously
mentioned in her postoperative course.
The electrophysiology service watched the patient closely
with us over the next couple of days and, by postoperative
day number seven, she was deemed stable and appropriate for
discharge, with follow-up, on anticoagulation therapy given
the intermittent episodes of atrial fibrillation.
DISCHARGE MEDICATIONS:
Coumadin 5 mg p.o.q.d.
Lopressor 12.5 mg p.o.b.i.d.
Aspirin 81 mg p.o.q.d.
Percocet p.r.n.
Colace 100 mg p.o.b.i.d.
FO[**Last Name (STitle) **]P: The patient was instructed to see Dr. [**Last Name (STitle) **] 48
hours from the time of discharge for a prothrombin time/INR
check and to see the electrophysiology service in one month
from the time of discharge. Additionally, she will see Dr.
[**Last Name (Prefixes) **] in one month from the time of discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSIS:
Atrial septal defect, status post VAT assisted atrial septal
defect repair complicated by postoperative sinoatrial node
dysfunction with tachy-brady dysrhythmia.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2200-12-17**] 12:48
T: [**2200-12-17**] 13:19
JOB#: [**Job Number 23971**]
|
[
"786.3",
"E878.8",
"997.1",
"427.81",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.71",
"89.62",
"99.04",
"39.61",
"34.21",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6632, 7097
|
7207, 7636
|
1909, 1987
|
2144, 6609
|
1848, 1882
|
2007, 2126
|
174, 1790
|
1813, 1824
|
7122, 7186
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,868
| 181,556
|
25151
|
Discharge summary
|
report
|
Admission Date: [**2133-8-28**] Discharge Date: [**2133-11-10**]
Date of Birth: [**2063-7-31**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2133-9-2**] - MVR (27mm St. [**Male First Name (un) 923**] Porcine Valve), Epicardial and
endocardial cryomaze, Left atrial appendage ligation, placement
of ICD wires.
[**2133-10-8**] - exploratory laparotomy, repair of gastric
perforation.
History of Present Illness:
The patient is a 70 year-old man who presented to [**Hospital1 63061**] with increasing congestive heart failure, atrial
fibrillation and ventricular tachycardia. Catheterization showed
normal coronary arteries, ejection fraction of 40% with severe
mitral regurgitation. He presented with ventricular tachycardia
and has paroxysmal atrial fibrillation and was treated with
lidocaine and amiodarone. He was transferred to the [**Hospital1 18**] for
surgical evaluation.
Past Medical History:
Hypothyroid
Diabetes mellitus
Sick sinus syndrome - s/p PPM [**2131**]
AF
GERD
VT
CML
Social History:
The patient lives in [**Location (un) 63062**], RI. No history of
tobacco or alcohol.
Family History:
Non-contributory.
Physical Exam:
Vitals: T 96.5, Tmax 97.8, BP 135/65 (115-148/59-75), HR 87
(84-94)AV paced, RR 17, 97% on AC 700x24, 0.5, PEEP 5 -->
7.35/40/76
I/O: 1474/393
Gen: agitated, no acute distress
HEENT: PERRL, EOMI, mmm, OP clear
Neck: JVP ~9cm, no LAD
Lung: diffusely coarse breath sounds with crackles
Chest: midline scar
Cor: distant heart sounds, regular rate and rhythm, nml S1,
mechanical S2
Abd: obese, NABS, soft NTND
Ext: 1+ pitting edema at ankles, erythema and crust on anterior
right thigh
Pertinent Results:
PMIBI ([**5-26**]): fixed apical defect, dilated LV, ? preserved EF
Cath ([**8-28**]): 30% prox LAD, 30% OM, 30% prox RCA
.
Admission Labs:
[**2133-8-29**] 12:45AM BLOOD WBC-10.7 RBC-3.63* Hgb-11.4* Hct-35.1*
MCV-97 MCH-31.3 MCHC-32.3 RDW-13.3 Plt Ct-243
[**2133-9-29**] 03:18AM BLOOD Plt Ct-191
[**2133-8-29**] 12:45AM BLOOD PT-15.1* INR(PT)-1.5
[**2133-8-29**] 12:45AM BLOOD Glucose-133* UreaN-51* Creat-1.5* Na-134
K-4.5 Cl-98 HCO3-28 AnGap-13
[**2133-8-29**] 12:45AM BLOOD ALT-17 AST-23 LD(LDH)-165 AlkPhos-90
TotBili-1.5
[**2133-8-29**] 12:45AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
[**2133-9-18**] 12:48AM BLOOD FREE T3-Test
.
Studies:
.
[**2133-8-29**] CXR
1. Moderate pulmonary edema.
2. Left ventricular and pulmonary artery prominence.
3. Small bilateral pleural effusions.
4. Right-sided pacemaker adjacent to the right atrium and right
ventricle.
.
[**2133-8-30**] Femoral Ultrasound
1. Findings consistent with right groin CFA->CFV AV fistula. 2.
Small hypoechoic area in the right groin measuring 3.7 x 2.6 cm,
likely representing a hematoma.
.
[**2133-9-7**] ECHO
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. Right ventricular systolic function is
borderline normal. The prosthesis cannot be adequately
assessed. There is no pericardial effusion.
.
[**2133-9-9**] Chest CT
1. Focal airspace consolidation at the lung bases bilaterally
consistent with pneumonia.
2. Nodular air-space opacities in a bronchovascular
distribution, predominantly affecting the upper lobes. There are
prominent mediastinal and symmetric hilar lymph nodes. These
findings raises the possibility of sarcoidosis although it would
be atypical in a 70-year-old male. Less likely causes include
lymphoma and metastasis/lymphatic spread of tumor.
3. Status post median sternotomy and mitral valve replacement.
Bilateral chest tubes without evidence of pneumothorax.
.
[**2133-9-10**] ECHO
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium. 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 borderline depressed (ejection fraction ?50%). Right
ventricular systolic function is borderline normal in suboptimal
views. There are complex (>4mm) atheroma in the aortic arch.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are mildly thickened. No aortic regurgitation is
seen. A bioprosthetic mitral valve prosthesis is present and
appears well-seated. The motion of the mitral valve prosthetic
leaflets appears normal. Trivial valvular and paravalvular
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is no pericardial effusion.
.
[**2133-9-26**] Abdominal Ultrasound
Unremarkable appearance of the gallbladder, bile ducts, and
pancreatic head.
.
[**2133-9-28**] CT Scan
There are bilateral pleural effusions, large layering on the
right and moderate on the left with fascial extension.
Atelectases both lower lobes are seen. The right and left main
bronchi and the segmental bronchi are compressed however appear
patent. Enlarging 16-mm paratracheal, enlarged 13-mm right
retrocrural, and stable subcentimeter diaphragmatic and
prevascular nodes are seen. Extensive atherosclerotic, aortic,
and coronary artery calcifications are seen along with mitral
annulus calcification. A pericardial catheter is seen in place.
There is no pericardial effusion. In the imaged upper abdomen
the unenhanced liver appears hyperdense with an attenuation
value of 60. The gallbladder is distended without wall
thickening. Spleen, adrenals, and imaged kidneys are
unremarkable. Minimal amount of ascites is seen. Degenerative
changes are present in the bones. Median sternotomy with normal
alignment of the sternal suture.
.
Abd CT [**10-8**]: 1. Large left psoas hematoma as described above.
2. Moderate amount of free air. No definite cause is identified.
This could be secondary to manipulation of the G-tube. Clinical
correlation with the history of procedures is recommended. 3.
Moderate amount of free fluid in the abdomen and pelvis. 4.
Moderate bilateral pleural effusions with associated
atelectasis. 5. Multiple retroperitoneal and pelvic lymph nodes.
They are larger than what
is normally seen. Although they are unchanged when compared to
the recent study, followup is recommended in three months to
assess for stability.
.
MICRO:
.
[**2133-10-23**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {YEAST,
PRESUMPTIVELY NOT C. ALBICANS, PSEUDOMONAS [**Year (4 digits) 35836**]};
ANAEROBIC CULTURE-FINAL INPATIENT
PSEUDOMONAS [**Year (4 digits) 35836**]
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM------------- 8 I
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
.
[**2133-10-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +, PSEUDOMONAS [**Year (4 digits) 35836**]} INPATIENT
STAPH AUREUS COAG +
| PSEUDOMONAS [**Year (4 digits) 35836**]
| |
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 2 S
IMIPENEM-------------- S
LEVOFLOXACIN---------- 4 I
MEROPENEM------------- 8 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 64 S
PIPERACILLIN/TAZO----- 64 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ <=1 S
[**2133-10-8**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {PSEUDOMONAS [**Last Name (LF) 35836**], [**First Name3 (LF) **] (TORULOPSIS)
GLABRATA}; ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE-FINAL
{[**Female First Name (un) **] (TORULOPSIS) GLABRATA} INPATIENT
PSEUDOMONAS [**Female First Name (un) 35836**]
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
IMIPENEM-------------- <=1 S
MEROPENEM------------- 8 I
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
.
[**2133-10-8**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {YEAST};
ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE-FINAL {[**Female First Name (un) **]
(TORULOPSIS) GLABRATA} INPATIENT
[**2133-10-5**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS [**Year (4 digits) 35836**], GRAM NEGATIVE ROD(S)} INPATIENT
PSEUDOMONAS [**Year (4 digits) 35836**]
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- I
MEROPENEM------------- 8 I
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
.
[**2133-10-3**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS [**Year (4 digits) 35836**], KLEBSIELLA OXYTOCA} INPATIENT
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
.
[**2133-9-27**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +, PSEUDOMONAS [**Year (4 digits) 35836**], GRAM NEGATIVE ROD
#2} INPATIENT
STAPH AUREUS COAG +
| PSEUDOMONAS [**Year (4 digits) 35836**]
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 2 S
IMIPENEM-------------- I
LEVOFLOXACIN---------- 4 R
MEROPENEM------------- 8 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 64 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ <=1 S
[**2133-11-5**] 4:15 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2133-11-8**]**
GRAM STAIN (Final [**2133-11-5**]):
>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
CLUSTERS.
RESPIRATORY CULTURE (Final [**2133-11-8**]):
RARE GROWTH OROPHARYNGEAL FLORA.
PSEUDOMONAS [**Month/Day/Year 35836**]. MODERATE GROWTH.
PSEUDOMONAS [**Month/Day/Year 35836**]. MODERATE GROWTH 2ND STRAIN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS [**Month/Day/Year 35836**]
| PSEUDOMONAS [**Month/Day/Year 35836**]
| |
CEFEPIME-------------- 8 S 16 I
CEFTAZIDIME----------- 4 S 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 4 S 8 I
IMIPENEM-------------- 8 I 8 I
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN---------- 32 S =>128 R
PIPERACILLIN/TAZO----- 64 S 64 S
TOBRAMYCIN------------ <=1 S <=1 S
[**2133-11-8**] 4:42 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2133-11-8**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2133-11-8**]):
REPORTED BY PHONE TO [**Location (un) 394**],A CC6D [**2133-11-8**] AT 1448.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
Brief Hospital Course:
CARDIAC SURGERY COURSE:
Mr. [**Known lastname 63063**] was admitted to the [**Hospital1 18**] on [**2133-8-28**] via transfer
from the [**Hospital1 **] Center for further management of his mitral
valve disease. Given his recent history of atrial fibrillation
and ventricular tachycardia, an electrophysiology consult was
obtained. Amiodarone was continued and an ICD postoperatively
was considered. He was found to be inducible for ventricular
tachycardia during a study and left ventricular mapping
demonstrated a basilar scar. Intraoperative ablation was thus
also recommended. His pacemaker was interrogated and his
underlying rhythm was found to be complete heart block. A right
groin ultrasound was obtained which revealed a common femoral
artery/vein fistula. Keflex was started for phlebitis. Vitamin K
was given to get his INR to an appropriate level for surgery. On
[**2133-9-2**], Mr. [**Known lastname 63063**] was taken to the operating room where he
[**Known lastname 1834**] a mitral valve replacement with a 27mm St. [**Male First Name (un) 923**]
Porcine valve, a cryo MAZE for atrial fibrillation, placement of
biventricular pacing leads, cryoablation for VT and a left
atrial appendage ligation. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. On
postoperative day one, coumadin was resumed. On postoperative
day two, Mr. [**Known lastname 63063**] was extubated. The EP (Electrophysiology
Service) made changes to his pacemaker as his epicardial pacing
wires were not capturing. Later on postoperative day two, Mr.
[**Known lastname 63063**] was reintubated for respiratory distress and several
episodes of ventricular tachycardia. Amiodarone and lidocaine
were loaded. He was gently diuresed. Beta blockade was started
and titrated as his blood pressure could tolerate. The EP
service recommended an AICD when ready. The pulmonary service
was consulted for his respiratory failure. A CT Scan was
performed which was suggestive of pneumonia and bronchovascular
nodules. Antibiotics were started. Mr. [**Known lastname 63063**] [**Last Name (Titles) 1834**] a
bronchoscopy for large amounts of secretions and mucus plugging.
A repeat echocardiogram was performed which was not suggestive
of a patent foramen ovale. On [**2133-9-11**], Mr. [**Known lastname 63063**] was
successfully extubated. A speech and swallow consult was
obtained and Mr. [**Known lastname 63063**] was found to be aspirating this
liquids. He remained on tube feeds. On [**2133-9-12**], Mr. [**Known lastname 63063**]
developed respiratory distress again and was reintubated. The
renal service was consulted for uremia and an elevated
creatinine. His medications were renal dosed and intravenous
fluids were started for acute tubular necrosis. Zosyn,
levofloxacin and vancomycin were continued for his pneumonia. An
echocardiogram was performed which showed a well seated mitral
valve and a borderline depressed ejection fraction. An abdominal
ultrasound was performed for an elevated amylase and lipase
which was normal. A CT scan of his abdomen was obtained which
revealed enlarged mesenteric, retroperitoneal and retrocrural
lymph nodes and no pancreatitis. Creatinine rose to 3.2
(baseline 1.1-1.7), with BUN 101 and sodium of 150 on [**9-14**].
Renal was consulted and felt that acute renal failure likely
related to aggressive diuresis in the setting of repeat
extubations. Recommended renal dosing medications (Zosyn) and
keeping BP elevated with colloid infusion for improved renal
perfusion. Creatinine continued to rise and renal was concerned
that prerenal picture had turned into ATN picture. FENa however
was calculated at 0.43% and Renal advised normal saline
infusion. Trach and PEG placed on [**2133-9-15**]. At this point,
there was a concern for worsening heart failure. Renal function
improved to 3.1 on [**9-19**] and 2.6 on [**9-20**]. Vancomycin and
metronidazole were started on [**9-19**] and were stopped on [**9-21**].
He was started on bicarbonate given low bicarb level and
non-anion gap metabolic acidosis with inadequate respiratory
compensation. Amiodarone was restarted and dosing changed
periodically per EP recs. The patient was transferred to the
MICU due to nursing concerns.
.
MICU COURSE:
Under MICU service care he was treated for renal failure with
CVVHD which was eventually transitioned to IHD on [**2133-11-4**]. It
was belived to be due from ATN as muddy brown casts were seen.
It was hoped that his renal function would improve.
He was weaned from the Pressure Support ventilator to trach mask
ventilation. After a lengthy course of antibiotics, he was found
to have Clostridium difficile in his stool. He was started on
metronidazole. Also, beta blockers were attempted on multiple
occasions in addition to the amiodarone. First, metoprolol was
tried and the pt became hypotensive and had poor mentation. This
was dc'd and the pt subsequently did well. Then a few days later
(on [**11-8**]), the patient was tried on Coreg with similar results.
No additional beta blockers were tried as the amiodarone was all
he could tolerate in addition to the HD.
.
1. Respiratory failure: He was intubated in the setting of his
surgery, and had three failed atempts at extubation, requiring
trach tube placement. He required varying levels of pressure
support and assist control throughout his stay depending on his
clinical condition. For several days before discharge he was
tolerating trach mask with .95 FiO2. He occassionally has
desaturations requiuring return to pressure support, but overall
tolewrates trach mask ventilllation well. At the time of
discharge he was on trach mask. His respiratory difficulties
were likely due to underlying lung disease, large pleural
effusions, and pulmonary edema. The plan is to wean [**Last Name (un) 834**]
ventilator and have him on trach mask for as much of the day as
tolerated. When requiring pressure support he has been on 12 of
pressure support and 8 of PEEP.
.
2. Renal failure: He has a history of chronic kidney disease
(baseline creatinine 1.1-1.6). Acute renal failure thought to be
due to ATN and prerenal state from poor foward flow. Of note, he
received IV contrast for CT study on [**9-25**], which correlates with
the time at which his Cr began rising. Continually rising Cr and
decreased UOP led to the initiation of CVVHD. CVVHD was
transitioned to HD, which began on [**2133-10-12**]. The Pt. was
continued on epoitin at [**Numeric Identifier 2686**] QMWF. He is currently in oliguric
renal failure getting IHD MWF. He may have reversable kidney
failure, though unlikely, so he should be follwed up by a
nephrologist to determine further need for dialysis.
.
3. Pancreatitis: Had varying levels of amylase and lipase
elevation during stay. Multiple etiologies, including
medications, post-op/ischemic, hypertriglycerides, other GI
cause, or renal failure. He is abdominal pain free on discharge
and will likely continue to have asymptomatic elevation in
amylase and lipase.
.
4. Peritonitis: He had apparent leakage from around his G tube
in to his peritoneum, evident on CT of abd. He [**Numeric Identifier 1834**] exlap
([**2133-10-8**]) and had repair of gastric wall perforation and
placement of J tube. Intra-op peritoneal cultures grew out
Pseudomonas aerginosa and [**Female First Name (un) **] glabrata, for which he
received a 28 day course of ambisome/imipenum/flagyl. He
subsequently has been fed through his J tube and his G tube
should remain clamped and in place indefinately.
5. Sepsis: He had several episodes of sepsis with no obvious
source other than his prior peritoneal infection. No blood
cultures were ever positive.
.
6. CHF: EF preserved after MVR, diastolic dysfunction. Given
renal failure, pt was dependent on hemodialysis and CVVH
intermittently for fluid removal. He has Bilateral pleural
effusions, which are chronic, and transudative on multiple taps.
He should have fluid removed with dialysis. If possible, though
his blood presure would not tolerate it, we would like him to be
on a beta blocker and an ACE inh for his heart failure.
.
6. Refractory monomorphic VT. The pt received a lidocaine bolus
and was started on amiodarone gtt for recurrent brief runs of
VT. Continued on heparin gtt after MAZE procedure for atrial
fibrillation, currently awaiting ICD placement. He was
eventually placed on an oral dose of amiodarone which controlled
his ventricular ectopy but was unable to tolerate beta blocker
for PVC prevention, rate control of AF or CHF given low BP. Plan
was made to place ICD by having him return to [**Hospital1 18**] after his
discharge from rehab in [**Doctor Last Name **]. If any questions, please
call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34490**] office for scheduling([**Telephone/Fax (1) 5862**].
.
7. Psych: Delirium - He was noted to be have delusions on
several occasions. Possible etiologies include medications,
infection, uremia, and ICU confusion. He tolerated olanzepine
QAM and QHS. Depression - He had previously been on zoloft, but
it was discontinued per psychiatry as it was a very small dose
and there was concern for polypharmacy.
.
8. Adrenal Insufficiency- thought to have adrenal insufficinency
given improvement in blood pressure while on steroids. He was
discharged on Prednisone taper. Please taper slowly.
.
9. Chronic Leukemia- type unknown, likely explains frequent
leuko and lymphocytosis; no acute concerns. Contact pts primary
hematologist Dr. [**Last Name (STitle) 63064**] in RI if questions, [**Telephone/Fax (1) 63065**]
.
10. Left psoas hematoma: stable. no evidence of expansion on
subsequent CT scans. Likely due to spontaneous bleed in the
setting of supertherapeutic anticoagulation for his AFib/Maze
procedure.
.
11.ID: Vent Associated Pneumonia: He was treated with vancomycin
and zosyn for pseudomonas and coag-positive staph aureus
pneumonia. He continued to have pseudomonas in his sputum
throughout his stay. Peritonitis: Following surgery,
recommendations were for empiric treatment with vancomycin,
levofloxacin, metronidazole, and fluconazole. On [**2133-10-11**],
peritoneal fluid culture grew non-Candidal yeast and
pseudomonas. The antibiotic regimen was adjusted to vancomycin,
metronidazole, ambisome, cefepime, and gentamicin after
discussion with ID. This was later consolidated to imipenum,
vancomycin, and ambisome for a total 28 day course. C. Diff:
treating with IV flagyl 7 day course to end on [**2133-11-14**].
.
12. Abdominal wound: surgical wound from ex lap. Initially
closed with staples. Wound dehisced after staples removed 3
weeeks after surgery. Allowing to heal by secondary intention
.
13. DM: was variably on fixed dose insulin, insulin drip, and
sliding scale insulin to control blood sugars. He will need his
glargine adjusted asd the prednisone is tapered. Please also
consider adding ASA as patient is diabetic without coroary
disease.
.
14. FEN: The long term nutrition goal during the hospitalization
was to transition from parenteral nutrition to tube feeds. The
originial PEG tube placed on [**2133-9-15**] yielded high residuals
when tube feeds were started, and goal rate could not be met,
even with trials of reglan and IV erythromycin. Plan was to
advance tube to post-pyloric position, but before this occurred,
the Pt. [**Date Range 1834**] surgery for perforated viscus, and a new
G-tube and J-tube were placed. Post-operative J-tube tube feeds
were well tolerated, and parenteral nutrition was d/c'd. G tube
is clamped and remains in place but should never be used. Per
Dr.[**Name (NI) 1381**] surgery team, the tube should never be pulled given
high risks for infection and perforation. If fully
rehabilitated, pt may discuss having tubes pulled with Dr. [**Last Name (STitle) 816**]
or other primary providers as an outpatient in the distant
future.
.
15. PPX: Heparin transitioned to coumadin. PPI.
.
Lines:
Right Brachial PICC was placed on [**2133-11-3**].
Left Subclavian Dialysis line (tunneled catheter) placed
[**2133-10-16**].
Medications on Admission:
MEDS (on admission):
Lasix 40mg IV bid
Gluctrol 5mg daily
ASA 325mg daily
Amiodarone 400mg TID (started [**8-25**])-> 200mg tid on transfer
Altace 5mg [**Hospital1 **]
Lopressor 50mg [**Hospital1 **]
Folate 1mg daily
.
MEDS (on transfer):
Acetaminophen prn
Albuterol-Ipratropium 2p Q4
Amiodarone 400mg [**Hospital1 **]
ASA 81mg dailoy
Bisacodyl 10mg prn
Calcium Gluconate prn
Colace 100mg [**Hospital1 **]
Dolasetron 12.5mg IV q8h
Epo 4000U MWF
Fluticasone 2p [**Hospital1 **]
Heparin 1000U/hr
Hydralazine 25mg q6, prn
Insulin SC sliding scale
Lansoprazole 30mg daily
Levothyroxine 40mcg daily
Lorazepam 05mg q6h prn
Metoprolol 25mg [**Hospital1 **]
Morphine sulfate 0.5-4mg q2h prn
Nystatin 5ml QID
Olanzapine 5mg qhs
Piperacillin-Tazobactam 2.25mg q8h
Sodium Bicarb 650mg [**Hospital1 **]
Ursodiol 300mg [**Hospital1 **]
Vancomycin 1g IV daily
.
ALL: PCN, Sulfa
Discharge Medications:
1. Insulin Sliding Scale
Humalog
Glucose Insulin Dose
0-50 mg/dL [**11-23**] amp D50
51-120 mg/dL 0 Units
121-160 mg/dL 5 Units
161-200 mg/dL 10 Units
201-240 mg/dL 15 Units
241-280 mg/dL 20 Units
281-320 mg/dL 25 Units
321-360 mg/dL 30 Units
361-400 mg/dL 35 Units
> 400 mg/dL Notify M.D.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for T>38.
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed.
7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
8. Epoetin Alfa 4,000 unit/mL Solution Sig: Four (4) ml
Injection QMOWEFR (Monday -Wednesday-Friday).
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
11. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID
(2 times a day) as needed for constipation.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please follow INR with goal INR of [**12-25**].
15. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO daily ()
for 2 doses: starting [**2133-11-10**].
16. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 doses: starting [**2133-11-12**].
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
3 doses: starting [**2133-11-14**].
18. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days: to finish 7 day course on [**2133-11-14**].
21. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26)
units Subcutaneous once a day.
22. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Eleven (11) ml Intravenous ASDIR (AS DIRECTED): Please
cont heparin IV until INR therapeutic at 2-3
Initial Heparin Infusion Rate: 1100 units/hr
please titrate to PTT 60-80 sec
PTT <40: 1000 units Bolus then Increase infusion rate by 250
units/hr
PTT 40 - 59: 500 units Bolus then Increase infusion rate by 100
units/hr
PTT 60 - 80*: PTT 80 - 120: Reduce infusion rate by 100 units/hr
PTT >120: Hold 60 mins then Reduce infusion rate by 250 units/hr
.
23. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) mg
mg Injection TID (3 times a day) as needed for severe agitation:
please monitor QTc if administering haldol.
Discharge Disposition:
Extended Care
Facility:
Rehab Hospital Of [**Doctor Last Name **]
Discharge Diagnosis:
Paroxysmal Atrial Fibrillation
Ventricular Tachycardia
Peritonitis
Chronic Renal Failure
Acute Renal Failure
End Stage Renal Disease on Hemodialysis
Acute Intensive Care Unit Psychosis
Hypothyroidism
Diabetes Mellitus
Sepsis
Adrenal Insufficiency
Heart Failure
Transudative Pleural Effusions
Clostridium Difficile infection
S/P Mitral valve replacement with porcine bioprosthesis
S/P Maze procedure
S/P Left atrial apendage ligation
S/P ICD wire implantation
Discharge Condition:
Stable, on trach mask, afebrile.
Discharge Instructions:
Please note, patient's blood pressure with the cuff in the right
arm is the same as his true arterial pressure as measured in an
arterial line in the ICU. His left arm continually measures 20
pts less than the A line or cuff pressure.
You are being discharged to a rehab facility to improve you
rlung function so that you will no longer need to use the
ventilator to assist in breathing.
You will get hemodialysis three times per week. Please ensure
that you get to dialysis as scheduled.
Please take all medications as directed.
Followup Instructions:
Needs to see Nephrologist for renal failure/Hemodialysis
Management.
Needs to return to [**Hospital1 18**] for ICD placement after rehab finished.
Needs to see cardiologist in light of recent cardiac surgery.
Needs to follow up with his PCP [**Name9 (PRE) 63066**] discharge from rehab.
Right Brachial PICC was placed on [**2133-11-3**].
Left Subclavian Dialysis line (tunneled catheter) placed
[**2133-10-16**].
Completed by:[**2133-12-8**]
|
[
"995.92",
"038.9",
"425.4",
"584.5",
"707.03",
"250.00",
"424.0",
"V53.31",
"459.2",
"997.4",
"427.1",
"427.31",
"428.0",
"577.0",
"536.42",
"403.91",
"560.1",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"99.15",
"88.67",
"46.39",
"43.19",
"37.26",
"39.64",
"37.27",
"39.95",
"37.34",
"00.41",
"37.33",
"31.1",
"33.24",
"39.61",
"38.95",
"96.6",
"39.50",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
28749, 28817
|
12763, 24833
|
304, 550
|
29320, 29354
|
1814, 1938
|
29933, 30377
|
1277, 1296
|
25748, 28726
|
28838, 29299
|
24859, 25725
|
29378, 29910
|
1311, 1795
|
257, 266
|
578, 1048
|
1954, 12740
|
1070, 1157
|
1173, 1261
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,739
| 149,532
|
28423
|
Discharge summary
|
report
|
Admission Date: [**2170-10-23**] Discharge Date: [**2170-11-3**]
Date of Birth: [**2105-11-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
tranfer from OSH for pancreatitis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
64 female with PMH HTN, Hyperchol, h/o DVTs and PE on lifelong
AC, presented to OSH with 1 day epigastric abdominal pain,
nausea, and vomiting. At [**Hospital3 **], Cr of 2.0, Ca 9.7, AST
of 189, ALT 131, Amylase of 6062, Lipase of 13,155, INR of 2.9,
WBC of 25.2, HCT of 43. Transferred to [**Hospital1 18**] for further
evaluation. CT @ OSH demonstrating pancreatitis and an ileus.
AT [**Hospital1 18**], she was found to have cholelithiasis and it was felt
that she may need ERCP for presumed gallstone pancreatitis.
Given her high INR (3.5), she was given 2 bags FFP on [**10-23**] to
reverse her INR. Then on [**10-24**], she was given another 2 bags of
FFP. In the late morning of [**10-24**], she was noted to have an
increased oxygen requirement ultimately desating to 91% on 3LNC
and 80% on RA, increased SOB, increased rales and wheezing on
exam noted after 1st bag of FFP. At that time, it was felt that
she may have become fluid overloaded. She was given 10 IV lasix,
FFP stopped and IVF stopped.
.
She was transferred to [**Hospital Unit Name 153**] for closer monitoring. Upon arrival
to ICU, T 102.4 BP 105/64 HR 97 RR 30 O2 FM 92%.
Currently denies any abdominal pain, SOB, cough, discomfort of
any type. She is otherwise not able to give a coherent history.
Past Medical History:
HTN
hyperlipidemia
h/o multiple DVTs/PE on lifelong coumadin (last DVT 15yrs ago)
h/o LLE phlebitis
Social History:
Tob: quit 15 yrs ago EtOH: none Illicit drug: none
Family History:
non contributory
Physical Exam:
Tm 102.4 BP 105/64 HR 97 RR 30 Sat 92% FM
Gen: breathing using excessory muscles, but able to converse
without becoming SOB
HENNT: MMM, anicteric, PERRL, EOMI
Neck: JVP 8 cm
CV: RRR, nl S1S2, No M/R/G
Lungs: decreased BS bilaterally at bases
Abd: soft, NT/ND, +BS, No HSM
Ext: no edema, strong DP pulses bilaterally
Neuro: A&Ox3; however, not compltely coherent
Skin: no rash
Pertinent Results:
[**10-23**]: Liver/GB U/S:
1. Normal-appearing pancreas with limited views.
2. Mild gallbladder wall thickening with no evidence of
distention or pericholecystic fluid.
3. Cholelithiasis with no evidence of choledocholithiasis
.
[**10-24**] CXR: Bilateral low lung volumes with probable bibasilar
atelectasis. No evidence for CHF or ARDS
[**2170-10-22**] 11:53PM WBC-18.8* RBC-4.58 HGB-13.5 HCT-40.1 MCV-88
MCH-29.4 MCHC-33.6 RDW-13.3
[**2170-10-22**] 11:53PM NEUTS-90.1* BANDS-0 LYMPHS-6.9* MONOS-2.0
EOS-0 BASOS-1.0
[**2170-10-22**] 11:53PM PLT SMR-NORMAL PLT COUNT-270
[**2170-10-22**] 11:53PM PT-33.6* PTT-30.3 INR(PT)-3.6*
[**2170-10-22**] 11:53PM GLUCOSE-124* UREA N-40* CREAT-1.8* SODIUM-139
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-19* ANION GAP-17
[**2170-10-22**] 11:53PM ALT(SGPT)-105* AST(SGOT)-118* ALK PHOS-92
AMYLASE-3359* TOT BILI-0.4
[**2170-10-22**] 11:53PM LIPASE-4398*
[**2170-10-22**] 11:53PM TRIGLYCER-125
ON DISCHARGE:
[**2170-11-3**] 06:45AM WBC= 11.1* Hb=8.8* Hct=26.4* Plt=432
[**2170-11-3**] 06:45AM Gluc=87 BUN=10 Cr=0.6 Na=137 K=3.6 CL=103
HCO3=25
ALT=106* AST=71* ALK PHOS=278* Tbili=0.3
INR=3.5
Brief Hospital Course:
1) Hypoxia: Unclear etiology. TRALI vs. flash pulm edema from
overly aggressive IVF for pancreatitis remain on the
differential, although no convincing story for either. She does
not appear to be volume overloaded at all, in fact CVP is low
and she is hypotensive. No PE on CTA. No evidence of pneumonia.
Transfusion medicine was alerted as to possibility of
transfusion reaction/TRALI induced by FFP received this AM.
Cardiac enzymes and echo ruled out cardiogenic pulmonary edema.
She was intubated in ICU, then given clinical improvement, she
was extubated and placed on supplemental oxygen. Over the next
day, she was weaned down on oxygen and by [**2170-10-29**], she was no
longer requiring supplemental O2.
.
2) Gallstone pancreatitis:
This resolved as amylase/lipase trending down rapidly. It is
likely that if she had biliary obstruction, the stone passed on
its own resulting in a precipitous decline in [**Doctor First Name **]/lip. She has
also been aggressively hydrated for pancreatitis. MRCP revealed
fluid around pancreas. Surgery was consulted and felt that based
on housfield units, this was not blood. Surgery concurred with
need for cholecystectomy but felt it should be done as outpt
once she is recovered from her acute illness. After ICU stay,
her LFTs were trending up again so lipitor d/c'd. They were
trending down for 2 days prior to discharge. [**Month (only) 116**] have been
secondary to colitis. She should stay off lipitor until they
are rechecked in 1 week and normalize.
.
3) Colitis: She had MRCP findings suggestive of colitis. In
addition, beginning on [**10-27**], she began to have increased stool
output (3L/day), guaiac negative. C. diff was sent and negative
X4, toxin B was sent which is pending at this point, but given
strong clinical suspicion, she was started on Flagyl 500 TID
empirically on [**2170-10-29**]. She will complete a 2 week course.
Her diarrhea was improving by discharge.
.
4) h/o DVT: Initially, INR was supratherapeutic. Coumadin was
held. Then heparin gtt was started given possibility of
surgery. Once it was deemed that pt would not have surgery as
inpt, coumadin restarted at 4mg daily. Her INR increased to 3.0
and 3.5 so coumadin held for 2 days and pt instructed to take
2mg day after discharge. She will have INR rechecked by PCP 2d
after discharged.
.
5) Fever: Spiked a fever to 102 upon arrival from floor.
Initially concerning for ascending cholangitis, cholecystitis,
abscess; however, no evidence of jaundice, fever curve has
remained low/afebrile since initial spike, or abdominal pain.
Blood cx; mycotic blood cx, U/A, UCx negative. She was
initially started empirically on Zosyn and Vancomycin, but as
she remained afebrile throughout the remainder of her ICU
course, Zosyn and Vanc were d/c'd.
.
6) Hemodynamics: Her BP and HR have been stable with occasional
fluid boluses. She transiently required Levophed for several
hours to maintain BP; however, for remainder of ICU and hospital
course, was hemodynamically stable.
.
7) HTN: She was initially held on all antihypertensives. Once
out of the ICU, her beta blocker were restarted and then her
Mavik. Her Maxzide was held due to diarrhea.
.
8) ANEMIA: After her ICU stay, her Hct remained in mid to high
20s. There was no evidence of bleeding. Iron studies were done
and show anemia of chronic inflammation.
Medications on Admission:
Atenolol 100 mg daily
Mavik 4 mg daily
Maxide 37.5/25 (years)
Coumadin 4 mg daily
Lipitor 10 daily
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
2. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Mavik 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime: hold
on [**11-3**], take on [**11-4**].
Disp:*30 Tablet(s)* Refills:*0*
5. Oxycodone 5 mg Capsule Sig: [**1-1**] Capsules PO every six (6)
hours as needed for pain for 2 weeks.
Disp:*30 Capsule(s)* Refills:*0*
6. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
CBC, AST/ALT, alk phos, total bili in about one week
8. Outpatient Lab Work
INR on monday [**11-5**]
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Cholelithiasis
Respiratory failure
Colitis, NOS
Discharge Condition:
Good
Discharge Instructions:
Please take medications as prescribed. Note the change in your
coumadin dose (do not take any tonite and then 2mg tomorrow) and
the fact that you should not take Maxzide or Lipitor until your
diarrhea liver tests are rechecked.
Follow up as instructed below.
Stay on a low-fat diet indefinitely.
Please call Dr. [**Last Name (STitle) **] if you experience abdominal pain,
severe nausea/vomiting, inability to tolerate food, worsening
diarrhea.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] this monday as planned. At
that time you should have your INR rechecked (last INR today is
3.5). He should also check your blood counts and liver function
tests--this doesn't need to be done monday but better to be done
later this upcoming week.
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**] in about 1 week (([**Telephone/Fax (1) 6347**])
to set up a follow up appointment for your gallbladder surgery.
|
[
"V58.61",
"518.81",
"272.4",
"574.20",
"790.4",
"558.9",
"V12.51",
"401.9",
"584.9",
"276.6",
"577.0",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7852, 7858
|
3481, 6844
|
351, 364
|
7973, 7980
|
2308, 3250
|
8476, 8978
|
1878, 1896
|
6994, 7829
|
7879, 7952
|
6870, 6971
|
8004, 8453
|
1911, 2289
|
3264, 3458
|
278, 313
|
392, 1670
|
1692, 1794
|
1810, 1862
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,485
| 100,133
|
36948
|
Discharge summary
|
report
|
Admission Date: [**2196-9-27**] Discharge Date: [**2196-10-17**]
Date of Birth: [**2151-3-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESLD
Major Surgical or Invasive Procedure:
[**2196-9-27**] liver transplant
History of Present Illness:
45M with history of EtOH cirrhosis, MELD 28 and Child class
C cirrhosis recently admitted to [**Hospital1 18**] last month for fevers,
anemia, ascites and ARF. In brief, during his recent hospital
course, he was treated for C.perfringens bacteremia and was
treated with Zosyn. Paracentesis was performed and did not
reveal
spontaneous peritonitis. EGD evaluation only showed Grade I
varices. His renal failure issues responded to octreotide and
midodrine. He was resumed on his diuretic and last Cr normalized
at baseline (1.0).
He is admitted in preparation for a liver transplant. Denies any
change in health since previous admission. Afebrile but still
rather lethargic at home. Tolerating regular diet. Normal bowel
habits, described as often loose. No abdominal tenderness but
tender to paracentesis site. Has not had any food since
midnight.
Past Medical History:
EtOH cirrhosis
EtOH Abuse
Gout
s/p appendectomy several yrs ago
h/o HTN now normotensive off all meds
[**2196-9-27**] liver transplant
Social History:
lives with wife and sons 10 and 14 yo. Works as an energy
broker. Denies drug or tobacco use. Quit drinking 6 weeks ago
Family History:
Adopted so family hx is unknown
Physical Exam:
98.9 91 128/77 18 98RA
Gen: AAOX3, NAD
HEENT: scleral icterus, MMM, EOMi, NCAT
Skin: Jaundice
Cardio: RRR
Pulm: CTAB
Abd: Soft, obese, umbilical hernia noted, tender to paracentesis
site, distended/ascites, spider angiomas
Ext: 3+ pitting edema b/l LE
Neuro: no focal deficits
CXR:
EKG: Sinus rhythm. Non-specific anterior ST-T wave changes.
Delayed precordial R wave transition
Labs:
135 97 11 estGFR: >75
---|----|----< 104
4.3 28 1.0
Ca: 9.7 Mg: 1.7 P: 3.4
ALT: 16 AST: 48 AP: 92 Tbili: 18.6 Alb: 4.0
7.7> 8.2 <149
25.1
PT: 27.2 PTT: 55.8 INR: 2.7
Fibrinogen: 59
Most recent workup:
Liver/RUQ US ([**2196-8-26**]): 1) Cirrhosis with ascites. 2) New,
partially occlusive main portal vein thrombosis extending into
the left portal vein. Please note, the study is limited because
the right portal vein, splenic vein, portal venous confluence
was
not well visualized. 3) Distended gallbladder without signs of
acute cholecystitis. Findings may be due to a fasting state
EGD ([**2196-8-26**]): Varices at the lower third of the esophagus and
gastroesophageal junction, Linear non bleeding erosion at 35 cm.
Erythema, abnormal vascularity and mosaic appearance in the
whole
stomach compatible with portal hypertensive gastropathy.
Otherwise normal EGD to second part of the duodenum
TTE [**8-30**]: EF> 60%
Pertinent Results:
[**2196-10-17**] 04:53AM BLOOD WBC-9.5 RBC-2.90* Hgb-8.7* Hct-27.0*
MCV-93 MCH-29.9 MCHC-32.1 RDW-16.4* Plt Ct-334
[**2196-10-13**] 09:32AM BLOOD PT-11.7 PTT-23.6 INR(PT)-1.0
[**2196-9-30**] 02:52AM BLOOD Fibrino-180
[**2196-9-27**] 05:00AM BLOOD Glucose-104 UreaN-11 Creat-1.0 Na-135
K-4.3 Cl-97 HCO3-28 AnGap-14
[**2196-9-28**] 04:16PM BLOOD Glucose-114* UreaN-30* Creat-2.3* Na-142
K-4.6 Cl-104 HCO3-28 AnGap-15
[**2196-9-30**] 10:50PM BLOOD Glucose-122* UreaN-70* Creat-4.6* Na-137
K-5.8* Cl-97 HCO3-26 AnGap-20
[**2196-10-2**] 06:10AM BLOOD Glucose-137* UreaN-87* Creat-5.2* Na-135
K-5.2* Cl-93* HCO3-26 AnGap-21*
[**2196-10-7**] 05:07AM BLOOD Glucose-147* UreaN-94* Creat-3.6* Na-130*
K-4.2 Cl-94* HCO3-24 AnGap-16
[**2196-10-17**] 04:53AM BLOOD Glucose-93 UreaN-69* Creat-2.0* Na-132*
K-5.2* Cl-100 HCO3-21* AnGap-16
[**2196-9-27**] 05:00AM BLOOD ALT-16 AST-48* AlkPhos-92 TotBili-18.6*
[**2196-10-17**] 04:53AM BLOOD ALT-33 AST-31 AlkPhos-276* TotBili-1.6*
[**2196-10-17**] 04:53AM BLOOD Calcium-8.7 Phos-4.7* Mg-1.5*
Brief Hospital Course:
On [**2196-9-27**], he underwent deceased donor liver transplant.
Surgeon was Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Two 19-French [**Doctor Last Name 406**] drains were
placed posterior to the liver and behind the portal structures.
Please refer to operative note for complete details. Aggressive
blood product resuscitation by anesthesiology staff as well as
administration of protamine was performed. Induction
immunosuppression was started intraop (solumedrol).
Postop, he was transferred to the SICU for management where he
received blood products to maintain hemodynamic stability per
protocol. LFTs initially increased as expected. Hepatic duplex
revealed inadequate flow demonstrated within the right posterior
portal vein which could have been technical in nature versus a
small amount of thrombus. Patency and appropriate direction of
flow within the hepatic arteries, hepatic veins, and the left
and main portal veins was seen. Splenomegaly was noted. A repeat
study on [**10-1**] revealed patency and appropriate direction of flow
within the hepatic and portal venous systems. High flow
velocities in the main portal vein, with aliasing in the
expected region of the anastomosis were noted. There was
notation of fatty infiltration of the liver. LFTs trended down
(ast 580, alt 530, alk phos 130, t.bili 6.6). JP outputs
remained high averaging 900-1100ml per day. LFTs started to
trend up on postop day 4 and 5. JP output appeared foamy.
On [**10-4**], an ERCP was performed noting common bile duct with mild
narrowing at the bile duct anastomosis, and minimal associated
proximal ductal
dilatation. There were no filling defects in the CBD or
intrahepatic ducts.
There was no evidence of bile leakage. A plastic biliary stent
was placed. Post procedure, amylase and lipase were wnl. JP
drain outputs continued to be high averaging as much as
2200ml/day. IV fluid replacements and albumin were administered
per output. The lateral JP was removed on [**10-5**]. The medial JP
continued to drain as much as 1800ml per day. IV lasix was given
for anasarca over several days. Teds stockings were applied with
improvement of edema. Weight decreased to 90.4 Kg on [**10-16**] from
117.4 on [**9-26**]. The medial JP was removed on [**9-14**]. The site
remained dry after suturing.
Of note, alk phos continued to rise to 518. Repeat ERCP was done
on [**10-13**]. There was no obstruction of the biliary stent. The
stent was exchanged. The alk phos continued to increase. On
[**10-14**], a liver biopsy was performed noting no rejection. Marked
bile ductular proliferation with associated neutrophilic
inflammation, focal ductal dilation, marked cholestasis, bile
plug formation and portal tract edema; Rare foci of mild portal
mononuclear inflammation with scattered eosinophils; no
endothelialitis or diagnostic involvement by acute cellular
rejection identified. No steatosis or viral inclusion was seen.
Rare peri-venular lipofuscin-laden macrophages, suggestive of
resolving reperfusion injury. After the ERCP, LFTS trended down
(ast 31, alt 33, alk phos 276, t.bili 1.6). The postop pyloric
feeding tube was replaced on [**10-6**] as this was removed during the
ERCP.
He experienced ATN likely from intraop hemodynamics. Creatine
was 1.0 on on [**9-27**]. This started to rise postop to as high as
5.2 on postop day 5. Very gradually, creatinine improved with.
Creatinine decreaed to 1.8 on [**10-13**], but started to trend up
again to 2.0 likely from Prograf as this trough was elevated.
Levels increased to 14.1 on [**10-16**]. Prograf dose was adjusted to
0.5mg [**Hospital1 **] on [**10-16**] for 1mg [**Hospital1 **]. Immunusuppression consisted of
cellcept 1gram [**Hospital1 **] which was well tolerated. Solumedrol which
was tapered per transplant protocol to prednisone. Prograf was
started on postop day 1 and adjusted per trough levels.
Diet was slowly advanced, but poorly tolerated as the patient
had no appetite. A postpyloric feeding tube was placed and tube
feedings were started (novasource renal). Oral intake slowly
increased, but was insufficient to support caloric needs.
On [**10-10**] Dermatology biopsied his L thumb for a chronic
non-healing, bleeding punctate lesion (started in [**4-21**]). Biopsy
report noted many features suggestive of lichen simplex
chronicus/prurigo nodularis, and the mild atypia which is
present is favored to be reactive in this context. The central
ulceration could be secondary to excoriation; alternatively, it
may represent a channel for transepidermal elimination of a
foreign body or in the setting of a perforating disorder
(although the clinical history is not suggestive of the latter).
An underlying pyogenic granuloma cannot be entirely excluded on
the basis of this sample; if clinical suspicion persists, deeper
sampling may be helpful for more definitive diagnostic
evaluation. The bleeding stopped and site remained clean and
dry.
PT worked with him extensively during this hospital course for
deconditioning. He did experience a fall onto right hip(slipped
while transferring to bed). He had pain with hip flexion and
pain on exam over greater trochanter. Xrays of the hip were
negative. He required contact guard and a rolling walker at time
of discharge, but was not ready for discharge to home. Rehab was
recommended and [**Hospital1 **] accepted him. He was transferred there
on [**10-17**].
Medications on Admission:
Folic Acid 1, Thiamine HCl 100, Ursodiol 300''', Ranitidine
HCl 150'', lactulose, Furosemide 20, Spironolactone 100, Zofran
4, Maalox, Rifaximin 200'''
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours): Please fax prograf trough levels to
[**Telephone/Fax (1) 697**].
Call [**Telephone/Fax (1) 673**] for dose adjustments, attn [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN
coordinator.
13. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
follow taper schedule per [**Hospital1 18**] Transplant .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
etoh cirrhosis s/p liver transplant [**2196-9-27**]
bile duct narrowing, s/p stent
malnutrition
Left thumb bleeding s/p biopsy: pyogenic granuloma
ATN, resolving
Discharge Condition:
good
Discharge Instructions:
Please call the [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 673**] if fever,
chills, nausea, vomiting, inability to take any of your
medications, jaundice, abdominal distension, increased abdominal
pain, edema, dizziness, incision redness/bleeding/drainage or
any concerns
Continue tube feedings as ordered (Novasource renal at 45cc/hr
continuously via the feeding tube)
Labs every Monday and Thursday by 9am for cbc, chem 10, LFTs,
albumin and trough prograf level with results fax'd to [**Hospital1 18**]
Transplant Office [**Telephone/Fax (1) 697**] attention [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN
coordinator [**Telephone/Fax (1) 10575**]
[**Month (only) 116**] shower, no heavy lifting/straining
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2196-10-20**] 3:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2196-10-27**]
11:30
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2196-10-27**] 1:20
Completed by:[**2196-10-17**]
|
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57,050
| 182,342
|
37198
|
Discharge summary
|
report
|
Admission Date: [**2129-12-18**] Discharge Date: [**2129-12-30**]
Date of Birth: [**2045-6-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
This is an 84 year old male with a history of emphysema, atrial
fibrillation, type II diabetes, and history of AAA repair who
presents from [**Hospital3 **] hospital with hematuria, hematemasis and
elevated lactate. History is taken per the patient's family.
He presented twice to Cape Code hospital within the past 24
hours. His initial presentation was for hematuria for which he
was prescribed ciprofloxacin. He presented again with
hematemasis and respiratory distress. He was found to be
tachypnic and unresponsive and was intubated. He had a foley
catheter placed which was subsequently palpable in the patient's
scrutum. He received methylprednisolone, albuterol, atrovent,
succinylcholine, etomidate, propofol and zosyn. He had a CT
abdomen and pelvis, the results are pending. He was transferred
here for further management.
.
In the ED, initial vs were: T 97.2 P 116 BP 106/76 R 25 96 O2
sat, Vent settings not listed. Noted to have new renal failure
and elevated lactate. The patient underwent a urology
evaluation, cystoscopy and foley placement attempt. He received
Levaquin, Versed and Propofol. Head CT here wnl. Abdominal CT
initially concerning for free air in abdomen. Also of note, the
patient was found to have unequal pupils R (surgical) pupil 5mm,
L pupil 1mm, that resolved after a negative Head CT.
.
On arrival to the ICU, the patient is intubated and sedated.
When sedation is lightened, the patient is non responsive.
Urology is present and attempting to replace the patient's Foley
catheter that does not appear to be in place.
.
A discussion with his wife reveals recent hematemesis for the
past 24 hours with hospitalization, the details of her story
were unclear. Additionally, she reports a medical history of
only "aneurysms down the front" which have been repaired by a
Dr. [**Last Name (STitle) **] on [**Location (un) 945**].
.
Review of systems: Unable to obtain
Past Medical History:
Atrial Fibrillation s/p PCM
Emphysema
DVT from Trauma
CAD, Htn, HLD
Hematuria
BPH
Urosepsis
DM2
H/o CVA
s/p AAA repair
s/p Appy
s/p CCY
Social History:
Lives with wife, unclear past habits. Son and wife unaware of
patients wishes regarding end of life.
Family History:
Father with stomach CA, mother unknown
Physical Exam:
Vitals: T: 93.1 BP: 130/62 P: 118 R: 31 O2: 100% on Invasive
Ventillation
General: Cachetic intubated man, not responsive to any stimuli.
HEENT: R surgical pupil, equal and reactive. Dry mucous
membranes.
Neck: JVP not elevated
Lungs: Wheezing and crackles throughout all lung fields.
CV: S1 & S2 fast and irregular, no murmur appreciated.
Abdomen: Thin/rigid, bowel sounds not present.
GU: Foley in place with blood at meatus, draining bloody urine
Ext: Cold, no edema, 1+ distal pulses.
Pertinent Results:
10:56am
7.28/43/204/21
Na:135 K:4.8 Cl:98 Glu:>500
freeCa:1.03
Lactate:10.5
Hgb:10.0 CalcHCT:30
O2Sat: 99
.
05:27a K:5.8 Lactate:7.7
140 102 47
-----------< 221
5.6 19 2.4
estGFR: 26/31 (click for details)
CK: 56 MB: Notdone
Mg: 2.3 P: 5.7
ALT: 26 AP: 179 Tbili: 1.0 AST: 36 TProt: 7.3
Dig: 1.7
.
12.7
32.5>---<291 13.7 291
43.2
N:93 Band:2 L:1 M:4 E:0 Bas:0
Poiklo: 1+ Macrocy: 1+ Tear-Dr: 1+
.
PT: 11.7 PTT: 27.3 INR: 1.0
[**12-29**] CXR:
Cardiac size is normal. NG tube tip is out of view below the
diaphragm but
likely in the stomach. Right IJ catheter tip is in the upper
SVC. Left
transvenous pacemaker lead terminates in unchanged position one
in the right atrium and the second one could be just at the
entrance of the right
ventricle. Moderate to large right pleural effusion has
minimally increased in size. Right IJ catheter tip in the
cavoatrial junction. Bilateral pulmonary enlargement is stable.
The lungs are hyperinflated due to emphysema. Right apical
opacity likely related with past tuberculosis and fibrotic
changes is stable. Left apical pleural thickening is also
stable. Asymmetric opacification of the lungs that is mild,
greater on the right side has increased on the right mid lung
and suggest a new area of infectious process. Otherwise mild
edema is stable.
[**12-26**] UE US: No evidence of deep vein thrombosis in the right
arm. The right cephalic vein could not be identified.
[**12-21**] CTA Head:
IMPRESSION: No significant abnormalities on CT angiography of
the head.
[**12-21**] CT Head:
IMPRESSION:
1. No evidence of acute hemorrhage or vascular territorial
infarction.
2. Evidence of remote infarction, possibly embolic.
[**12-19**] TTE:
Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. There
is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. The pulmonic valve leaflets are thickened. There
is moderate pulmonic valve stenosis. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade. Echocardiographic signs of tamponade may be absent in
the presence of elevated right sided pressures.
IMPRESSION: Hyperdynamic LV systolic function. There is an
increased gradient seen along the right ventricular outflow
tract. This could be from infra-pulmonic, supra-pulmonic or
pulmonic valve stenosis. There may be extrinsic compression of
the RVOT/proximal pulmonary artery causing this gradient. No
other valvular abnormality seen. No evidence of endocarditis
(cannot exclude). Small anteriori pericardial effusion without
evidence of tamponade.
[**12-18**] CT Cystogram/Pelvis:
1. The Foley catheter is within the urinary bladder. There is no
evidence of contrast leak. Multiple bladder diverticula are
seen.
2. Minimal amount of free air as well as small volume of free
fluid within
the deep pelvis (subperitoneal), consistent with history of
recent Foley
trauma.
[**12-18**] CXR (official read):
1. ET tube and NG tube as described above. The NG tube should be
advanced.
2. Left lower lobe peribronchiolar opacity concerning for
possible
aspiration. Follow up radiograph is recommmended.
3. Biapical pleural scarring, fibrosis and volume loss. Mild
right CP angle blunting. Likely due to granulomatous infection
(TB). The chronicity of this findings is unknown, follow up is
recommended.
[**12-18**] CT abdomen/pelvis:
. Malpositioning of the Foley catheter. The tip of the Foley
catheter is
seen outside of the urethra in the soft tissues of the left
hemipelvis with surrounding subperitoneal fluid, representing a
mixture of urine and
hemorrhage. The balloon of the Foley catheter is inflated in the
prostatic
portion of the urethra.
2. Trabeculated bladder with multiple large bladder diverticula
as described above.
3. No free intra-abdominal air.
4. Status post aorto-biiliac bypass.
5. Compression fracture of L1 of indeterminate age.
[**12-18**] CT Head:
MPRESSION: No evidence of hemorrhage.
NOTE AT ATTENDING REVIEW: The hypodensity, likely representing
chronic small vessel infarction, is most evident in the right
frontal periventricular white matter.
OSH Head CT: Head CT: Encephalomalacia is noted within the R
frontal lobe, prior infarct, no hemorrhage.
Head CT: IMPRESSION: No evidence of hemorrhage.
NOTE AT ATTENDING REVIEW: The hypodensity, likely representing
chronic small vessel infarction, is most evident in the right
frontal periventricular white matter.
Brief Hospital Course:
An 84 year old gentleman admitted from [**Hospital3 **] Hospital with
respiratory failure, hematuria, and urosepsis with enterococcus
and strep viridans in urine.
.
#Sepsis: On presentation appeared to have urosepsis w/ positive
UCx requiring pressors, though all blood has been negative. Pt
has had multiple previous UTI??????s, and had a traumatic foley
placement at OSH. OSH cultures positive for GPC??????s. and was
started on Ampicillin but spiked higher temps and coverage was
broadened to Vanc/Cefipime/Cipro when enterococcus and strep
viridans grew out in urine. He was on Ampicillin but
subsequently had coverage broadened to Vanc/Cefepime/Cipro on
day 2 due to fevers and hypotension, and respiratory distress
(believed to be from ventilator associated pneumonia - see
below). Patient improved and had pressors weaned off, extubated
successfully (see below for description of respiratory
distress). Patient was continued on a 14-day course of
Vanc/Cefepime/Cipro, but was then switched back to Ampicillin
after he clinically stabilized and after cultures were negative
for 48 hours. Is currently completeing a 14 day course of
Ampicillin (currently day [**1-9**] on day of discharge). Currently
afebrile and significantly improved mental status and
respiratory status with negative cultures. PICC line in place.
.
#Respiratory Failure: Initially intubated for respiratory
failure due to most likely VAP given fevers, but did not have
positive cultures. CT scan showed severe emphysema. CXR showed
possible left sided infiltrate. Patient was started on broad
spectrum abx as above (Vanc/Cipro/Cefepime), and respiratory
status improved, was sucessfully extubated and place on face
tent, then face mask. CXRs showed subsequent improvement but
did show pulmonary edema. Pt received Lasix with improvement of
respiratory status. Pt also received Albuterol and ipratropium
nebulizers during his hospital stay. The patient aspirated
during a repeat speech and swallow evaluation on the day of
anticipated discharge, and had a transient oxygen desaturation.
He was monitored overnight in-house with PO2 in the mid- to high
90's subsequently without evidence of infection. The patient
was instructed to take Lasix if he develops shortness of breath,
and to return to the hospital if shortness of breath does not
improve.
.
# Leukocytosis: No evidence of infection, may be reactive [**2-28**]
aspiration the day prior to discharge but no fever and no
evidence of infection, PO2 high 90's. Patient had C. diff sent
also, though no diarrhea. Will f/u with physician in rehab. If
patient develops diarrhea, given that he has been on
antibiotics, low threshold to test for c.diff and start
appropriate treatment.
.
#Atrial fibrillation/PVCs: Patient s/p pacemaker for unclear
underlying rhythm, although [**Hospital3 **] hospital notes history of
atrial fibrillation. He was monitored on telemetry, and was in
sinus tachycardia with PVC??????s, intermittent conduction block, and
his current rhythm is paced and tachycardic. Digoxin level was
normal, and patient was started on home Digoxin. Patient on
full-dose aspirin. The possibility of anticoagulation was
discussed, but this will have to be discussed further with his
primary care provider given his high risk of falls but history
of CVA.
.
# Neck soreness ?????? appears MSK due to position, extubation, etc.
Used warm compresses and wrote for standing Tylenol and morphine
liquid elixir drops on tongue (failed speech & swallow).
.
#Altered mental status: Initially had altered mental status,
likely multifactorial due to infection and toxic/metabolic from
medications. CTA of head and neck did not reveal abnormalities.
Improved with resolution of urosepsis.
.
# Right Upper Extremity Edema: Mild right upper extremity edema
without pain ?????? UE US ruled out thrombus. Edema self??????resolved.
.
#Acute Renal Failure: Initially in likely pre-renal acute renal
failure in the setting of sepsis, also possibly with component
of ATN and initially post-renal obstruction. Foley catheter was
successfully placed, IVF administered, Cr resolved currently at
baseline.
.
#Traumatic Foley Placement: Patient transferred after concern
that foley may be placed in scrotum. Initial CT concerning for
intraabdominal placement, but then believed pt has a bladder
diverticulum. Urology did cystoscopy to placed a Foley. They
recommended to keep Foley in place, do not remove without asking
urology first, keep secure to thigh with 2 catheter secures, f/u
with Urology when acute illness over. The patient was instructed
not to remove the Foley catheter until he saw Urology.
.
#Elevated Blood Sugars: Initially had elevated blood sugars in
the 500s on arrival to the MICU and started on insulin gtt.
Hyperglycemia resolved, insulin Gtt discontinued.
.
#Coronary Artery Disease: Details were unclear, continued home
Aspirin 81mg daily.
.
#Hyperlipidemia: Continued home Lipitor 10mg daily.
.
#FEN: Tubefeeds per Dobhoff.
.
Code: DNR, DNI.
Communication: Wife [**Name (NI) **] [**Telephone/Fax (1) 83765**]
Medications on Admission:
Lipitor 10mg PO daily
Aspirin 81mg PO daily
Pyrimidine, Cipro (recent for UTI)
Calcium Carbonate 1250mg PO daily
Prilosec 20mg PO daily
Multivitamin 1 tab PO daily
Digoxin 0.25mg PO daily
? Coumadin
Discharge Medications:
1. Digoxin 125 mcg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
3. Calcium 500 500 mg (1,250 mg) Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
once a day.
4. Multivitamin Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO once a day.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Telephone/Fax (1) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
6. Ampicillin Sodium 1 gram Recon Soln [**Telephone/Fax (1) **]: One (1) Recon Soln
Injection Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution [**Telephone/Fax (1) **]: One (1) Inhalation
Q6H (every 6 hours).
8. Acetaminophen 650 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
9. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1)
Injection TID (3 times a day).
10. Nystatin 100,000 unit/mL Suspension [**Telephone/Fax (1) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
11. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO BID (2 times a day).
12. Morphine 2 mg/mL Syringe [**Telephone/Fax (1) **]: 0.5-2 mg Injection Q4H (every
4 hours) as needed for pain: Must have droplets on tongue, as pt
is high aspiration risk and must be strict NPO.
13. Aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
14. Lansoprazole 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Urosepsis
Ventilator associated pneumonia
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 presented to [**Hospital3 **] from [**Hospital3 **] hospital for bloody
urine, bloody vomit, difficulty breathing, and abnormal lab
tests. You had a breathing tube placed at the outside hospital
for difficulty breathing, and also had a foley catheter placed
at [**Hospital3 **] hospital which had extended into your scrotum. A CT
scan at [**Hospital3 **] showed this was likely due to an open
fistula between your bladder and scrotum. The urologists placed
a foley catheter in the operating room to ensure it was in the
correct position, and you should follow up with them prior to
having anyone remove your foley catheter.
.
While in the hospital, you were treated with antibiotics for
your urinary tract infection, and also required medications to
keep your blood pressure elevated. You also had pneumonia
requiring antibiotics. You subsequently improved, and the
breathing tube was removed and the medications to increase your
blood pressure were able to be discontinued.
.
If you develop shortness of breath, you should take Lasix 20mg
IV to help your shortness of breath. If your shortness of
breath does not improve with Lasix, speak to your doctor and
return to the hospital.
.
The following changes were made to your medications:
- Ampicillin was started for a total of fourteen days. You
received this in the hospital, and will need one more day of the
antibiotic after leaving the hospital.
- Aspirin was increased to 325mg daily
.
If you develop any difficulties breathing, fever,
nausea/vomiting, or other concerning symptoms, please call your
doctor and return to the hospital.
Followup Instructions:
You will be seen by the doctor at the rehabilitation center.
Please also follow up with your primary care doctor once you
leave the rehabilitation center.
.
You will need to see a urologist once you leave the
rehabilitation facility to follow up on your foley catheter,
which you had placed in the hospital. DO NOT remove the foley
catheter until you see the urologist.
.
Your blood test (white blood cell count) was abnormal when you
left the hospital, but you did not have a fever and had no signs
of infection. You had a stool test sent but you should return
to the hospital if you develop fevers, cough, confusion, or
other concerning symptoms.
Completed by:[**2129-12-30**]
|
[
"785.52",
"427.69",
"038.9",
"V12.51",
"518.81",
"V85.0",
"427.31",
"276.2",
"414.01",
"349.82",
"492.8",
"300.00",
"723.1",
"V45.01",
"599.0",
"707.25",
"584.5",
"E849.7",
"486",
"507.0",
"996.31",
"272.4",
"285.9",
"E879.6",
"250.00",
"596.3",
"995.92",
"276.3",
"782.3",
"707.03",
"041.04",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"57.32",
"87.77",
"38.93",
"57.94",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14886, 14958
|
7920, 11440
|
321, 333
|
15043, 15043
|
3135, 4666
|
16839, 17522
|
2569, 2609
|
13256, 14863
|
14979, 15022
|
13033, 13233
|
15213, 16816
|
2624, 3116
|
2256, 2275
|
275, 283
|
361, 2237
|
7377, 7583
|
7693, 7897
|
15057, 15189
|
2297, 2434
|
2450, 2553
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,750
| 161,730
|
31491
|
Discharge summary
|
report
|
Admission Date: [**2131-8-17**] Discharge Date: [**2131-8-31**]
Date of Birth: [**2082-4-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic Dissection
Major Surgical or Invasive Procedure:
[**2131-8-17**] - Emergent Repair of Type A Aortic Dissection
1. Replacement of ascending aorta with a 26 mm Dacron tube
graft.
2. Complete aortic arch replacement with a 26 mm Dacron
tube graft and a 16 x 8 bifurcated Dacron graft going
from the neo ascending aorta to the left common
carotid artery and the innominate artery.
History of Present Illness:
The patient is a 49-year-old gentleman who presented with acute
chest pain. CT scan performed in an outside hospital made the
diagnosis of an acute type A aortic dissection with the
dissection extending from the sinotubular junction down to and
including both common iliac arteries. The origination of the
tear was thought to be in the mid to distal arch. The patient
was emergently transferred to [**Hospital1 1170**] for surgical management.
Past Medical History:
HTN
Cocaine/Alcohol abuse
Social History:
+ Smoking and alcohol use. + Cocaine use.
Family History:
Unknown
Physical Exam:
BP 112/62
Sedated/Intubated
NCAT, anicteric sclera, ETT in place
Coarse breath sounds bilaterally
RRR, No murmur
Abdomen is soft, nondistended. Guaiac negative
Extremities warm, 1+ edema. Right DP pulse absent and 1+ right
femoral pulse.
Pertinent Results:
[**2131-8-17**] Ultrasound
Preserved arterial flow within each kidney and the celiac axis.
Peak arterial velocity within the left kidney is decreased
compared to the right, though diastolic flow is preserved
bilaterally. See comments.
[**2131-8-17**] ECHO
PRE-BYPASS:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. A
mobile density is seen in the ascending aorta, arch and
descending thoracic aorta consistent with an intimal flap/aortic
dissection. There is flow in the false lumen. The point of
origin seems to be in the distal arch. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. There is no pericardial effusion.
There is left pleural effusion. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
POST_BYPASS:
Normal biventricular systolic function. LVEF 55% Aortic graft is
seen in the ascending and arch position without any initimal
flap. The intimal flap starts from the distal arch and going all
the way into the distal thoracic aorta visualized. There is no
aortic regurgitation. Tirvial MR, TR.
[**2131-8-27**] MRA
1. Status post repair of extensive type A aortic dissection with
intact and patent ascending aortic graft and bifurcated graft
which is anastomosed to the left common carotid and right
brachiocephalic arteries. A small amount of perigraft fluid is
demonstrated. No evidence of leakage from the graft.
2. Dissection flap noted to involve the proximal aspect of the
left subclavian artery and extending inferiorly into the
abdomen.
3. Evaluation of the dissection flap within the abdominal aorta
is limited due to technique with marked compression on the true
lumen demonstrated in the abdominal aorta. Previous CT from
[**Hospital3 10377**] Hospital demonstrated marked compression
of the true lumen, which supplied the celiac and superior
mesenteric arteries. The right renal artery is supplied by both
lumens, with the dissection flap extending into the proximal
aspect. Two left renal arteries are demonstrated, the superior
one appearing to be supplied by both lumens with the dissection
flap extending into its proximal aspect, and the inferior left
renal artery supplied by the false lumen.
Brief Hospital Course:
Mr. [**Name13 (STitle) 37081**] was admitted to the [**Hospital1 18**] on [**2131-8-17**] via med
flight for emergent management of his type A aortic dissection.
He was taken directly to the operating room where he underwent
repair of a type A aortic dissection. Please see operative note
for details. Postoperatively he was taken to the intensive care
unit for monitoring. The vascular surgery service was consulted
regarding his renal perfusion. Although decreased left renal
blood flow was noted, his urine output was sufficient and it was
decided to observe him. The nephrology service was also
consulted and followed him daily for acute tubular necrosis
related to hypoperfusion during his surgery. He remained
intubated due to agitation however was able to be extubated on
postoperative day three. Lasix was used for diuresis and to
maintain an adequate urine output. Labetolol was used to control
his blood pressure. A swallow evaluation was performed which
showed him to swallow effectively. Mr. [**Known lastname 12997**] continued to
have periods of confusion requiring restraint as he pulled out
his catheter and intravenous lines. Ativan was used with
successful control of his agitation and a 24 hour sitter was
placed in his room. He was transfused for anemia. The addiction
service was consulted for assistance with his prior drug and
alcohol abuse.
On postoperative day seven, Mr. [**Known lastname 12997**] was transferred to the
step down unit for further recovery. A renal MRA was obtained
which showed the right renal artery was supplied by both lumens,
with the dissection flap extending into the proximal aspect. Two
left renal arteries were demonstrated, the superior one
appearing to be supplied by both lumens with the dissection flap
extending into its proximal aspect, and the inferior left renal
artery supplied by the false lumen.
Labetalol restarted on [**9-26**] for hypertension and his renal
function was monitored closely for possible continuing
compromise of flow. Gentle diuresis restarted on [**8-29**] after
renal perfusion scan done.Renal artery intervention was
discussed with the pt., but he refused. Left arm phlebitis
continued to improve.Addiction service also consulted. BP meds
titrated and cleared for discharge to home with services on POD
#14. Labs are scheduled for [**9-5**] and appt. with Dr. [**Last Name (STitle) **] (
vascular) scheduled for [**9-7**]. Repeat CXR will be done with appt.
for Dr. [**Last Name (STitle) 914**] on [**9-12**].
Medications on Admission:
benicar
lotrel
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Diltiazem HCl 420 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*0*
13. Outpatient Lab Work
Please obtain Chem 10 on [**2131-9-5**].
Please have the results faxed to Dr. [**Last Name (STitle) **] at FAX: ([**Telephone/Fax (1) 74117**] prior to your office visit.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Location (un) 5503**]
Discharge Diagnosis:
Type A Aortic Dissection
Cocaine/Alcohol abuse
HTN
Discharge Condition:
Good.
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] (PCP) in [**1-9**] weeks
Dr. [**Last Name (STitle) 914**] (Cardiac Surgery) Phone:[**Telephone/Fax (1) 170**], [**Hospital Ward Name **].
[**Hospital Unit Name **] on [**2131-9-12**] at 2:30. CXR prior to seeing Dr. [**Last Name (STitle) 914**].
Dr. [**Last Name (STitle) **] (nephrology) in 1 week
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Vascular Surgery) in his office ([**Last Name (NamePattern1) 8028**], LMOB 5B on [**9-7**] at 1:30PM. You will need to have a
Chemistry 10 / Complete Metabolic Panel drawn to assess your
Creatinine 2 days prior to your visit. Please have the results
faxed to Dr. [**Last Name (STitle) **] at FAX: ([**Telephone/Fax (1) 25065**] prior to your office
visit.
Completed by:[**2131-10-9**]
|
[
"307.9",
"305.01",
"584.9",
"401.9",
"441.01",
"305.62",
"276.8",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
8399, 8476
|
4245, 6743
|
294, 640
|
8571, 8579
|
1519, 4222
|
9294, 10084
|
1237, 1246
|
6808, 8376
|
8497, 8550
|
6769, 6785
|
8603, 9271
|
1261, 1500
|
237, 256
|
668, 1113
|
1135, 1162
|
1178, 1221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,236
| 100,151
|
19040
|
Discharge summary
|
report
|
Admission Date: [**2146-10-13**] Discharge Date: [**2146-10-23**]
Date of Birth: [**2072-12-29**] Sex: M
Service: Hepatobiliary
REASON FOR ADMISSION: This is an admission for a head of the
pancreas mass.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
healthy gentleman who presented to an outside hospital in
[**2146-7-26**] with cholangitis and gram-negative bacteremia.
After he was transferred to [**Hospital1 188**], later in his hospital course, workup with an
endoscopic retrograde cholangiopancreatography revealed a
smooth stricture in the distal common bile duct and a
subsequent computed tomography noted no evidence of a
pancreatic mass; however, later evaluations did reveal a
pancreatic mass.
He is currently asymptomatic without fevers, chills, nausea,
vomiting, pruritus, jaundice, dark urine, or loose stools.
He is here for elective resection of the pancreatic mass
which was shown on the [**9-29**] computerized axial
tomography.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Transient ischemic attacks.
3. Cholangitis.
PAST SURGICAL HISTORY: None.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: (His medications included)
1. Aspirin 81 mg by mouth once per day; last took aspirin on
[**2146-9-28**].
2. Lotrel 5 mg and 10 mg respectively by mouth once per day.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Hepatobiliary Surgery Service and was taken to the
operating room for a Whipple procedure. Please review the
previously dictated Operative Note by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] from
[**2146-10-14**] for the specifics of this procedure.
In brief, an open cholecystectomy and pylorus-preserving
Whipple procedure were performed.
The patient tolerated the procedure well. Postoperatively,
he was transferred to the Postanesthesia Care Unit and then
to the floor without complications.
His postoperative pain was initially controlled with a
Dilaudid epidural which he tolerated until day four, at which
time he started to complain of hallucinations. The epidural
was stopped, and the patient was placed on Toradol until he
tolerated by mouth medications.
1. CARDIOVASCULAR ISSUES: Cardiovascularly, the patient did
well. However, he did have some problems with tachycardia
and some atrial ectopy which presented itself on
postoperative day six. These tachycardic episodes were
controlled with Lopressor, and a Cardiology consultation was
obtained. The Cardiology team decided that anticoagulation
was not necessary as it was neither was it atrial
fibrillation nor what they considered to be a chronic or
continuing process.
An echocardiogram was performed on postoperative day six
which showed a normal left ventricle, with an ejection
fraction of greater than 55%, and a moderately dilated left
atrium, and mildly thickened aortic and mitral valves.
2. RESPIRATORY ISSUES: The patient did have some
postoperative atelectasis which was controlled with incentive
spirometry and pulmonary toilet.
3. GASTROINTESTINAL ISSUES: Gastrointestinally, after the
surgery the patient was obviously nothing by mouth and given
intravenous fluids. In addition, he was given octreotide and
Reglan to reduce his pancreatic juice output and to increase
his gastric motility.
Prior to his discharge, on postoperative day six, the amylase
in his [**Location (un) 1661**]-[**Location (un) 1662**] drain was checked and was 201. It was
decided to keep the [**Location (un) 1661**]-[**Location (un) 1662**] drain in until his
follow-up appointment with Dr. [**Last Name (STitle) 468**].
Of final note, one complication of this procedure was a wound
infection. The patient was maintained on oxacillin for
several days postoperatively for erythema surrounding the
wound. Eventually, the erythema got a little bit worse. On
[**10-22**], the wound was opened with some expulsion of
purulent material. This was packed open, and the patient
defervesced and any signs of fluctuance relieved themselves.
At the time of discharge, the patient had been afebrile for
greater than 24 hours.
Finally, the patient's pathology from the surgery revealed
pancreatic adenocarcinoma, a moderately differentiated ductal
adenocarcinoma, with a TNM classification of T3 N1 MX. The
patient had [**2-6**] lymph nodes involved. The margins of the
resected mass were not involved by carcinoma, and there was
no lymphatic vessel invasion.
On the day of discharge, the patient was afebrile with stable
vital signs. In general, he appeared well. In no apparent
distress. Cardiovascular examination revealed a regular rate
and rhythm. The lungs were clear to auscultation
bilaterally. The abdomen was obese, soft, nontender, and
nondistended with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain in the right upper
quadrant. The abdominal wound from the surgery was open with
a wick in it with no signs of continued infection. He still
had some slight pedal edema.
DISCHARGE DISPOSITION: Therefore, on [**10-23**] (which was
postoperative day 10). The patient was discharged home with
visiting nurse services with the following diagnoses:
DISCHARGE DIAGNOSES:
1. Pancreatic adenocarcinoma (stage T3 N1).
2. Status post pylorus-sparing Whipple procedure.
3. Hemodynamic monitoring with central venous catheter.
4. Hypovolemic ............ including resuscitation.
5. Hypokalemia.
6. Hypermagnesemia.
7. Postoperative atelectasis.
8. Atrial fibrillation.
9. Cellulitis.
10. Wound infection.
11. Hyperglycemia.
MEDICATIONS ON DISCHARGE: (His discharge medications
included)
1. Vicodin one tablet by mouth q.4-6h. as needed (for
breakthrough pain).
2. Amlodipine 5 mg by mouth once per day
3. Benazepril 10 mg by mouth once per day.
4. Reglan 10 mg by mouth four times per day.
5. Protonix 40 mg by mouth once per day.
6. Metoprolol 50 mg by mouth twice per day.
7. Levofloxacin 500 mg by mouth once per day.
8. Miconazole powder applied as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. [**Hospital6 407**] was sent to assist with wound
care, drain education and blood glucose monitoring.
2. He has a follow-up appointment with Dr. [**Last Name (STitle) 468**] on the
13th.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2146-10-25**] 21:32
T: [**2146-10-28**] 09:09
JOB#: [**Job Number 52004**]
|
[
"157.0",
"196.2",
"427.31",
"575.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"52.7"
] |
icd9pcs
|
[
[
[]
]
] |
5077, 5230
|
5251, 5609
|
5636, 6056
|
1184, 1361
|
6089, 6546
|
1096, 1157
|
1390, 5053
|
252, 981
|
1003, 1071
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
188
| 192,557
|
20258
|
Discharge summary
|
report
|
Admission Date: [**2160-11-25**] Discharge Date: [**2160-11-28**]
Date of Birth: [**2105-5-18**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Ambien / Shellfish Derived
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 55 yo M with PMHx sig. for hep C and HCC, s/p
failed liver [**First Name3 (LF) **] in [**2156**] and currently in decompensated
liver failure with recurrent encephalopathy and ascites, who
presents with hepatic encephalopathy. He presented to [**Hospital 7912**] today with malaise, fatigue x 1 day. He was noted
to be encephalopathic. CT scan was normal. His ammonia level was
357. He received lactulose 30 cc and was sent to [**Hospital1 18**].
.
Of note, he was recently discharged from [**Hospital1 18**] on [**11-22**] for an
admission for hepatic encephalopathy, which improved with
lactulose and rifaximin and decreasing narcotic regimen. Per the
sister, who is a nurse, on [**Name (NI) 1017**], the patient was initially
only given 30 cc of lactulose instead of 60 cc due to confusion
with discharge instructions. His sister had caught this mistake
and gave the patient extra lactulose [**Name (NI) 1017**] afternoon. On
[**Name (NI) 766**], he was doing relatively well. However, he was
complaining of back pain and received an extra dose of oxycodone
5 mg in the evening. On Tuesday, his mental status deteriorated
throughout the day until his wife found him unresponsive.
.
In the ED, VS: 97.6, 178/100, 60, 18, 97RA. Pt was obtunded. A
history could not be obtained. Exam was positive of ascites,
nontender. Labs were sig. for INR 1.6, TB 1.9. Cr was 2.1, at
baseline. He received lactulose. He has an NGT.
Past Medical History:
- Hepatitis C cirrhosis and hepatocellular carcinoma s/p
radiofrequency ablation x 3, s/p liver transplantation [**1-10**]
- Recurrent Hep C after Transpant- last viral load 69 on [**2158-7-11**].
- HTN
- Hx of Type II DM
- Adrenal Insufficiency: [**2158-11-6**]. After CortisalStimulation
test.
- s/p appendectomy
- s/p tonsillectomy
- s/p cervical laminectomy
- s/p right forearm ORIF
- s/p bone graft from right hip to elbow
- s/p knee surgery
Social History:
Former fireman and barowner; positive tobacco history; 2 packs
per day x 30 years, quit prior to liver [**Year (4 digits) **]. He is not
using IV drugs.
Family History:
His father has renal failure. His mother has hypothyroidism.
Physical Exam:
PHYSICAL EXAM
GENERAL: Pleasant, well appearing, NAD, mild jaundice, drowsy,
HEENT: Normocephalic, atraumatic. No conjunctival pallor.
PERRLA/EOMI. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 SEM,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Abdomen distended, non tender
EXTREMITIES: 2+ pitting edema to knees, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Oriented to person and place, somnolent but arousable,
moves all extremities, + asterixis, has difficulty understanding
questions. when asked for date, he said "[**Hospital3 **]"
Pertinent Results:
[**2160-11-25**] 09:00PM URINE HOURS-RANDOM
[**2160-11-25**] 09:00PM URINE GR HOLD-HOLD
[**2160-11-25**] 09:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2160-11-25**] 09:00PM URINE [**Month/Day/Year 3143**]-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-NEG
[**2160-11-25**] 09:00PM URINE RBC-[**4-10**]* WBC-[**4-10**] BACTERIA-NONE
YEAST-NONE EPI-[**4-10**] RENAL EPI-0-2
[**2160-11-25**] 08:10PM GLUCOSE-279* UREA N-32* CREAT-2.1* SODIUM-134
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-13* ANION GAP-13
[**2160-11-25**] 08:10PM ALT(SGPT)-38 AST(SGOT)-58* ALK PHOS-133* TOT
BILI-1.9*
[**2160-11-25**] 08:10PM LIPASE-144*
[**2160-11-25**] 08:10PM AMMONIA-163*
[**2160-11-25**] 08:10PM WBC-5.7 RBC-2.71* HGB-8.7* HCT-26.5* MCV-98
MCH-32.2* MCHC-32.9 RDW-16.1*
[**2160-11-25**] 08:10PM NEUTS-78.4* LYMPHS-11.4* MONOS-5.8 EOS-4.3*
BASOS-0.2
[**2160-11-25**] 08:10PM PLT COUNT-101*
[**2160-11-25**] 08:10PM PT-17.7* PTT-35.6* INR(PT)-1.6*
Brief Hospital Course:
#. Hepatic encephalopathy - On admission, he was restarted on
his home dose of lactulose, rifaximin and cipro. His home
oxycodone was held. Abdominal ultrasound was deferred as
recently performed on [**2160-11-3**]. On transfer to the floor his
mental status improved. As he had no fever, no leukocytosis,
and no abdominal pain, diagnostic paracentesis was not
performed. On discharge his mental status was at his baseline.
He was alert and oriented to person, place and time and could
answer detailed questions about his background.
.
#. ESLD s/p [**Date Range **] - He was continued home doses of
tacrolimus and bactrim. His dose of tacrolimus was decreased to
0.5mg PO daily on discharge. Follow up was arranged with the
liver [**Date Range **] center.
.
#. Low back Pain - Oxycodone was stopped completely. Pain was
controlled with lidocaine patches. On discharge, patient said
his pain was much improved.
.
#. Adrenal insufficiency - His home dosing of hydrocortisone was
continue throughout this hospitalization.
.
#. DM - Patient was continued on his home dose of insulin 70/30
68 units q am, and 55 units q pm, with a humalog sliding scale.
.
#. Depression - Patient was continued on his home dose of paxil.
Medications on Admission:
- Doxazosin 1mg PO QHS
- Ciprofloxacin 750mg PO Qweek
- Hydrocortisone 10mg PO QAM, 5mg QHS
- Lactulose 60ml PO QID
- Metoprolol tartrate 50mg PO BID
- Oxycodone 5-10mg PO Q8hrs PRN pain
- Pantoprazole 40mg PO Q12hrs
- Paroxetine 20mg PO daily
- Rifaximin 600mg PO BID
- Sucralfate 1gram PO BID
- Tacrolimus 0.5mg PO Q12hrs
- Trimethoprim-Sulfamethoxazole 80-400mg PO QMWF
- Ferrous sulfate 325mg (65mg Iron) PO BID
- Magnesium oxide 400mg PO daily
- Insulin dosing: NPH 50units QAM, 40units QPM; Humalog ISS
Discharge Medications:
1. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
2. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF ([**Date Range 766**]-Wednesday-Friday).
12. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO QSUN
(every [**Date Range 1017**]).
13. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO every
4-6 hours: Titrate to [**4-9**] BM /day.
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
15. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
16. Insulin
Please administer insulin 70/30, 68 units every morning, and 55
units at bedtime. Please continue fingerstick glucose
measurements 4 times daily, and continue administering humalog
according to your sliding scale.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Hepatic Encephalopathy
Hepatitis C Cirrhosis
s/p liver [**Hospital3 **]
Discharge Condition:
Stable, alert and oriented to person, place and time.
Ambulating without assistance.
Discharge Instructions:
You were admitted with confusion and abdominal distention. We
stopped your oxycodone and gave you lactulose and your mental
status improved.
The following changes were made in your medications:
- STOP taking oxycodone
- Please CHANGE your dose of prograf (tacrolimus) to 0.5 mg by
mouth, once daily.
- Please take 60 mL lactulose every 4-6 hours as needed to have
[**4-9**] bowel movements/day. If you become confused, take lactulose
every two hours until your confusion resolves.
It is very important that you stop taking oxycodone. It is also
very important that you take your lactulose regularly and that
you increase the amount of lactulose you take if you begin to
get confused.
Please adhere to your follow-up appointments. They are important
for managing your long-term health.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please follow up with the following appointments:
Liver [**Month/Day (3) 1326**] Center - [**Location (un) **] [**Hospital **] Medical Office
Building - [**Last Name (NamePattern1) **]. [**Location (un) 86**], MA. [**12-15**], 8:00am.
|
[
"789.59",
"E878.0",
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"571.5",
"285.21",
"287.5",
"255.41",
"585.9",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7679, 7730
|
4227, 5451
|
308, 315
|
7846, 7933
|
3182, 4204
|
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|
2434, 2497
|
6010, 7656
|
7751, 7825
|
5477, 5987
|
7957, 8991
|
2512, 3163
|
259, 270
|
343, 1776
|
1798, 2247
|
2263, 2418
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,496
| 130,022
|
40617
|
Discharge summary
|
report
|
Admission Date: [**2138-6-10**] Discharge Date: [**2138-6-12**]
Date of Birth: [**2058-12-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a pleasant 79 year old male who presented earlier
today with complains of BRBPR. In the past several days he has
been experiencing abdominal cramps and was evaluated at the [**Hospital **]
Hospital, where patient stated he was admitted for about 2 days.
We do not have records from the visit. Patient reports there was
no bleeding per rectum on that admission. This morning he
noticed
bright blood with his bowel movements and felt little bit
lightheaded. At the [**Hospital1 18**] [**Location (un) 620**], his HCT was 40.8 and repeat
was 35. He had a CT abdomen and pelvis which showed active
bleeding at the sigmoid [**Location (un) 499**]. He was subsequently transferred
to
us for angiogram. Patients is hemodynamically stable. He has
continued bright red blood per rectum. He denies any fevers,
chills. He reports history of similar episode of BRBPR about 15
years ago, which was stopped. Patient had a colonoscopy at that
time. One and a half year ago he had another episode of BRBPR
rectum which seemed to originate from the internal hemorrhoids,
which were banded at that times. Patient has not had any
problems
with the hemorrhoids since.
Past Medical History:
PMH:
- sigmoid diverticulosis
- lower GI bleed 15 years ago
- internal hemorrhoids
- hypertension
- hyperlipidemia
- CAD s/p CABG in [**2123**]
PSH:
- CABG [**2123**]
- appendectomy 44 years ago
- TURP [**2121**]
Social History:
no etoh, no smoking, lives alone, drives, is independent,
visits gym regularly, lifts weights
Family History:
one out of six brothers had [**Name2 (NI) 499**] cancer in his 50s
Physical Exam:
Temp 98.2 HR 88 BP 123/88 RR 16 O2 sat 100% RA
gen: NAD
CV: RRR
pulm: CTA b/l
abd: mildly softly distended, hypoactive bowel sounds, minimally
tender, no rebound, no guarding
rectal: no external hemorrhoids, there is bright red blood in
the
rectum
extremities: no edema
Pertinent Results:
[**2138-6-10**] 07:45PM WBC-21.0* RBC-4.12* HGB-12.2* HCT-35.3*
MCV-86 MCH-29.7 MCHC-34.6 RDW-14.9
[**2138-6-10**] 07:45PM PLT SMR-NORMAL PLT COUNT-218
[**2138-6-10**] 07:45PM PT-12.6 PTT-23.5 INR(PT)-1.1
[**2138-6-10**] 07:45PM GLUCOSE-116* UREA N-18 CREAT-1.1 SODIUM-131*
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-10
[**2138-6-10**] CTA ABd/pelvis :
1. FOCUS OF ACTIVE EXTRAVASATION WITHIN THE SIGMOID [**Month/Day/Year **].
SIGNIFICANT SIGMOID DIVERTICULOSIS.
2. SIX MM RIGHT MIDDLE LOBE PULMONARY NODULE FOR WHICH
FOLLOW-UP
CHEST CT IN ONE YEAR IS RECOMMENDED.
[**2138-6-10**] CT Angiogram :
1. [**Female First Name (un) 899**] angiography demonstrated conventional anatomy.
2. [**Female First Name (un) 899**] angiography and selective sigmoid branch angiography did
not
demonstrate any active extravasation. Specifically, branches
that were
corresponding to the area of concern on the prior CTA were
targeted, and no extravasation was identified.
Brief Hospital Course:
Mr. [**Known lastname 77996**] was evaluated by the Acute Care team in the
Emergency Room and admitted to the hospital for further work up
of his GI bleed. He was admitted to the ICU and made NPO and
hydrated with IV fluids. On [**2138-6-10**] he underwent an angiogram
which demonstrated no active bleeding. His hematocrit was 32 on
admission and remained in that range of 30-32.
Following transfer to the Surgical floor his hematocrit remained
stable. He started a regular diet and was having formed BM's
although he did have blood noted on the toilet paper. The GI
service recommended a colonoscopy in 4 weeks as long as his
hematocrit was stable. He also requested referral for a new PCP
and was given that information. He will need a follow up chest
CT in 1 year as he had a 5mm RML nodule found on his CT scan
from [**Location (un) 620**]. He was discharged on [**2138-6-12**] and will follow up
with the GI service.
Medications on Admission:
metoprolol 25 mg [**Hospital1 **], aspirin 81 mg once daily, lipitor 15 mg
once daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. atorvastatin 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with rectal bleeding and
your blood count decreased, indicating that you had an active
bleed. An angiogram was done which showed no active bleeding at
this time and your blood count has been stable for the last 24
hours.
* Continue to eat a regular diet and stay well hydrated. Make
sure that you take a stool softener daily.
* You will need a colonoscopy in one month and you can book it
with the [**Hospital **] Clinic for a convenient time.
* If you develop any increased bleeding, dizziness or any other
symptoms that concern you please call your doctor or return to
the Emergency Room.
Followup Instructions:
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 463**] for a follow up appointment
in 4 weeks with a colonoscopy.
Call [**Hospital6 733**] at [**Telephone/Fax (1) 250**] to arrange an
appointment with a primary care doctor. You will need a Chest CT
scan in one year to follow up on a small nodule in your right
lung.
Completed by:[**2138-6-12**]
|
[
"272.4",
"V45.81",
"790.01",
"569.3",
"414.00",
"401.9",
"518.89",
"455.0",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
4653, 4659
|
3273, 4206
|
319, 326
|
4712, 4712
|
2265, 3250
|
5516, 5873
|
1882, 1951
|
4343, 4630
|
4680, 4691
|
4232, 4320
|
4863, 5493
|
1966, 2246
|
264, 281
|
354, 1515
|
4727, 4839
|
1537, 1753
|
1769, 1865
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,264
| 133,806
|
9112
|
Discharge summary
|
report
|
Admission Date: [**2102-8-14**] Discharge Date: [**2102-8-24**]
Date of Birth: [**2061-5-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
nausea, dry heaving, rectal bleeding
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Pt is a 41 yo F w/ PMHx of seizure d/o, chronic back pain,
partial gastrectomy, for obesity, who presented with vague hx of
intermittent nausea and dry heaving for 3-4 months, not
associated w/ abdominal pain, but associated with anorexia and
recently, over the past week with occasional fevers (to 102),
chills, weakness, fatigue. She admits to poor PO intake over
recent weeks, as well as occasional dizzyness when standing up
and a syncopal episode.
.
(Hx below from prior admission notes and verified during Pt
interview):
.
She has had a 25-30 pound wt loss over the past 2 months, as
well as leg and arm swelling. There was no recent travel,
unusual foods, sick contacts, or new pets. She also notes
constipation x3 mos leading to painful straining and bloody
stools, which was evaluated by flex sig at OSH showing
hemorrhoids. She was started on docusate and notes loose stools
lately associated with taking more laxatives.
.
Since admission, CT was done and showed pancolitis. GI was
consulted and did upper endoscopy which was normal. Colonoscopy
was aborted for poor prep. Two days ago, the patient developed
sharp chest pain radiating to her shoulders, no exertional
component, no change with inspiration or cough. She has had
dyspnea and chest pressure for the past week that has been
constant. Cardiac markers showed trop peak at 0.41 with CK/CKMB
normal and no EKG changes. Cards was consulted and felt this was
not an MI, maybe myocarditis, and requested TTE. This was done
today showing systolic and diastolic dysfunction (LVEF 20-30%)
with a small effusion and possible early tamponade.
.
During this admission, Pt has been persistently tachycardic
(100s to 120s) and this evening Pt was noted to have a HR
130s-140s.
.
On review of systems, s/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. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- Epilepsy
- Cholelithiasis
- Degenerative disc disease
- Partial gastrectomy for obesity
- Lysis of adhesion 3 weeks after gastrectomy
Social History:
single, works at [**University/College **] as administrator. Recent breakup from
boyfriend. Lives alone. Brother is a support
-Tobacco history:None
-ETOH: social
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T= 97.4 BP= 104/75 HR= 104 RR= 18 O2 sat= 99%
GENERAL: NAD, Alert and Oriented x3. Flat affect.
HEENT: NCAT. Sclera anicteric. Pupils somewhat dilated but
equally round and reactive to light and accomodation, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with non elevated JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ lower extremity and upper extremity edema. No
clubbing or cyanosis
SKIN: traumatic erythematous patch on R lower extremity
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
On Admission:
[**2102-8-14**] 01:04PM WBC-18.5*# RBC-4.59 HGB-13.1 HCT-44.4#
MCV-97# MCH-28.5 MCHC-29.5*# RDW-14.0
[**2102-8-14**] 01:04PM NEUTS-84.0* LYMPHS-11.0* MONOS-4.6 EOS-0.1
BASOS-0.3
[**2102-8-14**] 01:04PM PLT COUNT-577*#
[**2102-8-14**] 01:04PM ALBUMIN-2.6*
[**2102-8-14**] 01:04PM LIPASE-7
[**2102-8-14**] 01:04PM ALT(SGPT)-45* AST(SGOT)-68* ALK PHOS-159* TOT
BILI-2.3*
[**2102-8-14**] 01:04PM GLUCOSE-114* UREA N-12 CREAT-0.9 SODIUM-139
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-14
[**2102-8-14**] 03:11PM PT-17.5* PTT-37.5* INR(PT)-1.6*
[**2102-8-15**] 12:00AM PLT COUNT-353
[**2102-8-15**] 12:00AM WBC-7.9# RBC-3.10*# HGB-9.1*# HCT-30.0*#
MCV-97 MCH-29.2 MCHC-30.2* RDW-13.9
[**2102-8-15**] 12:00AM CALCIUM-7.3* PHOSPHATE-2.6* MAGNESIUM-2.0
[**2102-8-15**] 12:00AM LIPASE-7
[**2102-8-15**] 12:00AM ALT(SGPT)-27 AST(SGOT)-24 ALK PHOS-98
AMYLASE-15 TOT BILI-0.7
[**2102-8-15**] 12:00AM GLUCOSE-110* UREA N-12 CREAT-0.6 SODIUM-144
POTASSIUM-4.0 CHLORIDE-115* TOTAL CO2-22 ANION GAP-11
TSH [**8-16**]: 3.6
PTH [**8-16**]: 66
B12 [**8-16**]: 1835
HCG [**8-19**]: negative
HIV neg
HCV neg
Trig 185
Vitamin B1 370 (normal)
prealbumin 7
CPK ISOENZYMES CK-MB cTropnT proBNP
[**2102-8-19**] 03:09AM NotDone1 0.07*2 3928*
protein electrophoresis [**8-22**] normal
Upep [**8-21**]: 27 (normal)
.
[**2102-8-14**] RUQ ULTRASOUND:
1. Cholelithiasis without secondary signs to suggest
cholecystitis.
2. Echogenic liver most compatible with fatty infiltration.
Please note that other forms of hepatic disease such as
cirrhosis/fibrosis are not excluded.
.
[**2102-8-15**] CT ABD/PELVIS:
1. Pancolitis as decribed above.
2. Cystic lesion in tail of pancreas, not fully evaluated on
this
examination. Would recommend MRI in 6 months for further
characterization.
3. Focal narrowing in sigmoid colon may represent focal
collapsed bowel,
however, bowel wall lesion cannot be excluded. Would recommend
imaging
correlation such as colonoscopy or barium study as available.
.
[**2102-8-16**] MRCP:
1. Severe hepatic steatosis.
2. Biliary tree shows no abnormalities.
3. Colonic wall thickening and mucosal enhancement, related to
colitis as
seen on recent CT scan.
4. Cystic, non-enhancing lesion in the tail of the pancreas,
that is most likely in keeping with a pseudocyst, however, a
side branch IPMN cannot be excluded, although less likely. A
followup MRI is suggested in six months for further evaluation.
5. Jejunal biopsy negative.
.
[**2102-8-17**] CT ABD/PELVIS:
1. No evidence of esophageal perforation.
2. Resolution of colonic wall thickening demonstrated on prior
CT.
3. Hepatic steatosis.
4. Low-attenuation lesion at the tail of the pancreas is
compatible with a cyst versus dilated side branch. It is
unchanged from prior recent MRCP and CT. As described on prior
MRCP report, followup of this with MRCP in six months is
recommended to assess for expected stability.
.
[**2102-8-18**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 20-30 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. Right ventricular chamber size
is normal. with focal hypokinesis of the apical free wall. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is a small to moderate
sized pericardial effusion. No right atrial or right ventricular
diastolic collapse is seen. However, the right ventricle appears
underfilled.
IMPRESSION: severe anterior and apical hypokinesis/akinesis;
small, primari8ly anterior pericardial effusion possibly with
early tamponade.
.
[**2102-8-21**] CARDIAC CATHETERIZATION:
1. Selective coronary angiography in [**Last Name (un) **] left dominant system
demonstrated no flow limiting lesions. The LMCA had minimal
plaquing in
the mid portion of the vessel. The LAD had minimal luminal
irregulairites with 15% stenosis at the origin of the vessel.
The distal
LAD wraps around the apex with diffuse plaquing in the distal
LAD. The
Cx had minimal luminal irregularities and gave off a small
caliber OM1,
an atrial branch a modest OM2, a large LPL and a moderate LPDA.
The RCA
was a small nondominant vessel that initially had catheter
induced
vasospasm that improved after intracatheter nitroglycerine.
2. Limited resting hemodynamics revealed elevated right and left
filling
pressures with an RVEDP of 17 mmHg and an LVEDP of 28 mmHg.
There was
mild pulmonary artery hypertension with a PASP of 38 mmHg. The
cardiac index was preserved at 3.3 l/min/m2. The SVR was
slightly
low at 754 dynes-sec/cm5 and the PVR was preserved at 69
dynes-sec/cm5.
The central aortic pressure was 103/68 mmHg. There was no
transaortic
valve gradient on pullback from the LV to the aorta.
FINAL DIAGNOSIS:
1. Coronary arteries have no flow limiting lesions.
2. Mild pulmonary arterial hypertension.
3. Severe left ventricular diastolic dysfunction.
.
On Discharge:
Negative Lyme, MRSA swab, HIV, HCV and urine cx
EBV, Vitamin D [**12-25**] and CMV are still pnd
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2102-8-23**] 05:13AM 7.5 3.03* 9.1* 29.4* 97 29.9 30.8* 15.0
431
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2102-8-23**] 05:13AM 91 12 0.7 139 3.7 107 27 9
Cosyntropin stimulation test [**8-23**]:
Cortisol prior: 6.31
Cortisol 30 min after cosyntropin: 23.9
Cortisol 60 min after cosyntropin: 28.5
.
Brief Hospital Course:
The patient is a 41 year old female with seizure disorder,
gastrectomy, degenerative disc disease who presented with vague
GI complaints, weight loss, and admitted to CCU after an episode
of chest pain and she was found to have severe systolic/dystolic
function as well as tachycardia. On [**2102-8-24**], the
patient was discharged in good condition, with stable vital
signs, with appropriate outpatient follow-up arranged.
Ms.[**Known lastname 31410**] hospital course was notable for:
.
# Hypotension: Has been intermittantly hypotensive this
admission but asymptomatic, likely [**1-2**] low EF. Hct is low and
drfting down. Random cortisol low normal and cortisone
stimulation test was normally responsive. Pt is not orthostatic
or dizzy, is able to ambulate easily and denies any symptoms.
Her Lisinopril and Metoprolol was started at a very low dose.
.
# Upper back pain: Pt has a history of lower back scoliosis,
Myofascial pain syndrome and Facet arthropathy that affects her
lower back. Her upper back pain is new. Pt feels that her pain
may be [**1-2**] bedrest, and is relieved by morphine. No radicular
symptoms. On muscle relaxer at home and chronic narcotics
(Roxicet) which pt states is ineffective. Pt reports that
clonazepam did not help as an additional muscle relaxer. She was
given a limited morphine PO prescription and instructed to
contact the pain clinic at [**Hospital1 18**] which she had used in [**2098**].
According to the patient, they recommended surgery which she has
been reluctant to do.
.
# Acute Systolic dysfunction: Cath [**8-21**] showed no CAD. Noted
increased filling pressures and furosemide and Lasix po started.
No O2 requirement or SOB at present despite fluid overload.
Unclear etiology but fatigue in last few months may be related.
TSH neg. Multiple viral tests performed, all negative except for
EBV and CMR which are pending. Pt was discharged on Lisinopril
2.5 mg and Long acting Metoprolol with furosemide twice daily.
Instructed to weigh herself daily and follow a low sodium diet.
Pt will follow-up with Dr.[**Name (NI) 3733**] for in [**Month (only) 359**].
.
# Nausea, weight loss: Pt had recent CT scan which showed
pancolitis, and f/u CT scan which showed interval resolution.
Also w/ cholelithiasis and steatotic hepatitis. Pt w/ fairly
substantial GI surgical hx. GI and surgery following with plan
for outpt CT colonoscopy for further evaluation. GI also
recommends outpatient MRI enterography for further evaluation.
Symptoms may represent malabsorption syndrome, such as celiac
sprue, or possibly related to surgical gastric resection.
Albumin 2.0, thought to be contributing to her peripheral edema.
EGD done, Bx showed inflmmation only. Weight loss is at least in
part r/t very decreased and erratic intake. Pt describes very
poor protein and calorie intake last 2 months. Spoke with pt's
mother who states that pt has not worked in 2 months, is
considering disability, has been increasingly isolated in her
apt with limited contact with friends. Dr. [**Name (NI) 31411**], pts
outpatient psychiatrist was informed of this information.
Worsening depression is suspected. She is tolerating PO's at
discharge. She has had extensive nutritional counseling after
her gastric bypass but would consider outpatient referral again.
.
# Anemia: Normochromic, normocytic. On Fe supplementation as Fe
studies suggest Fe deficiency. No signs of acute bleed. Had
some rectal bleeding with stools recently, [**1-2**] hemmorhoids.
Needs repeat outpt colonoscopy. On Fe, B12 q week, folic acid
supplements.
.
# Epilepsy: No sz activity noted. Continued home meds of
levetiracetam, venlafexime, topiramate
.
# Depression: See note above about poor PO intake. Increasing
isolation, ahedonia and decreased intake all point to worsening
depression. Psych team saw pt in house but had no
recommendations as they did not have accurate information from
the patient. Outpt psychiatrist was contact[**Name (NI) **] about symptoms and
will f/u with pt. Note that pt is very reluctant to discuss some
information with her caregivers.
Medications on Admission:
B12 injection 1,000mcg monthly
Iron 65mg daily
Zolpidem 10mg HS prn
Folic acid 1mg daily
Venlafaxine 300mg daily
Amitriptyline 25mg HS (has not taken recently)
Clonazepam 1mg daily prn anxiety
Topiramate 100mg HS
Tizanidine 8mg HS
Roxicet 5/325 q6h prn
Levetiracetam 500mg [**Hospital1 **]
Omeprazole 20mg daily (no longer taking)
Discharge Medications:
1. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for anxiety.
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take with iron.
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection
Injection once a week.
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. Tizanidine 4 mg Capsule Sig: Two (2) Capsule PO at bedtime.
13. Venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO once a day.
14. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Heart Failure: systolic dysfunction (EF 20-30%) and diastolic
dysfunction
Colitis
Discharge Condition:
stable
Discharge Instructions:
You had nausea and vomiting and were admitted to the
gastroenterology service. Multiple tests were performed, you
were found to have colitis, an irritation of the lining of your
gastrointestinal tract. This is now resolving without treatment.
Your heart rate became high and you were evaluated by the
cardiology team. Your heart function is about 50% weaker than it
should be. We have done many tests to find the cause of this
weakness but have not identified a cause as yet. You did not
have a heart attack. You need to eat a balanced diet with
adequate protein and calories every day. Because your heart is
weak, you may retain fluid in your legs, lungs or hands. Not
eating enough protein makes your swelling worse. Weigh yourself
every morning, call Dr. [**Last Name (STitle) **]"[**Doctor Last Name **] if weight > 3 lbs in 1 day or
6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters per day or about 8 cups
.
In addition, you had a cortisol stimulation test to evaluate
your low blood pressure. Please review the results of this test
with your primary care provider at your next visit.
.
.
Medication changes:
1. START Furosemide (Lasix) to decrease the amount of fluid in
your body
2. Lisinopril: to help your heart pump better, this will lower
your blood pressure slightly
3. Metoprolol: to slow you heart rate and help your heart work
better
4. Thiamine and Vitamin C: to correct nutritional deficencies
and help your anemia
.
Please call Dr.[**Name (NI) 3733**] if you notice any trouble breathing,
increased swelling or cough.
Followup Instructions:
Cardiology:
Provider: [**First Name4 (NamePattern1) 4648**] [**Name Initial (NameIs) **] Phone: [**Telephone/Fax (1) 62**] Date/Time:
[**2102-9-12**] 2:20
.
Primary Care:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD [**First Name8 (NamePattern2) 151**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:
[**Telephone/Fax (1) 250**] Date/Time: [**9-6**] at 3:25pm. Please call
insurance and change PCP.
.
Gastroenterology:
Cystic lesion in tail of pancreas, not fully evaluated on this
examination. Would recommend MRI in 6 months for further
characterization. Pt needs to have a MR enterography and
colonoscopy as an outpt.
|
[
"729.1",
"786.51",
"276.51",
"573.3",
"401.9",
"428.0",
"783.21",
"455.2",
"579.3",
"783.0",
"V45.86",
"427.89",
"428.41",
"737.30",
"273.8",
"423.9",
"280.9",
"311",
"556.6",
"263.8",
"577.2",
"458.29",
"574.20",
"345.90",
"E942.6",
"416.8",
"721.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.15",
"38.93",
"45.23",
"45.16",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
15913, 15919
|
10004, 14080
|
351, 377
|
16045, 16054
|
4109, 4109
|
17667, 18346
|
3007, 3122
|
14461, 15890
|
15940, 16024
|
14106, 14438
|
9307, 9452
|
16078, 17201
|
3137, 4090
|
9466, 9981
|
17221, 17644
|
275, 313
|
405, 2631
|
4123, 9290
|
2653, 2790
|
2806, 2991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,242
| 121,087
|
19839
|
Discharge summary
|
report
|
Admission Date: [**2176-2-12**] Discharge Date: [**2176-2-15**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 83-year-old gentleman
with severe aortic stenosis admitted for cardiac
catheterization prior to AVR surgery and CABG. Patient notes
that since [**Month (only) 216**] he has been experiencing worsening lower
extremity edema and dyspnea with exertion. He currently has
shortness of breath after walking 100 feet. He denies chest
pain, orthopnea, PND, or claudication. Patient was admitted
for a catheterization, which showed moderate LM and
three-vessel disease, moderate-to-severe aortic stenosis and
moderate pulmonary hypertension. Hemodynamics: Wedge
pressure of 40, RA of 9, cardiac output of 5.26, cardiac
index 2.64. He was transferred to CCU for observation prior
to surgery.
PAST MEDICAL HISTORY:
1. Aortic stenosis.
2. Hypertension.
3. Status post PTCA [**81**] years ago at BU. Denies history of
MI.
4. PE in [**2146**].
5. Asbestosis.
6. AFib.
7. Hypothyroidism.
8. Spinal meningitis at age 7.
9. Upper GI bleed four years ago.
10. Status post cataract surgery.
11. Status post thyroidectomy.
12. Status post cholecystectomy.
13. Status post left lower extremity vein stripping.
14. Status post IVC clip.
ALLERGIES: Morphine causes a rash.
MEDICATIONS:
1. Occunt drops two b.i.d.
2. Armour Thyroid 180 q.d.
3. Verapamil 240 in the morning, 120 at night.
4. Zantac 150 twice a day.
5. Lanoxin 0.25 alternating with 1.25 q.d.
6. Coumadin held since [**2-7**].
7. Proscar 5 q.d.
8. Singulair 10 q.d.
9. Advair 100/50 b.i.d.
10. Imdur 60 q.d.
11. Lasix 40 q.d.
12. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 40 q.d.
FAMILY HISTORY: Father died of a MI in his 50's.
SOCIAL HISTORY: He is a widower. Wife passed away in
[**Month (only) 216**]. Tobacco includes smoking 26 years ago. Smoked 40
years at 2.5 packs per day.
PHYSICAL EXAM: Vital signs: Temperature 96.9, blood
pressure 148/53, heart rate 66, respiratory rate 20, and sats
98% on room air. In general, pleasant, elderly man in no
acute distress. HEENT is normocephalic, atraumatic. Pupils
are equal, round, and reactive to light. Extraocular muscles
are intact. Moist mucous membranes. Oropharynx is clear.
Neck: Jugular venous pressure at about 8 cm, delayed carotid
upstrokes. Left subclavian Swan. Cardiovascular:
Irregularly, irregular S1, 3/6 systolic ejection murmur at
the right upper sternal border going to the carotids. Lungs:
Crackles at the bases. Abdomen is soft, nontender, and
nondistended, positive bowel sounds. Extremities: No
cyanosis, clubbing, or edema.
LABORATORIES ON ADMISSION: White count 7.7, hematocrit 38,
platelets 157. Sodium 136, K 3.8, chloride 104, bicarb 25,
BUN 22, creatinine 0.9, glucose 203. INR 1.5, albumin 3.8,
ALT 19, AST 20, alkaline phosphatase 122, total bilirubin
1.2, direct bilirubin 0.4.
Cardiac catheterization showed 40% stenosis of the distal
LMCA, 40% diffuse mid lesion of the LAD, 50% mid D1, left
circumflex 60% mid vessel stenosis after the OM-1. OM-1 was
not obstructed. OM-2 40% mid vessel stenosis. RCA minimal
luminal irregularities, 40% proximal stenosis, PDA tandem 60%
stenosis. Hemodyamics: Wedge pressure of 22, RA pressure of
9, cardiac output 5.26, cardiac index 2.64. PA pressure of
63/34, mean of 40. LV of 190/14. Aortic valve area of 0.88.
Aortic valve gradient of 46.
Chest x-ray with a left subclavian PA catheter.
Echocardiogram in [**2175-12-17**] with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated.
RA mildly dilated. Symmetric LVH. Left ventricular ejection
fraction greater than 55%. RV free wall is hypertrophied,
severe AS, 1+ MR, moderate PA hypertension.
HOSPITAL COURSE: This was an 83-year-old gentleman with
severe aortic stenosis and three vessel coronary artery
disease status post catheterization with elevated wedge
pressure in the CCU and anticipation of AVR and CABG.
1. CAD: Patient with three-vessel disease. Was continued on
his aspirin, started on low dose beta-blocker, continued on
his Imdur. Patient was planned for CABG with his AVR.
Surgery is planned for [**Last Name (LF) 766**], [**2-19**]. Otherwise, patient
remained chest pain free throughout the course of his stay.
2. Fluid overload: Patient had elevated wedge pressures and
left sided heart pressures. Patient initially euvolemic was
diuresed with 40 mg IV Lasix and put out total was 5 liters
negative throughout the course of his CCU admission.
Eventually, Swan was pulled with stable numbers and otherwise
euvolemic.
3. Atrial fibrillation: Patient was continued on his digoxin
and his home regimen. Continued on a calcium-channel blocker
and also started on low dose beta-blocker and titrated down
on his calcium-channel blocker, which can eventually be
discontinued as his beta-blockers titrated up. Patient's
Coumadin was on hold initially and was started on Lovenox at
therapeutic b.i.d. dosing and in anticipation of surgery.
This can be held the morning of surgery and the patient can
be anticoagulated until that time.
4. Hypothyroidism: The patient was stable on his home
regimen of Armour Thyroid at 180 mcg q.d.
5. Peptic ulcer disease: Patient was stable. Continued on
his Zantac.
6. Asthma: Patient was stable and continued on his Singulair
and was transitioned to salmeterol and fluticasone for dosing
here. Can continue Advair at time of discharge.
7.[**Last Name (STitle) 53610**]c stenosis: Patient was stable. Valve area of 0.88,
gradient of 46. The patient will return on [**Last Name (LF) 766**], [**2-19**]
for surgery by Dr. [**Last Name (Prefixes) **]. Patient had preoperative
workup done during this admission and was started on
perioperative beta-blocker during this admission. Patient
was given some vitamin K to help decrease his INR. His INR
had still not reached goal of 1.2, so the patient was
discharged home on Lovenox and off Coumadin to come back for
surgery once his INR is below 1.2 anticipated [**Last Name (Prefixes) 766**].
Patient had carotid Dopplers at [**Hospital1 1474**] which were negative
on [**1-24**].
8. Hypertension: The patient was stable on low dose
beta-blocker and lower dose of calcium-channel blocker and
otherwise stable after diuresis.
DISCHARGE DIAGNOSES:
1. Three vessel coronary artery disease.
2. Severe aortic stenosis.
3. Atrial fibrillation.
4. Asthma.
5. Hypertension.
DISCHARGE MEDICATIONS:
1. Armour Thyroid 180 mcg q.d.
2. Zantac 150 mg p.o. b.i.d.
3. Lanoxin 0.125 mg alternating with 0.25 mg q.o.d.
4. Finasteride 5 mg p.o. q.d.
5. Singulair 10 mg p.o. q.d.
6. Advair Diskus one puff b.i.d.
7. Imdur 60 mg p.o. q.d.
8. Colace 100 mg p.o. b.i.d.
9. Senna one tablet p.o. b.i.d.
10. Verapamil 120 mg sustained release p.o. b.i.d.
11. Metoprolol 25 mg p.o. b.i.d.
12. Aspirin 325 mg p.o. q.d.
13. Lovenox 80 mg subq q.12. for five doses until he returns
for surgery.
DISCHARGE FOLLOWUP: Patient is to followup with his PCP [**Last Name (NamePattern4) **]
[**5-25**] days after discharge from surgery. Patient is to
followup with Dr. [**Last Name (STitle) **] on [**4-16**]. Patient is to followup
with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] on [**Last Name (LF) 766**], [**2-19**] for cardiac
CABG and AVR surgery.
DISCHARGE CONDITION: Good. Patient is ambulating without
difficulty, not requiring oxygen. Patient is shortness of
breath and pain well controlled.
DISCHARGE STATUS: Discharged to home with services.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2176-2-15**] 15:19
T: [**2176-2-16**] 10:00
JOB#: [**Job Number 53611**]
|
[
"428.0",
"427.31",
"416.8",
"501",
"414.01",
"424.1",
"276.6",
"493.90",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7328, 7788
|
1709, 1743
|
6312, 6433
|
6456, 6934
|
3757, 6291
|
1918, 2647
|
6955, 7306
|
116, 817
|
2662, 3739
|
839, 1692
|
1760, 1902
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,765
| 138,299
|
51492+51493
|
Discharge summary
|
report+report
|
Admission Date: [**2141-2-21**] Discharge Date: [**2141-2-28**]
Date of Birth: [**2067-2-11**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old,
Spanish speaking female, status post cholecystectomy [**58**] years
ago, complaining of abdominal pain since the day prior to
admission. She described the pain over the area of an
incisional hernia on the medial edge of her cholecystectomy
scar. She also complained or right lower quadrant abdominal
pain radiating to the back. She had an episode of emesis the
day prior to admission, and according to the patient, her
last bowel movement was two days prior to admission to the
Emergency Department. She was passing flatus. She had
similar symptoms in the past with negative CT scan.
CT scan on [**1-31**] was done for an elevated alkaline
phosphatase and just revealed her incisional hernia with
omentum. The patient is also status post endoscopic
retrograde cholangiography on [**2137-7-13**] with sphincterotomy
and was found to have biliary and common duct dilatation.
PAST MEDICAL HISTORY: Type 2 diabetes, hypertension, asthma,
bronchiectasis, diverticulitis, rheumatoid arthritis. She is
status post cholecystectomy [**58**] years ago. She is status post
right breast biopsy. She is status post hysterectomy.
MEDICATIONS: Albuterol 2 puffs q.4 hours, Celebrex 100 mg
p.o. q.d., Combivent 2 puffs 4 times a day, Aspirin 81 mg
p.o. q.d., Diabetic tussin 5-10 cc q.4-6 hours p.r.n.,
Flovent 220 mcg 4 puffs b.i.d., NPH 48 U q.a.m., 30 U q.p.m.,
Lisinopril 5 mg p.o. q.d., Premarin 0.625 mg p.o. q.d.,
Terazol drops 0.8%, Trusopt 2% drops 1 GTT O.U. t.i.d.,
Ultram 50 mg p.o. t.i.d. p.r.n., Zantac 150 mg p.o. b.i.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: She does not drink any alcohol. She smokes
tobacco.
PHYSICAL EXAMINATION: Vital signs: Temperature 104??????, heart
rate 100-120, blood pressure 130/70, oxygen saturation 91% on
room air, 97% on 4 L. General: She was an obese, elderly,
female, in moderate distress secondary to pain.
Cardiovascular: She was tachycardia but regular, rate and
rhythm. Pulmonary: She had coarse breath sounds with
rhonchi. Abdomen: She was noted to be obese with a
well-healed right costal scar with a palpable hernia in the
medial aspect that was easily reducible. She had tenderness
to palpation over this area with voluntary guarding. She
also had right lower quadrant pain radiating around to the
right lower back reproducible with palpation. She also had
voluntary guarding in the right lower quadrant. She had no
rebound. No tenderness to percussion. She had no CVA
tenderness. Rectal: Guaiac negative. She had no stool in
the vault. No masses.
LABORATORY DATA: On admission white count was 14, hematocrit
39, platelet count 302, 88% polys, 0 bands; CHEM7 was within
normal limits except for a glucose of 415; ALT 152, AST 170,
alkaline phosphatase 560, amylase 2693, lipase greater than
6000.
KUB showed positive air in the rectum, single air-fluid
level. Chest x-ray revealed no infiltrate, chronic
interstitial disease of the right lung, no free air.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit with the diagnosis of pancreatitis and ascending
cholangitis. She was given fluid resuscitation and then was
seen by GI Service an ERCP. The patient underwent a ERCP
which revealed stones in the common bile duct and also
revealed frank pus. The patient at this time had also been
started on antibiotics of Ampicillin, Ceftriaxone, and
Flagyl.
Status post ERCP and secondary to antibiotics, the patient's
condition began to improve, and on postprocedure day #1, the
patient was transferred to the floor in stable condition.
Her amylase and lipase improved. Her right upper quadrant
abdominal pain also improved. The patient's diet was
advanced slowly. She occasionally expressed feelings of
nausea but never had any episodes of emesis.
The patient has a history of bronchiectasis and therefore
received chest physical therapy while in-house. She normally
received three times weekly as an outpatient to ensure that
her respiratory status was stable.
On postprocedure day #7, hospital day #8, she was tolerating
p.o. intake, and she was tolerated p.o. antibiotics. Her
abdominal exam had completely resolved to normal. She was
felt to be ready for discharge to rehabilitation.
DISCHARGE MEDICATIONS: All previous outpatient medications.
In addition she will finish 6 more days of Levofloxacin 500
mg p.o. q.d., and Flagyl 500 mg p.o. t.i.d. x 6 days. She
will also started Actigall 250 mg p.o. b.i.d. She will also
continue taking Diltiazem 30 mg p.o. q.i.d. and will also
continue taking all of her previous medications as noted
previously including NPH 48 U q.a.m., 30 U q.p.m., Zantac 150
mg p.o. b.i.d., Lisinopril 5 mg p.o. q.d., Ultram 50 mg p.o.
t.i.d. p.r.n., Celebrex 10 mg p.o. q.d., Albuterol 2 puffs
q.4 hours, Combivent 2 puffs q.4 hours, Flovent 220 mcg 4
puffs b.i.d., Diabetic tussin 5-10 cc q.4-6 hours p.r.n.,
Premarin 0.625 mg p.o. q.d., Aspirin 81 mg p.o. q.d., Terazol
0.8% GTT, Trusopt 2% 1 GTT O.U. t.i.d.
FOLLOW-UP: The patient will follow-up with Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**]
in two weeks. She can call [**Telephone/Fax (1) 106761**] for an appointment.
DISCHARGE DIAGNOSIS:
1. Pancreatitis.
2. Ascending cholangitis.
3. Status post endoscopic retrograde cholangiography.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 9704**]
MEDQUIST36
D: [**2141-2-28**] 13:37
T: [**2141-2-28**] 13:38
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern4) 106762**] Admission Date: [**2141-2-21**] Discharge Date: [**2141-2-28**]
Date of Birth: [**2067-2-11**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old,
Spanish speaking female, status post cholecystectomy [**58**] years
ago, complaining of abdominal pain since the day prior to
admission. She described the pain over the area of an
incisional hernia on the medial edge of her cholecystectomy
scar. She also complained or right lower quadrant abdominal
pain radiating to the back. She had an episode of emesis the
day prior to admission, and according to the patient, her
last bowel movement was two days prior to admission to the
Emergency Department. She was passing flatus. She had
similar symptoms in the past with negative CT scan.
CT scan on [**1-31**] was done for an elevated alkaline
phosphatase and just revealed her incisional hernia with
omentum. The patient is also status post endoscopic
retrograde cholangiography on [**2137-7-13**] with sphincterotomy
and was found to have biliary and common duct dilatation.
PAST MEDICAL HISTORY: Type 2 diabetes, hypertension, asthma,
bronchiectasis, diverticulitis, rheumatoid arthritis. She is
status post cholecystectomy [**58**] years ago. She is status post
right breast biopsy. She is status post hysterectomy.
MEDICATIONS: Albuterol 2 puffs q.4 hours, Celebrex 100 mg
p.o. q.d., Combivent 2 puffs 4 times a day, Aspirin 81 mg
p.o. q.d., Diabetic tussin 5-10 cc q.4-6 hours p.r.n.,
Flovent 220 mcg 4 puffs b.i.d., NPH 48 U q.a.m., 30 U q.p.m.,
Lisinopril 5 mg p.o. q.d., Premarin 0.625 mg p.o. q.d.,
Terazol drops 0.8%, Trusopt 2% drops 1 GTT O.U. t.i.d.,
Ultram 50 mg p.o. t.i.d. p.r.n., Zantac 150 mg p.o. b.i.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: She does not drink any alcohol. She smokes
tobacco.
PHYSICAL EXAMINATION: Vital signs: Temperature 104??????, heart
rate 100-120, blood pressure 130/70, oxygen saturation 91% on
room air, 97% on 4 L. General: She was an obese, elderly,
female, in moderate distress secondary to pain.
Cardiovascular: She was tachycardia but regular, rate and
rhythm. Pulmonary: She had coarse breath sounds with
rhonchi. Abdomen: She was noted to be obese with a
well-healed right costal scar with a palpable hernia in the
medial aspect that was easily reducible. She had tenderness
to palpation over this area with voluntary guarding. She
also had right lower quadrant pain radiating around to the
right lower back reproducible with palpation. She also had
voluntary guarding in the right lower quadrant. She had no
rebound. No tenderness to percussion. She had no CVA
tenderness. Rectal: Guaiac negative. She had no stool in
the vault. No masses.
LABORATORY DATA: On admission white count was 14, hematocrit
39, platelet count 302, 88% polys, 0 bands; CHEM7 was within
normal limits except for a glucose of 415; ALT 152, AST 170,
alkaline phosphatase 560, amylase 2693, lipase greater than
6000.
KUB showed positive air in the rectum, single air-fluid
level. Chest x-ray revealed no infiltrate, chronic
interstitial disease of the right lung, no free air.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit with the diagnosis of pancreatitis and ascending
cholangitis. She was given fluid resuscitation and then was
seen by GI Service an ERCP. The patient underwent a ERCP
which revealed stones in the common bile duct and also
revealed frank pus. The patient at this time had also been
started on antibiotics of Ampicillin, Ceftriaxone, and
Flagyl.
Status post ERCP and secondary to antibiotics, the patient's
condition began to improve, and on postprocedure day #1, the
patient was transferred to the floor in stable condition.
Her amylase and lipase improved. Her right upper quadrant
abdominal pain also improved. The patient's diet was
advanced slowly. She occasionally expressed feelings of
nausea but never had any episodes of emesis.
The patient has a history of bronchiectasis and therefore
received chest physical therapy while in-house. She normally
received three times weekly as an outpatient to ensure that
her respiratory status was stable.
On postprocedure day #7, hospital day #8, she was tolerating
p.o. intake, and she was tolerated p.o. antibiotics. Her
abdominal exam had completely resolved to normal. She was
felt to be ready for discharge to rehabilitation.
DISCHARGE MEDICATIONS: All previous outpatient medications.
In addition she will finish 6 more days of Levofloxacin 500
mg p.o. q.d., and Flagyl 500 mg p.o. t.i.d. x 6 days. She
will also started Actigall 250 mg p.o. b.i.d. She will also
continue taking Diltiazem 30 mg p.o. q.i.d. and will also
continue taking all of her previous medications as noted
previously including NPH 48 U q.a.m., 30 U q.p.m., Zantac 150
mg p.o. b.i.d., Lisinopril 5 mg p.o. q.d., Ultram 50 mg p.o.
t.i.d. p.r.n., Celebrex 10 mg p.o. q.d., Albuterol 2 puffs
q.4 hours, Combivent 2 puffs q.4 hours, Flovent 220 mcg 4
puffs b.i.d., Diabetic tussin 5-10 cc q.4-6 hours p.r.n.,
Premarin 0.625 mg p.o. q.d., Aspirin 81 mg p.o. q.d., Terazol
0.8% GTT, Trusopt 2% 1 GTT O.U. t.i.d.
FOLLOW-UP: The patient will follow-up with Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**]
in two weeks. She can call [**Telephone/Fax (1) 106761**] for an appointment.
DISCHARGE DIAGNOSIS:
1. Pancreatitis.
2. Ascending cholangitis.
3. Status post endoscopic retrograde cholangiography.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 9704**]
MEDQUIST36
D: [**2141-2-28**] 13:37
T: [**2141-2-28**] 13:38
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern4) 106762**]
|
[
"576.1",
"250.00",
"714.0",
"574.51",
"577.0",
"493.90",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
10314, 11246
|
11267, 11368
|
9050, 10290
|
7742, 9032
|
6044, 6955
|
6978, 7648
|
7665, 7719
|
11393, 11767
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,706
| 153,897
|
28746
|
Discharge summary
|
report
|
Admission Date: [**2119-8-25**] Discharge Date: [**2119-9-5**]
Date of Birth: [**2056-3-28**] Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominla Pain, Jaundice, Hypokalemia
Major Surgical or Invasive Procedure:
ERCP
CT Guided [**Name (NI) **] (PTBD)
Right Chest Tube (VATS)
History of Present Illness:
This is a 63 year old male with obstructing ampullary mass. He
was transferred from [**Hospital6 33**] where he was admitted
on [**2119-8-22**]. His chief complaint was jaudice and epigastric pain.
His jaudice had been progressing over the preceeding week. He
also noted puritis, and light colored stool. He was referred to
[**Hospital1 18**] for ERCP. An ERCP revealed a fungating mass near the
ampulla. The ampulla could not be cannulated.
Past Medical History:
HTN, mild asthma, GERD, chronic LBP, ?NASH, s/p spinal fusion,
ETOH abuse, cirrhosis
Social History:
No tobacco
one quart of rum/day
works in pest control
lives with son
Family History:
Mother died at age 63 from CAD
Father died at age 85 from asbestos exposure.
Physical Exam:
Gen: comfortable, nontoxic, jaundice significantly improved
Neck: supple, no cervical/superclavicular adenopathy
Lungs: CTAB
CV: regular rate and rhythm, no murmurs
Abd: Soft, nontender, nondistended
Pertinent Results:
[**2119-8-25**] 04:57PM BLOOD WBC-9.1 RBC-3.51* Hgb-10.6* Hct-31.7*
MCV-90 MCH-30.3 MCHC-33.6 RDW-15.3 Plt Ct-246
[**2119-8-28**] 06:17PM BLOOD WBC-9.5 RBC-2.76* Hgb-8.5* Hct-25.6*
MCV-93 MCH-30.9 MCHC-33.3 RDW-15.7* Plt Ct-269
[**2119-8-28**] 10:48PM BLOOD WBC-11.1* RBC-2.64* Hgb-8.3* Hct-23.3*
MCV-88 MCH-31.3 MCHC-35.4* RDW-16.2* Plt Ct-249
[**2119-8-29**] 01:15AM BLOOD WBC-10.0 RBC-2.52* Hgb-7.9* Hct-22.3*
MCV-89 MCH-31.4 MCHC-35.4* RDW-16.1* Plt Ct-223
[**2119-9-5**] 06:36AM BLOOD Hct-29.4*
[**2119-8-25**] 04:57PM BLOOD ALT-159* AST-189* AlkPhos-610* Amylase-31
TotBili-17.9*
[**2119-9-5**] 06:36AM BLOOD ALT-78* AST-118* AlkPhos-216*
TotBili-16.8*
CHEST (PRE-OP PA & LAT) [**2119-8-27**] 4:53 PM
FINDINGS: PA and lateral views of the chest demonstrates some
mild compressive changes at both bases. The cardiac and
mediastinal silhouettes are normal. There is no infiltrate or
effusion. The right humerus is slightly low in the glenoid
fossa. It is unclear if this is positional or if there is slight
inferior dislocation.
CTA ABD W&W/O C & RECONS [**2119-8-27**] 10:48 AM
IMPRESSION: Almost circumferential mass in the second portion of
the duodenum with resulting intrahepatic and pancreatic duct
dilatation secondary to the ampullary obstruction. Multiple
areas of low attenuation in the liver, which are non-specific in
appearance but are concerning for metastatic disease given the
presence of a duodenal mass. Few prominent para-aortic and caval
nodes are alos concerning for spread of disease.
[**Numeric Identifier 69479**] INTRO PERC TRANHEPATIC CATH [**2119-8-28**] 7:49 AM
IMPRESSION: Successful placement of an 8-French percutaneous
transhepatic biliary drainage catheter into the left biliary
system with the pigtail coiled into the common bile duct.
CHEST (PORTABLE AP) [**2119-8-29**] 6:33 AM
Large right pleural fluid collection which decreased between
5:43 p.m. and 9:51 p.m. following insertion of a right basal
tube has not changed in volume subsequently. Mediastinum is
midline indicating a degree of atelectasis corresponding to the
pleural fluid volume. Left lung clear. Heart size normal. No
pneumothorax. A drainage catheter projects over the upper
abdominal midline but its precise location cannot be determined
on this study. No substantial pneumoperitoneum is demonstrated.
CHEST (PORTABLE AP) [**2119-8-31**] 3:47 PM
FINDINGS: AP single view of the chest has been obtained with
patient in marked lordotic position. The previously described
two right-sided chest tubes remain in unchanged position. No
pneumothorax has developed since the preceding examination
obtained 4 hours earlier. Mediastinal and cardiac contours
unchanged with no evidence of CHF. Right-sided suprahilar
mediastinal prominence, unchanged.
Brief Hospital Course:
63 year old male with epigastric pain and jaundice due to a 4.8
cm pancreatic head mass and failed ERCP decompression on
[**2119-8-25**]. Prior to the [**Date Range 19843**] placement, he received 4 units of
FFP for an elevated INR of 2.0. He then proceeded with placement
of a biliary [**Date Range 19843**] via percutaneous transhepatic cholangiogram
on [**2119-8-28**]. Radiology confirmed the presence of a left biliary
system drainage catheter draining CBD. Post-ERCP, he developed
large right hemothorax. His O2 sats dropped to 90% and his BP
was 90/60. His HCT dropped from 26 to 22. A chest tube placed
was promptly placed and it drained serosanguinous fluid. He was
transferred to the SICU for monitoring of hypotension. He was
transfused x 4 with PRBC. A CT confirmed thoracic placement of
chest tube.
On [**2119-8-30**] he had a VATS with the Thoracic service. A second
chest tube was placed. A HCT after the procedure was 32.8. He
continued to do well after evacuation of the clotted hemothorax
and was transferred out of the ICU on [**2119-8-31**].
On [**2119-9-1**], he had both CT D/C'd without incident. Over the next
few days he improved markedly. By the time of discharge was
tolerating a regular diet, his [**Date Range 19843**] was collecting
approximately 300cc of bile each day, he was ambulating well,
and his pain was well-controlled.
Pathology:
Pathology results revealed an invasive adenocarcinoma.
Medications on Admission:
MS contin 100", Atenolol 100', HCTZ 25'
Discharge Medications:
1. OxyContin 80 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO twice a day.
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for Wheeze.
Disp:*1 vial/aerosol* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Obstructive Jaundice
Pancreatic Head Mass
Right Hemothorax
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered. Restart previous
medications.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule.
Completed by:[**2119-9-12**]
|
[
"998.11",
"303.90",
"511.8",
"576.2",
"156.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"45.14",
"34.21",
"51.10",
"87.51",
"34.04",
"51.98",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
6097, 6148
|
4146, 5573
|
303, 368
|
6252, 6259
|
1362, 4123
|
6500, 6644
|
1049, 1127
|
5663, 6074
|
6170, 6231
|
5599, 5640
|
6283, 6477
|
1142, 1343
|
226, 265
|
396, 839
|
861, 947
|
963, 1033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,871
| 188,368
|
8064
|
Discharge summary
|
report
|
Admission Date: [**2135-5-24**] Discharge Date: [**2135-6-1**]
Date of Birth: [**2056-8-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
epigastric pain, incidental AAA identified, transfered from OSH
for assessment of surgical intervention upon AAA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname **] is a 78 yom presented to OSH with epigastric pain,
shortness of breath, cough and chills, s/p fall on his right
chest with ecchymosis, diagnosed OSH with possible NSTEMI (BNP
of 1100, TropT of 0.09, 0.13, 0.13), PNA, CHF with EF of 25%,
and AAA (6.7x6.5 cm). At OSH ED, he was noted to have ecchymosis
on the right chest, unable to lie flat and was hypotensive. He
was urgently intubated to perform CT scans of the chest and
abdomen. CT scan showed a 6.7x6.5 infrarenal abdominal aortic
aneurysm with no suggestion of acute leakage or bleed and
bibasilar atelectasis vs airway disease. ECG showed ST
depression in V2 & V3 and prominent T-waves diffusely, RBBB, 1st
degree AV block.
.
At the OSH ([**Hospital6 33**]), patient was treated for
pneumonia with Zosyn and levaquin. He was intubated for 1 day
duration. His cultures were reportedly unremarkable. He was
evaluated by cardiology due to his extensive coronary artery
disease. On the OSH echo, he was noted to have a depressed EF
of 20-25% which was noted to be worse than prior reports (at
[**Hospital6 10353**]). Patient did have several episodes of
acute pulmonary edema that was with increased BB, diuresis,
ACEI, and BiPAP. He was evaluated by surgery for the newly
discovered abdominal aortic aneurysm, which he was recommened to
have endovascular repair. He was transferred to [**Hospital1 18**] for
catheterization and management of AAA repair evaluation.
.
On review of systems, he has a persistent non-productive cough.
He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, abdominal pain, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. He denies recent fevers or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems was negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea (sleeps with 1
pillow at night), ankle edema, palpitations, syncope or
presyncope.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Congestive Heart Failure of uncertain type
- Moderate aortic regurgitation (Diagnosed [**2134-8-15**])
- Previous admission to [**Hospital6 10353**] for a possible
acute cardiac situation of unclear description
- CABG: emergency procedure at [**Hospital1 18**] ([**2123**])
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Obstructive Sleep Apnea not on CPAP
- Asthma
- Asbestosis
- Benign Prostatic Hypertrophy
Social History:
The patient lives with his wife, per wife patient is full code
(per report on d/c summary). He is independent in his activities
of daily living. Uses a cane or walker to ambulate. Currently
retired, has previously worked in the shipyard industry.
- Tobacco history: Denies ever smoking.
- ETOH: None
- Illicit drugs: None
.
Family History:
- He recalled his mother had "trouble with heart" but could not
elaborate further.
- Otherwise, no family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
.
Physical Exam:
PHYSICAL EXAMINATION
GENERAL: NAD. Oriented x1-2 confused, tachypnic to the 30's,
moderate respiratory distress HEENT: PERRL, EOMI. no pallor or
cyanosis
NECK: Supple, no JVD
CHEST: bruise over right lower anterior chest, midline
sternotomy scar with 2 corresponding sub-centimetre horizontal
scars inferiorly. Irregular rhythm with impression of
extrasystolic beats, heart sounds distant. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: diffuse expiratory > inspiratory wheezing and ronchi,
bibasilar crackles, prolonged expiratory phase.
ABDOMEN: Umbilical herniation, Soft, NTND, no peritoneal signs.
No HSM or tenderness. Abd aortic pulsation positive.
EXTREMITIES: Old saphenous vein harvest scar on right medial
aspect of leg. No c/c/e. No femoral bruits. Distal phalanx of R
thumb not present. No peripheral gangrene or amputations.
SKIN: Dry, shiny and excoriated skin with patches of erythema
bilaterally on forearms. Fungal intertriginous eruption with
some skin breakage in perineal are and groins, Dystrophic nail
changes/onychomycosis noted on toes.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 4+ wide very prominent !!
aneurysm? DP 1+ PT +/-
Left: Carotid 2+ Femoral 2+ Popliteal 4+ wide very prominent !!
aneurysm? DP 1+ PT + /-
Neuro: normal symmetric gross CN, motor and sensorium function,
peripheral fasciculations resolved, cogwheeling in upper limbs
right > left.
.
Pertinent Results:
ADMISSION - LABORATORY DATA:
.
[**2135-5-24**] 10:01PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2135-5-24**] 10:01PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2135-5-24**] 10:01PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2135-5-24**] 10:01PM URINE HYALINE-18*
[**2135-5-24**] 10:00PM GLUCOSE-107* UREA N-33* CREAT-1.2 SODIUM-141
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-33* ANION GAP-11
[**2135-5-24**] 10:00PM estGFR-Using this
[**2135-5-24**] 10:00PM ALT(SGPT)-19 AST(SGOT)-24 CK(CPK)-53 ALK
PHOS-46 AMYLASE-49 TOT BILI-0.5
[**2135-5-24**] 10:00PM LIPASE-17
[**2135-5-24**] 10:00PM CK-MB-6 cTropnT-0.17*
[**2135-5-24**] 10:00PM ALBUMIN-3.8 CALCIUM-9.5 PHOSPHATE-3.5
MAGNESIUM-2.0 CHOLEST-131
[**2135-5-24**] 10:00PM %HbA1c-5.7 eAG-117
[**2135-5-24**] 10:00PM TRIGLYCER-101 HDL CHOL-45 CHOL/HDL-2.9
LDL(CALC)-66
[**2135-5-24**] 10:00PM WBC-10.3 RBC-3.73* HGB-12.5*# HCT-36.4*#
MCV-98 MCH-33.6* MCHC-34.4 RDW-14.1
[**2135-5-24**] 10:00PM NEUTS-91.1* LYMPHS-4.4* MONOS-4.2 EOS-0.2
BASOS-0.1
[**2135-5-24**] 10:00PM PLT COUNT-154
[**2135-5-24**] 10:00PM PT-14.1* PTT-33.4 INR(PT)-1.2*
.
TTE [**5-25**]: The left atrium is normal in size. The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is top normal/borderline
dilated. There is mild to moderate regional left ventricular
systolic dysfunction with hypokinesis of the mid-distal anterior
wall, apex, and distal anterior septum (LVEF 35-40%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild-moderate focal left ventricular dysfunction c/w
CAD. Mild aortic regurgitation. Mild dilatation of the aortic
root.
.
CXR [**5-25**]:
Cardiomegaly and widened mediastinum are unchanged.
Small-to-moderate
bilateral pleural effusions, left greater than right, are
stable. There are
bilateral extensive pleural plaques. Right PICC remains in place
in standard position. There is mild vascular congestion,
minimally increased. Bibasilar opacities are consistent with
atelectasis. The sternal wires are aligned with unchanged
fracture of the first wire. Patient is status post CABG. There
areno new lung abnormalities or evident pneumothorax.
CTA [**5-29**]:
IMPRESSION:
1. Stable appearance of 6.9 cm abdominal aortic aneurysm with no
evidence of contained or impending rupture. Imaging surveillance
is recommended if other intervention is not performed.
Additionally, there is a right internal iliac aneurysm.
2. 2.0 x0.8 cm cystic lesion within the tail of the pancreas,
with a second in the pancreatic head which should be further
evaluated with MRI on a non-emergent basis, which will also
evaluate the renal lesions.
3. Gallstones.
4. Enlarged bladder, correlate with signs of outlet obstruction.
OSH workup:
DATE:
Echocardiogram done [**2134-5-18**]:
This was a technically difficult study. Left ventricular
systolic function was normal and there were no obvious wall
motion abnormalities. The left atrium is dilated but the other
[**Doctor Last Name 1754**] were normal. There was moderate aortic insufficiency
and mild mitral regurgitation. There was no pulmonary
hypertension.
.
Persantine Myoview stress test [**2134-5-17**]:
The test was negative for symptoms and EKG changes. The Myoview
perfusion scan showed a moderate sized perfusion defect in the
inferior and infra-apical walls. This was a fixed defect but no
reversible defects were seen.
.
Cardiac catheterization [**2134-5-18**]:
There was severe coronary artery disease with obstruction of the
left main coronary artery. There was a total obstruction of
the left anterior descending, circumflex and right coronary
arteries. The LAD artery beyond the graft filled poorly from
the graft because of severe distal disease. The 2 marginals
filled via the graft. The distal artery after its branches also
filled via the graft. Overall the bypass grafts were normal.
The proximal second marginal artery had a significant proximal
stenosis after the graft insertion, and could be treated
percutaneously if symptoms occurred.
Carotid ultrasound [**2134-5-19**] -Mild non-obstructive disease.
Historical studies:
MIBI [**2134**]:
Coronary artery bypass surgery [**2123**]:
He had a the vein graft to the LAD, a sequential vein graft to 2
marginal branches, and a vein graft to the distal right coronary
artery. A calcified aneurysm of the LAD was repaired at that
time.
Brief Hospital Course:
Mr [**Known lastname **] is a 78 yom who presented to OSH with epigastric pain,
shortness of breath, cough and chills, s/p fall on his right
chest with ecchymosis, at OSH found to have elevated trop and
BNP, fever, leukocytosis, CHF with EF of 25%, and AAA (6.7x6.5
cm), was treated with broad spectrum abx and diureses and
transfered here for consideration of surgical intervention for
AAA. Upon admission to the CCU was found to be in respiratory
distress with acute on chronic hypercarbic and hypoxic
respiratory failure. His hospital course included treatment for
an acute COPD exacerbation, pneumonia treatment and treatment of
acute pulmonary edema. In this setting, intervention upon the
AAA was deferred until after further recovery, and was discussed
with the patient and his family.
.
# COPD exacerbation: admitted in repiratory distress with acute
on chronic hypercarbia + hypoxia- the main pulmonary process per
physical findings and radiology is likely exacerbation of his
chronic respiratory disease (a combination of restrictive and
obstructive pulmonary disease given h/o asbestosis, sleep apnea,
and asthma) perhaps with some contribution from heart failure
and resulting pulmonary congestions given pleural effusions and
congestion on xray. Per fever and leukocytosis at OSH though he
was also covered with Abx for pneumonia, got Ceftriaxone,
azythro, Vanco then transitioned to levofloxacin. In the MICU
patient was put on BiPAP with improvement in ABG. He was started
on standing nebs; continued ipratroprium + started
levalbuterol(given ectopy). We also increased home advair to
500/50 (from 250/50). We started Prednisone day 1 = [**5-26**] (also
got IV solumedrol 125mg on the night of admission to the CCU).
We continued Levofloxacine for a total of 7 days. His blood
cultures and urine cultures were negative.
ON DISCHARGE: Patient is leaving on a prednisone taper - 30mg
for 3 days, 20mg for 3 days, and 10mg for 3 days. Will need to
continue with use of inhalers - this will need to be adjusted
based on patient's respiratory status. Patient will need his O2
sat monitored, with O2 therapy to maintain his O2 around 92%.
# ARRHYTHMIA: per telemetry here has PAF with rates to the
130??????s when in fib. Asymptomatic with stable HD. We restarted
his home carvedilol at 3.125 then uptitrated to 6.25. His CHADS2
score of 3 but does not appear to be candidate for
anticagulation given his poor functional status and evidence of
falls (bruise on chest), Family understood this.
# CAD: Patient has significant history of CAD with question of
MI. Had modest trop levels to 0.13 in the setting of CHF
exacerbation , echo here showed focal LV wall hypokinesis
consistent with CAD , these findings are unchanged from those on
MIBI in [**2134**] which showed akinesia and severe perfusion defects
in LAD territory. Thus patient is not thought to have had a
recent MI. Positive trop are likely [**2-16**] to leak in the setting
of CHF exacerbation +/- sepsis.
- Continued ASA 325 mg PO daily
- Continued lisinopril
- restarted home carvedilol
- continued home Simvastatin 80mg daily
.
# CHF: echo here: mild symmetric LVH, LV is top
normal/borderline dilated, mild to moderate regional left
ventricular systolic dysfunction with hypokinesis of the
mid-distal anterior wall, apex, and distal anterior septum (LVEF
35-40%). ??????left ventricular dysfunction c/w CAD, Mild aortic root
dilatation (1+) aortic regurgitation is seen. trivial mitral
regurgitation, mild PHTN.
Currently is not clinically fluid overloaded. LOS fluid balance
at tramsfer was -1600
- holding home lasix, goal I/O even for now
- restarted Acei once renal function improved
- restarted home carvedilol
- salt restrict to Na 2g/daily
On Discharge:
Continue to monitor I&Os - goal net- even daily.
Can restart home lasix if net positive. Monitor Creatinine if
restarting home lasix.
# AAA: infrarenal 7.5 cm newly found, no acute intervention per
vasc [**Doctor First Name **]. Also on phys exam susp politeal aneurysms. Patient
initially transferred here for evaluation of surgical
intervention. Vascular surgery followed patient daily. Currently
vascular feels that patient needs to improve functional status
prior to surgical intervention.
On Discharge:
Once patient is out of rehab he will need to follow up regarding
surgical intervention for his large AAA.
.
# HTN: Blood pressures currently holding well
- Continued lisinopril as above
- restarted home carvedilol on half home dose 6.25
On DISCHAREG:- Hold anti-hypertensives if SBP <100
.
# HLD:
- Continued Simvastatin 80mg daily for now
.
# Benign Prostatic Hyperplasia
- Continued Proscar
- Foley
ON DISCHARGE: Trial of Void in 2 days. If fails, reinsert foley
and consult Urology services.
TRANSITIONAL ISSUES:
#Pancreas Lesions - on CTA [**5-29**] - 2.0 x 0.8 cm cystic lesion
within the tail of the pancreas, with a second in the pancreatic
head which should be further evaluated with MRI on a
non-emergent basis, which will also evaluate the renal lesions.
#AAA - patient will follow up with surgery as outpatient for
elective endovascular repair of this aneurysm. Surgery will set
up all necessary services for pre-op.
Medications on Admission:
- Aspirin 325 p.o. daily
- Lisinopril 20 p.o. daily
- Lasix 20 p.o. daily
- Carvedilol 6.25 p.o. [**Hospital1 **]
- Simvastatin 80mg daily
- Advair 250 one inhalation twice daily
- Prilosec 20 p.o. daily
- Flonase 50mcg 1 puff [**Hospital1 **] in both nostrils
- Proscar 5mg p.o. daily
- Trazodone 50 p.o. hs
- Senokot once daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Senokot 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
9. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
11. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
Disp:*30 Tablet(s)* Refills:*0*
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
13. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*1 unit* Refills:*0*
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash area.
15. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): please take 30mg until [**6-2**], then take 20mg until [**6-5**],
then take 10mg until [**6-8**] then stop. .
16. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
18. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-16**] Sprays Nasal
DAILY (Daily) as needed for nasal dryness.
19. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4h ().
20. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
Primary Diagnosis:
1)COPD exacerbation
2)Abdominal Aortic Aneurysm
Secondary Diagnosis:
- CABG: emergency procedure at [**Hospital1 18**] ([**2123**])
- Obstructive Sleep Apnea not on CPAP
- Asthma
- Asbestosis
- Benign Prostatic Hypertrophy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were transferred to our facility with trouble breathing,
trouble walking, coughing as well as newly-discovered abdominal
aortic aneurysm. We have treated your COPD-exacerbation, and
your breathing has improved. We have also treated you for a
possible pneumonia. While in our care you were closely followed
by the surgical team, who felt that your aneurysm will be
repaired, but not during this admission.
THE FOLLOWING CHANGES WERE MADE TO YOUR MEDICATIONS:
START olanzapine 2.5 mg Tablet One Tablet at bedtime as needed
for agitation.
START tramadol 50 mg One (1) Tablet Q6H (every 6 hours) as
needed for back pain.
START Advair Discus at a new higher dose of 500-50 mcg twice a
day
START Prednisone - take 3 pills for 2 days, 2 pills for 3 days,
then 1 pill for 3 days, then stop.
START Sodium-chloride Nasal Spray - twice a day as needed
START Ipratropium-bromide Nebulizer treatments every 4 hours as
needed for shortness of breath.
START Levalbuterol Nebulizer Treatment every 4 hours as needed
for shortness of breath.
START fluticasone spray twice a day as needed.
Please hold your Lasix until told to restart it by your
physician.
Followup Instructions:
Please set up an appointment with primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from the rehab facility.
Department: VASCULAR SURGERY
When: TUESDAY [**2135-6-14**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2135-6-2**]
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17498, 17597
|
10044, 11882
|
415, 421
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17637, 17685
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17898, 18037
|
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2541, 2607
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3106, 3433
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,705
| 143,783
|
4185
|
Discharge summary
|
report
|
Admission Date: [**2183-11-23**] Discharge Date: [**2183-11-26**]
Date of Birth: [**2108-8-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Transfer for bronchial stent placement
Major Surgical or Invasive Procedure:
bronchoscopy (planned)
History of Present Illness:
75 yo W with COPD (on 3L home O2), tracheo-broncheo-malacia,
multiple past therapeutic bronchoscopies and Y stent
placement/removal in [**2182**] who was transferred form [**Hospital 18222**]
hospital after treatment for an acute episode of SOB/wheezing
and increased WOB for possible tracheal stent with IP.
.
She initially presented to OSH on [**2183-11-17**] with several days of
worsening SOB, DOE, wheezing and was felt to be in "extremis."
Was initially treated for COPD flare, but w/o steroids (received
Roceophin and azithro), however, the next day noted to have
incr. WOB and was transferred to ICU for WOB and non-AG met.
acidosis (bicarb of 20). with ABG of 7.24/28/186/20 on 100% O2.
She was treated w/ standing nebs/bicitra and ativan/haldol in
addition to above. Apparently given severe anxiety, was tx w/
IV Precedex. CPAP and BIPAP were tried during ICU stay (reasons
unclear, also unclear [**Name2 (NI) **] one worked best) and she was
eventually started on Prednisone, tapered to 10mg [**Hospital1 **] at time of
transfer to [**Hospital1 18**]. She completed course of Avelox per transfer
note.
.
Of note, she has had > 6 admissions to [**Hospital1 **] over the past 6
months for similar symptoms, each tx for COPD flare and felt to
be multifactrial: TBM/COPD/VC dysfunction. She was last d/ced
at beginning of [**Month (only) 359**], however 2wk prior to admission began to
experience incr. wheezing/DOE. She was tx by PCP w/ ABx and
steroids. Intermittent fevers and chills, subjective and chronic
cough, no change in sputum character. She continues to smoke,
only takes spiriva and pulmicort on a prn basis.
.
While in ICU, her O2 requirement had been decreased to 2L NC w/
94-96%. BPs remained in 116-151 range systolic and HR in 80s.
I/Os were -1.5L for hospital stay. She was treated with prn
nebs. Prednisone was stopped. She did not require frequent nebs
(< Q4H).
In addition to above, ROS notable for intermittent chest
tightness, w/o diaphoresis, n/v/radiation. She reports having
had a negative stress and coronary antio in the past, but does
not recall the time. She has chronic loose stools, which get
worse whenever she is admitted. Chronic LBP, unchanged from
prior as well as knee/hip pain, fatigue.
.
REVIEW OF SYSTEMS:
(+): as per HPI.
(-): night sweats, loss of appetite,chest pain, palpitations,
rhinorrhea, hemoptysis, orthopnea, paroxysmal nocturnal dyspnea,
nausea, vomiting, constipation, hematochezia, melena, dysuria,
urinary frequency, urinary urgency, focal numbness, focal
weakness.
Past Medical History:
Tracheobroncheomalacia s/p Y stenting in [**8-/2182**], which was
removed On [**2182-9-27**] given mucous plugging.
COPD on 2L home oxygen
Vocal Cord Dysfunction
Obesity hypoventilation syndrome
Chronic Diastolic heart failure
Hypothyroidism
Irritable bowel Syndrome
Vitamin D deficency
Coronary artery disease
Anxiety
Depression
Seizure disorder
H/o C. diff colitis
R colon cancer s/p hemicolectomy in [**2178**] (vs. neuroendocrine
tumor per some OSH reports)
s/p tonsillectomy
s/p thyroid lobectomy [**2151**]
s/p cholecystectomy [**2151**]
s/p appendectomy [**2179**] - for neuroendocrine tumor
Smoking
Psychosis with prednisone
Social History:
Lives in [**Location 18223**] MA, alone, independent in ADLs.
Tobacco - 55yrs of 1ppwk
Etoh, drugs - denies.
Family History:
Mother and father with CAD
No lung cancer or congenital lung diseases
Physical Exam:
Vitals: P-87, BP-136/58, O2 sat-94%
General: Alert, oriented X3 , elderly female in no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Audible wheezing without auscultation,Poor air flow
bilaterally, expiratory wheezes bilaterally in all lung fields,
insp. ronchi no crackles
CV: Regular rate and rhythm, soft 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
Pertinent Results:
Labs on Admission:
[**2183-11-23**] 05:40PM BLOOD WBC-9.7 RBC-4.34 Hgb-12.4 Hct-38.0 MCV-87
MCH-28.4 MCHC-32.5 RDW-15.6* Plt Ct-273
[**2183-11-23**] 05:40PM BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1
[**2183-11-23**] 05:40PM BLOOD Plt Ct-273
[**2183-11-23**] 05:40PM BLOOD Glucose-107* UreaN-8 Creat-1.0 Na-142
K-4.6 Cl-104 HCO3-29 AnGap-14
[**2183-11-23**] 05:40PM BLOOD Calcium-9.4 Phos-4.0 Mg-2.2
[**2183-11-23**] 08:12PM BLOOD Type-ART Temp-36.1 pO2-65* pCO2-39
pH-7.50* calTCO2-31* Base XS-6 Intubat-NOT INTUBA
[**2183-11-23**] 08:12PM BLOOD Lactate-0.7.
Bronchial washings:
.
[**2183-11-25**] 2:09 pm BRONCHIAL WASHINGS
GRAM STAIN (Final [**2183-11-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Preliminary):
OSH pertient results:
CXR [**10/2183**]- Cardiac and mediastinal silhouettes are grossly
normal. The aortic arch is calcified. Lungs are diffusuely
hyperaerated, with hyperlucency in the apices, and increased
linear markings in both bases.
EKG [**2182-9-30**]-Sinus rhythm. Within normal limits.
CXR [**2182-9-29**]-The heart size is normal. Mediastinal position,
contour and width are unremarkable. Bibasal linear opacities
have slightly improved and might represent interval improvement
in bronchiectasis or bronchial wall inflammation/infection
Bronchoscopy [**8-25**] demonstrated dynamic collapse in the
proximal/distal trachea, the right main stem bronchus, and the
bronchus intermedius, also laryngopharyngeal reflux.
.
PFT's [**8-/2182**]
Mechanics: The FVC and FEV1 are moderately reduced. The FEV1/FVC
ratio is normal. There was no significant change following
inhaled bronchodilator. Flow-Volume Loop: Moderate expiratory
coving with a moderately reduced volume excursion and an early
termination of exhalation. Lung Volumes: The TLC and FRC are
normal. The RV and RV/TLC ratio are elevated. DLCO: The Dsb
corrected for hemoglobin is moderately to markedly reduced.
.
CT trachea w/ forced expiratory maneuver [**11-24**]:
.
IMPRESSION:
1. Distal tracheal narrowing of 53% is borderline for
tracheomalacia.
2. No evidence of bronchomalacia.
3. Diffuse severe emphysema.
4. New bilateral lower lobe bronchial wall thickening suggestive
of small
airways disease. New lower lobe mucous plugging with and
subsegmental
atelectasis at both lung bases.
5. Chronic but not previously seen bilateral rib fractures
Brief Hospital Course:
75 yo F with history of COPD (on 2L home O2),
tracheo-broncheo-malacia,multiple past therapeutic
bronchoscopies and Y stent placement and removal in [**2182**]
presenting from a OSH for new stent placement and acute on
chronic hypoxemic respiratory failure.
.
# Acute on Chronic Hypoxemic Respiratory Failure: The patient
has a complicated pulmonary history with chronic COPD (continued
smoking), Vocal cord dysfunction and suspected
tacheo-broncheo-malacia.
Upon transfer to [**Hospital1 18**] she was much imroved (3L NC and satting
mid 90s). The underlying etiology of exacerbations in long term
was felt to be multifactorial: continued smoking, COPD flares in
setting of not using inhalers properly (used pulmicort and
ipratropium prn only), probably dCHF on initial presentation (at
time of [**Hospital1 18**] admission was euvolemic on exam), and suspected
TBM and VC dysfunction. Based on PFTs as above, it was felt
that most of her disease was due to COPD flares (stage II dz
based on PFTs from [**2182**]).
After 24 hrs in ICU, she was transferred to the floor, on 2L NC.
CT was performed showing severe emphasema and borderline TBM.
She underwent bronchoscopy showing
supraglottic edema, suggestive of GERD, hematoma at the level of
the left VC and excessive adduction of VCs during exhalation,
compatible with vocal cord dysfunction. Notes was diffuse
severe tracheobronchomalacia and thick secretions.
She was treated with prn nebulizers (used rarely) and standing
ipratropium, changed to tiotropium at time of discharge. She
was also restarted on Advair. Smoking cessation counseling was
provided. Calcium increased to 1500mg daily and Vit. D
increased given frequent steroid use and age. Anxiety component
may be treated with ativan if needed.
The plan is for her to be evaluated by ENT for vocal cord
dysfunction as well as treated with speech therapy and treatment
of underlying GERD more aggresively. In addition, she will
require pulmonary rehabiilitation as well as ensuring adherence
to medications. She was arranged follow up with interventional
pulmonary, PCP and ENT (see discharge paperwork).
At time of discharge, she had scant rhonchi on exam and required
2L NC for O2 sats > 90 while ambulating (at baseline uses 2-3L
NC only while sleeping).
# Coronary artery disease and CHF hx. Not active during
hospitalization. No hx of PUD or GIB per PCP. [**Name10 (NameIs) **] was started
on ASA 81mg for secondary prevention.
.
# Vocal Cord Dysfunction. see above.
.
# Obesity hypoventilation syndrome. Likely reason for baseline
acidosis at OSH, has never been treated or see by sleep. Should
be evaluated on outpatient basis.
.
# Hypothyroidism. Continued levothyroxine.
.
# Irritable bowel Syndrome. Loose stools consistent w/ this. No
leukocytosis or fevers or abd. pain to sugggest C.diff. No
clinical signs of infection.
- monitor
.
# Vitamin D deficency. Cont. Vit. D. Dose of Vit D increased to
800U daily.
.
# Depression/Anxiety. Euthymic during admission.
#.Seizure disorder. Followed by OP neurologist. Continued
Lamictal 100mg p.o daily.
Medications on Admission:
Spiriva takes prn
Perforomist (long acting beta, Rx by Shuttari, [**Hospital1 1562**] Pulm).
Pulmicort prn
Lamictal 100mg daily
[**Doctor First Name **]-D
Ativan PRN while inpatient
Calcium Supplements
Effexor 100mg [**Hospital1 **]
Nexium 20mg daily
Synthroid 125 mcg
Vitamins B12 and D - unknown.
Discharge Medications:
1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin rash .
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO BID (2 times a day).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
7. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day.
14. follow up
Please call the office of Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3020**]
to ensure appointment has been scheduled for patient
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 9188**] Care and Rehab
Discharge Diagnosis:
Primary: Hypoxemic respiratory distress
Secondary: COPD, trancheobronchomalacia, vocal cord dysfunction,
congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 18**] from [**Hospital 1562**] hospital for evaluation
of tracheobronchomalacia and treatment of your COPD. You
underwent a bronchoscopy which showed tracheobronchomalacia,
large amount of secretions and dysfunctional vocal cords. This
is in addition to your significant chronic obstructive pulmonary
disease.
You were urged to stop smoking.
You were also referred for pumonary and physical rehabilitation.
You were arranged for follow up appointments with your primary
care doctor, interventional pulmonary and ear nose and throat
doctor.
Several medications were changed (please see the final list
below)
You were discharged to a rehabilitation facility.
Should you develop any symptoms or signs concerning to you,
please call your doctor or go to the nearest emergency room.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital3 **] COMMUNITY HEALTH CLINIC
Address: [**Street Address(2) 18224**], Ste#1A [**Location (un) 6598**], [**Numeric Identifier 18225**]
Phone: [**Telephone/Fax (1) 18226**]
Appointment: Monday, [**12-8**] at 2:00PM
Name: [**Last Name (LF) 9328**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital **] INFIRMARY
Address: [**Doctor Last Name 18227**], [**Location (un) **],[**Numeric Identifier 18228**]
Phone: [**Telephone/Fax (1) 18229**]
Appointment: Wednesday, [**12-17**] at 12:45PM
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD
Location: [**Hospital1 18**] - DIVISION OF PULMONARY MEDICINE
Address: [**Location (un) **], [**Hospital1 **] 116, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3020**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within 6-8 weeks. You will be called at home with the
appointment. If you have not heard from the office within 2 days
or have any questions, please call the number above.**
Please call the office of Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3020**]
to ensure appointment has been scheduled for patient (see d/c
paperwork for details)
Completed by:[**2183-11-26**]
|
[
"278.03",
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"478.5",
"278.01",
"496",
"428.32",
"519.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
11761, 11827
|
6890, 9985
|
356, 380
|
12001, 12001
|
4453, 4458
|
13029, 14367
|
3750, 3822
|
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|
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|
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|
3837, 4434
|
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|
2674, 2950
|
278, 318
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408, 2655
|
4473, 5208
|
12016, 12160
|
2972, 3607
|
3623, 3734
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,066
| 169,733
|
37040+58119
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-7-27**] Discharge Date: [**2174-8-5**]
Date of Birth: [**2094-11-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic stenosis
Major Surgical or Invasive Procedure:
Aortic valve replacement (25mm St. [**Male First Name (un) 923**] tissue)[**2174-8-1**]
dental extractions [**2174-7-29**]
History of Present Illness:
This 79 year old white male has known aortic stenosis, with
progressive dyspnea on exertion. Catheterization previously has
demonstrated clean coronaries. He was transferred here for
surgery.
Past Medical History:
Aortic stenosis
s/p aortic valve replacement
peripheral vascular disease
s/p bilateral femoral popliteal bypass grafts
gout
noninsulin dependent diabetes mellitus
s/p Left shoulder calcium removal
s/p left knee surgery
Social History:
remote smoker
ETOH daily
retired contracter, lives with his wife
Family History:
noncontributory
Physical Exam:
ADMISSION:
Pulse: 66 Resp: 18 O2 sat: 96
B/P 150/82
Height:178cm Weight:107 (230 lbs)
Admission:
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] Murmur:SEM III/VI radiating to neck
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right: - Left:-
Pertinent Results:
[**2174-8-4**] 05:49AM BLOOD WBC-5.7 RBC-2.77* Hgb-8.9* Hct-25.2*
MCV-91 MCH-32.1* MCHC-35.3* RDW-14.8 Plt Ct-242
[**2174-8-4**] 05:49AM BLOOD Glucose-125* UreaN-26* Creat-1.0 Na-135
K-4.5 Cl-100 HCO3-27 AnGap-13
[**2174-8-3**] 05:51PM BLOOD Glucose-97 UreaN-21* Creat-0.8 Na-130*
K-4.2 Cl-98 HCO3-26 AnGap-10
Conclusions
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is
seen. The mitral valve leaflets are severely thickened/deformed.
There is severe mitral annular calcification. There is mild
functional mitral stenosis due to mitral annular calcification.
Physiologic mitral regurgitation is seen (within normal limits).
There is no pericardial effusion.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2174-8-2**] 16:08
Brief Hospital Course:
Following admission workup was undertaken.Dental extractions
were performed on [**7-29**]. Carotids ultrasounds were
nonobstructive.
On [**8-1**] he was taken to the Operating Room where aortic valve
replacement was done. See operative note for details. He weaned
from bypass with ventricular ectopy which resolved with deairing
and an Amiodarone bolus. Low dose neosynephrine and Propofol
were running at the end of the operation. He was extubated later
that night, and transferred to the floor on POD #2 to begin
increasing his activity level.
CTs were removed according to protocol and temporary pacing
wires were likewise removed (on POD 3). Physical therapy worked
with him for strength and mobility. Beta blockade and diuretics
were begun.
He remained stable, he diuresed nicely and remained in sinus
rhythm. He was ready for discharge and went to a rehabilitation
facility for further recovery before returning home.
medications, wound care and postoperative instructions were
included in the paperwork sent with the patient. STOP [**8-5**]
Medications on Admission:
Allopurinol 300mg/D
ASA 81mg/D
Glyburide 5mg [**Hospital1 **]
metformin 500mg TID
Lovaza 1000mg [**Hospital1 **]
Lisinopril 20mg/D
Simvastatin 20mg/D
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) 7658**]
Discharge Diagnosis:
Aortic stenosis
s/p aortic valve replacement
peripheral vascular disease
s/p bilateral femoral popliteal bypass grafts
gout
noninsulin dependent diabetes mellitus
s/p Left shoulder calcium removal
s/p left knee surgery
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in [**2-11**] weeks ([**Telephone/Fax (1) 53192**])
Dr. [**First Name8 (NamePattern2) 29069**] [**Name (STitle) 29070**] in 2 weeks
Please call for appointments
Completed by:[**2174-8-5**] Name: [**Known lastname 8954**],[**Known firstname **] W Unit No: [**Numeric Identifier 13281**]
Admission Date: [**2174-7-27**] Discharge Date: [**2174-8-5**]
Date of Birth: [**2094-11-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 741**]
Addendum:
See medication sheet
Chief Complaint:
see summary
Major Surgical or Invasive Procedure:
dental extractions [**2174-7-29**]
Aortic valve replacement (25mm St. [**Male First Name (un) 744**] tissue)[**2174-8-1**]
History of Present Illness:
see summary
Past Medical History:
Aortic stenosis
s/p aortic valve replacement
peripheral vascular disease
s/p bilateral femoral popliteal bypass grafts
gout
noninsulin dependent diabetes mellitus
s/p Left shoulder calcium removal
s/p left knee surgery
Social History:
remote smoker
ETOH daily
retired contracter, lives with his wife
Family History:
noncontributory
Physical Exam:
see summary
Pertinent Results:
[**2174-8-4**] 05:49AM BLOOD WBC-5.7 RBC-2.77* Hgb-8.9* Hct-25.2*
MCV-91 MCH-32.1* MCHC-35.3* RDW-14.8 Plt Ct-242
[**2174-8-3**] 05:51PM BLOOD WBC-5.6 RBC-2.67* Hgb-8.3* Hct-24.3*
MCV-91 MCH-31.2 MCHC-34.3 RDW-14.4 Plt Ct-187
[**2174-8-4**] 05:49AM BLOOD Glucose-125* UreaN-26* Creat-1.0 Na-135
K-4.5 Cl-100 HCO3-27 AnGap-13
[**2174-8-3**] 05:51PM BLOOD Glucose-97 UreaN-21* Creat-0.8 Na-130*
K-4.2 Cl-98 HCO3-26 AnGap-10
Brief Hospital Course:
see summary
Medications on Admission:
see summary
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 176**] - [**Location (un) 2570**]
Discharge Diagnosis:
Aortic stenosis
s/p aortic valve replacement
peripheral vascular disease
s/p bilateral femoral popliteal bypass grafts
gout
noninsulin dependent diabetes mellitus
s/p Left shoulder calcium removal
s/p left knee surgery
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 1477**])
[**Hospital Ward Name **] 6 wound clinic in 2 weeks
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13282**] in [**2-11**] weeks ([**Telephone/Fax (1) 13283**])
Dr. [**First Name8 (NamePattern2) 13284**] [**Name (STitle) 10776**] in 2 weeks
Please call for appointments
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2174-8-5**]
|
[
"401.9",
"362.50",
"285.9",
"424.1",
"413.9",
"272.4",
"724.9",
"250.00",
"600.00",
"521.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"23.19",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10387, 10464
|
8777, 8790
|
7760, 7885
|
10727, 10734
|
8331, 8754
|
11138, 11654
|
8267, 8284
|
8852, 10364
|
10485, 10706
|
8816, 8829
|
10758, 11115
|
8299, 8312
|
7709, 7722
|
7913, 7926
|
7948, 8168
|
8184, 8251
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,486
| 102,914
|
44601
|
Discharge summary
|
report
|
Admission Date: [**2112-5-2**] Discharge Date: [**2112-5-6**]
Date of Birth: [**2044-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Nitroglycerin / Lopressor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
CABG x 4 (Lima>LAD, SVG>diag, SVG>OM2, SVG>PDA) [**5-2**]
History of Present Illness:
67 yo M with history of MI and multiple stents, admitted with
exertional chest pain, cath showed 3VD. Referred for surgery.
Past Medical History:
Type 2 IDDM
CAD s/p IMI and multiple PCI??????s to the LCX and LAD
Hypertension
Polypectomy
Presumed embolic stroke [**2098**], on long term plavix without
residual deficits
S/P tonsillectomy
S/P Appendectomy
Bilateral cataracts
Diabetic retinopathy
S/P surgical repair of a right ankle fracture
Social History:
He is married with no children. He works part-time in financial
planning. He does not smoke and occasionally has an alcoholic
drink.
Family History:
no family history of premature CAD
Physical Exam:
NAD HR 68 RR 18 BP 148/82
Lungs CTAB anteriorly
Heart RRR
Abdomen benign
Extrem warm, no edema, no varicose veins
Pertinent Results:
[**2112-5-6**] 05:30AM BLOOD WBC-8.2 RBC-3.08* Hgb-9.3* Hct-27.8*
MCV-90 MCH-30.3 MCHC-33.6 RDW-16.7* Plt Ct-185
[**2112-5-2**] 11:56AM BLOOD WBC-9.6# RBC-2.89*# Hgb-8.2*# Hct-25.6*#
MCV-89 MCH-28.5 MCHC-32.2 RDW-17.6* Plt Ct-141*
[**2112-5-2**] 11:56AM BLOOD Neuts-85.9* Bands-0 Lymphs-10.6*
Monos-3.2 Eos-0.2 Baso-0.1
[**2112-5-6**] 05:30AM BLOOD Plt Ct-185
[**2112-5-6**] 05:30AM BLOOD Glucose-219* UreaN-21* Creat-1.1 Na-145
K-3.6 Cl-105 HCO3-28 AnGap-16
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 95489**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 95490**] (Complete)
Done [**2112-5-2**] at 7:35:21 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2044-4-25**]
Age (years): 68 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: TEE for hemodynamic instability post cardiac surgery
ICD-9 Codes: 780.2, 440.0
Test Information
Date/Time: [**2112-5-2**] at 19:35 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. Moderate regional LV
systolic dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: No thoracic aortic dissection.
AORTIC VALVE: No AR.
MITRAL VALVE: No MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient appears
to be in sinus rhythm.
Conclusions
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with Inferior wall
hyopokinesis in the mid to apical segments.. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-45
%). Right ventricular chamber size and free wall motion are
normal. No thoracic aortic dissection is seen. No aortic
regurgitation is seen. No mitral regurgitation is seen. There is
no pericardial effusion.
Impression: No obvious causes for increasing pressor or inotrope
requirements. Wall motion abnormality noted in this study was
seen in TEE earlier in the day, but appears slightly worse.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2112-5-3**] 13:51
Brief Hospital Course:
He was taken to the operating room on [**2112-5-2**] where he
underwent coronary artery bypass graft, please see operative
report for further details. He was transferred to the ICU in
critical but stable condition. He was initially hypotensive with
decreased cardiac index requiring mutiple drips, but they were
weaned to off on POD 1. He was weaned from sedation, awoke
neurologically intact and was extubated without difficulty. He
was transferred to the floor POD 2, and he had short burst of
atrial fibrillation that was treated with beta blockers and one
dose of amiodarone. He remained in sinus rhythm and his beta
blockers were titrated. He was gently diuresed towards his
preoperative weight. Physical therapy worked with him for
strength and mobility. He was ready for for discharge home with
services on POD 4.
Medications on Admission:
atenolol 25", lisinopril 20", asa 325', plavix 75', mvi,
protonix 20', norvasc 10', lipitor 10', humalog ss, lantus 30',
zetia 10", nitrostat prn, renexa 1g".
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
Disp:*qs qs* Refills:*2*
11. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: please continue with sliding
scale as prior to admission .
Disp:*qs qs* Refills:*2*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABG
CAD s/p MI '[**94**], CVA (embolic) '[**98**], stent LAD '[**94**] & 91',
polypectomy, b/l cataracts, DM, DM retinopathy, htn, s/p
tonsillectomy, appy, ankle fx repair.
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 check blood sugars before meals and bedtime, please
continue with lantus and sliding scale insulin but if BG > 200
please follow up with primary care physician
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 838**] 1 week
Dr [**Last Name (STitle) 120**] in 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Wound check [**Hospital Ward Name 121**] 6
Scheduled appt
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2112-6-21**] 4:00
Completed by:[**2112-5-6**]
|
[
"293.0",
"V12.54",
"401.9",
"414.01",
"411.1",
"412",
"276.6",
"362.01",
"250.51",
"E878.2",
"427.31",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6957, 7015
|
4496, 5325
|
323, 383
|
7241, 7249
|
1209, 4473
|
7928, 8281
|
1024, 1060
|
5534, 6934
|
7036, 7220
|
5351, 5511
|
7273, 7905
|
1075, 1190
|
262, 285
|
411, 536
|
558, 855
|
871, 1008
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,153
| 148,383
|
38585
|
Discharge summary
|
report
|
Admission Date: [**2169-2-6**] Discharge Date: [**2169-2-12**]
Date of Birth: [**2106-8-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
endotracheal intubation
mechanical ventilation
cardiac catheterization
pericaridocentesis, pericardial drain
Pleurovac placement, thoracentesis
right internal jugular central venous line placement
History of Present Illness:
The patient reports being in usual state of health developing
daily hemoptysis in [**2168-6-19**]. He was subsequently found to
have NSCLC with metastases to the adrenals.He was admitted to
the MICU on [**2168-8-15**] and required angiography w/ embolization for
a lung parenchyma bleed.
He had a course of radiation therapy finishing on [**2168-9-6**] and 4
cycles of chemotherapy finishing on [**2168-12-1**]. He notes having
morning recurrent hemoptys in the for the last few month. 4 days
prior to presentation, he noted having dependent ankle swelling
associated productive cough, orthopnea and increased dyspnea. He
has slept in a chair on occasion. This am, during an outpatient
imaging appointment for his leg, he was noted to be dyspnic and
he was sent to the ED.
In the ED, initial vs were: 98.1 118 161/81 28 89% on RA. Labs
were notable for a leukocytosis with bandemia of 9%, lactate 3.7
--> 3.1, and sodium 131. An 18g PIV was placed. He was given
vanc, cefepime, and levofloxacin. CXR and CT revealed a large
right pleural effusion. IP was contact[**Name (NI) **] and plan to do [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**]
today. VS prior to transfer: 100 111/74 12 99% 6L. He is DNR/I.
.
On the floor, he reports dyspnea associate with productive
cough, and he denies any fevers and chills, any chest pain,
nausea or palpitation.Denies any abdominal pain, diarrhea. He
notes 12 lbs weight lost in the last month.
The interventional pulmunology team placed a pigtail catheter
and drain 2 liters from the right lung cavity. The patient noted
improved breathing.
Past Medical History:
HTN
Hyperlipidemia
PTSD
Social History:
Lifetime cigarette non-smoker, rare cigar use; [**2-22**] drinks per
day (last drink day prior to admission). No current drug use.
No previous exposure to asbestos, but + [**Doctor Last Name 360**] [**Location (un) 2452**] in [**Country 3992**]
and + hydrofluoric acid at chemical plant (19 years) where
previously employed. Currently a hockey coach. Engaged to
[**Doctor First Name **], who previously had cancer and treatment.
Family History:
Father with NHL, died age 47
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:96.8 BP:132/79 P:106 R:30 18 O2:97 on 6 L nc
General: Alert, oriented, no acute distress, appears cachetic
HEENT: Sclera anicteric, tongue with white plaque
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation on left side,no breath sounds and
increased dullness to percussion on the right until middle of
lung. no wheezes, rales, ronchi
CV: tachy, Regular rate and rhythm, systolic murmur no 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, 1+ edema in LE, no
clubbing, cyanosis
DISCHARGE PHYSICAL EXAM:
Not applicable, patient expired.
Pertinent Results:
[**2169-2-6**] 12:55PM BLOOD WBC-29.0* RBC-3.22* Hgb-9.0* Hct-26.0*
MCV-81* MCH-27.8 MCHC-34.5 RDW-17.4* Plt Ct-277
[**2169-2-6**] 12:55PM BLOOD Neuts-77* Bands-9* Lymphs-2* Monos-2
Eos-10* Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2169-2-6**] 12:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2169-2-6**] 12:55PM BLOOD PT-14.2* PTT-24.3 INR(PT)-1.2*
[**2169-2-6**] 12:55PM BLOOD Plt Smr-NORMAL Plt Ct-277
[**2169-2-6**] 12:55PM BLOOD Glucose-105* UreaN-42* Creat-0.9 Na-131*
K-4.2 Cl-93* HCO3-25 AnGap-17
[**2169-2-6**] 05:06PM BLOOD ALT-40 AST-55* CK(CPK)-447* AlkPhos-76
TotBili-0.6
[**2169-2-6**] 05:06PM BLOOD TotProt-5.4* Calcium-9.8 Phos-4.2 Mg-1.8
[**2169-2-7**] 11:13PM BLOOD Cortsol-17.5
[**2169-2-7**] 08:15PM BLOOD Type-ART pO2-193* pCO2-97* pH-7.06*
calTCO2-29 Base XS--5
[**2169-2-6**] 12:46PM BLOOD Glucose-105 Lactate-3.7* Na-132* K-4.4
Cl-93* calHCO3-24
[**2169-2-7**] 08:15PM BLOOD O2 Sat-98
[**2169-2-6**] 09:36PM BLOOD freeCa-1.25
[**2-6**] CXR 1. Worsening perihilar opacities bilaterally, right
greater than left, and new lobulated nodular opacities within
the periphery of mid lung fields bilaterally. Findings are
concerning for progression of metastatic disease with possible
lymphadenopathy. Large right pleural effusion. No sizeable left
pleural effusion noted. Increased interstitial markings within
the right lung, which may reflect lymphangitic spread of tumor,
and less likely volume overload.
[**2-6**] CTA chest: 1. No acute pulmonary embolism or thoracic
aortic pathology. In this patient with known lung cancer, there
has been significant interval progression of metastatic disease
compared to the prior study. Numerous pulmonary and pleural
based nodules, mediastinal lymph nodes and adrenal masses, have
increased in size. Extensive bilateral hilar consolidations.
While a component may be secondary to radiation change, the new
or increased consolidations in the right middle and lower lobes
are concerning for metastatic disease or possibly
infection. Moderate-to-large right and a small left pleural
effusions.
[**2-6**] CT Head: There is no evidence of hemorrhage, edema, masses,
mass effect, or infarction. The ventricles and sulci are normal
in size and configuration. No fractures are identified. No soft
tissue swelling noted. The mastoid air cells and sinuses are
clear. No acute intracranial hemorrhage.
[**2-7**] ECHO: There is a moderate to large sized pericardial
effusion. There is right atrial collapse. There is right
ventricular diastolic collapse.LV function is preserved with an
EF of >55%.
[**2-7**] LENI: Grayscale and Doppler son[**Name (NI) 1417**] of bilateral common
femoral, superficial femoral, and popliteal veins demonstrate
normal compressibility, flow, and augmentation. Bilateral calf
veins showed normal flow. No evidence of DVT in veins of
bilateral lower extremities.
[**2-8**] ECHO: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size and free wall motion are normal. The aortic valve is not
well seen. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a very small pericardial effusion. The effusion appears
loculated. There are no echocardiographic signs of tamponade.
Suboptimal image quality. Very small pericardial effusion
localized to the right atrial free wall. Hyperdynamic left
ventricular function. Moderate pulmonary hypertension. Compared
with the prior report (images not able to be reviewed) of
[**2169-2-7**], the pericardial effusion is now only very small and
loculated adjacent to the right atrium.
Pleural Fluid cytology showed rare atypical epithelioid cells
with enlarged nuclei and prominent nucleoli, too few to
characterize.
and path showed predominantly inflammatory cells. The atypical
cells seen on ThinPrep are not seen.
Pericardial Fluid cytology showed predominantly blood with
lymphocytes, neutrophils, and few mesothelial cells. Negative
for malignant cells.
Brief Hospital Course:
62yo male with metastatic NSCLC s/p XRT and chemotherapy,
previous MICU admission [**7-/2168**] requiring embolization for lung
parenchymal bleed, recurrent hemoptysis, who presented with
increased ankle edema, productive cough, orthopnea, and dyspnea,
as well as worsening LLE pain. Work-up revealed large right
pleural effusion, which was drained after pigtail catheter
placement. Course c/b by aspiration event, hypercarbic
respiratory failure and acidemia requiring intubation,
hypotension in setting of probable sepsis and cardiac tamponade,
s/p pericardiocentesis.
.
# Shock: Multifactorial etiology, though continued shock was
most likely secondary to septic shock. Initial differential
included cardiogenic vs. septic vs. adrenal inusficiency.
Bedside echo revealed evidence of pericardial effusion and
possible cardiac tamponade, and after cardiology consulted
patient taken to cath lab for pericardiocentesis. 180cc
pericardial fluid drained on [**2169-2-7**] and follow up echo on
[**2169-7-11**] show very small pericardial effusion remaining.
Pericardial drained pulled on [**2169-2-9**]. A restrictive
cardiogenic process was considered, given hyperdynamic heart and
preload dependence. However, based on overall clinical picture,
central venous O2 sats, sepsis etiology felt to be most likely
in setting of pneumonia. Adrenal insufficiency was also likely
contributing. Patient treated with broad spectrum antibiotics
and aggressive volume resuscitation. Was gradually weaned off
levophed, but remained on vasopressin for BP support. After a
few days o of treatment he did not improve and he started to
develop a significantly elevated white count, refractory
hypotension and increasing oxygen requirements. He acutely
worsened overnight [**Date range (1) 85787**] and would have required
re-initation of pressors. A discussion was held with the family
and the decision was made to make him comfort care and he was
terminally extubated. A scopolamine patch was applied and a
morphine drip was started. He died at 7:55am on [**2-12**] shortly
after extubation.
.
#. Respiratory Distress: Initial dyspnea and hypoxia were most
likely secondary to right pleural effusion, and patient had
significant improvement in dyspnea following drainage of about
2L exudative effusion via pigtail catheter placement. Effusion
likely malignant; pleural fluid analysis showed atypical cells
on cytology and was negative for infection/empyema. Given
productive cough and leukocytosis, also had concern for PNA,
which was thought to be post-obstructive in nature. CTA was
negative for PE and LENIs also negative. Patient had
significant aspiration event on night of [**2-7**], with subsequent
development of acidemia and hypercarbia. Patient urgently
intubated, and antibiotics broadened from vanc/unasyn to
vanc/zosyn. Patient continued on broad spectrum antibiotics,
with regimen later broadened to include cipro for pseudomonas
double coverage as patient was continuing to spike fevers and
WBC was trending up. Patient also became volume overloaded and
developed pulmonary edema in setting of aggressive IVF
administration for shock (see below). Pao2/FiO2 was concerning
for possible development of ARDS. He started to having
increasing oxygen requirements as discussed above. The patient
was terminally extubated on [**2-12**] per his hcp and family wishes.
He died shortly after extubation.
.
#Adrenal Insufficiency: Patient has known adrenal mets, and
given eosinophilia on WBC differential, was concern for adrenal
insufficiency. Patient had cosyntropin stim test, without
appropriate response. Was started on hydrocortisone 50mg IV
Q6H, and dose later increased to 100mg IV Q6H given patient not
improving. Patient was eventually made comfort measures only and
was terminally extubated and he expired.
.
#Anemia: Baseline of 29-30 in [**11-29**]. Possible recurrence of lung
parenchymal hemorrhage in setting of malignancy. HCT monitored
closely while he was in the hospital until the time of his
death.
.
#Left hip pain: Patient with significant pain in LLE.
Differential for pain included possible bony metastases, as well
as DVT. Previous PET CT did not show any evidence of
metastases. Plain radiographs of left hip obtained and will need
MRI for further workup. LENIs negative for DVT. Patient
initially started on morphine PCA for pain control, was switched
to fentanyl gtt/bolus as needed for pain. A morphine drip was
started when he was made cmo.
.
#. Tachycardia: Likely multifactorial in setting of pain,sepsis
and restrictive cardiac pathology. Patient remained tachycardic
despite massive fluid ressucitation. Required levophed and
vasopressin support. Was able to be briefly weaned off of
pressors, however he acutely worsened overnight on [**5-3**] and
rather than reinstitute pressors his family decided to make him
CMO and he expired.
.
#Hyponatremia. Most likely due to hypovolemic hyponatremia.
Corrected with fluid administration.
#. Urinary Retention: Etiology unclear, and given known
malignancy and history of bony mets will need to monitor
closely. Patient has had recent MRI of lumbar spine in [**12/2168**]
which showed multiple levels of canal stenosis and bilateral
severe neural foraminal narrowing. Narcotics may also be
contributing to retention. Foley placed on [**2-7**] and having
30cc+ UO. This slowly trended down as he clinically worsened
until on the evening of [**2-11**] his urine output ceased entirely in
the setting of hypotension and worsening sepsis.
.
#Metastatic NSCLC with metastases to adrenals. Pt s/p palliative
XRT and chemotherapy. Palliative care at this point for his
disease. Given all of his underlying tumor burden and his
worsening clinicial condition, his family decided to start
comfort measures and he was terminally extubated. He died
shortly after being extubated.
Medications on Admission:
BENZONATATE - 200 mg Capsule - 1 Capsule(s) by mouth three times
a day as needed for cough
CODEINE-GUAIFENESIN - 200 mg-10 mg/5 mL Liquid - 10 ml by mouth
every 4 hours as needed for cough
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff INH twice a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 2 Capsule(s) by mouth DAILY (Daily)
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every 8
hours as needed for nausea, vomiting
OXYCODONE - 10 mg Tablet - 1 Tablet(s) by mouth every 3-4 hours
as needed for pain
POLYETHYLENE GLYCOL 3350 - 17 gram Powder in Packet - 17 grams
by
mouth daily as needed for constipation
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every 6 h ours as needed for nausea
SERTRALINE - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth HS (at bedtime) as needed for Insomnia
Discharge Medications:
Not applicable, patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Pneumonia
Septic Shock
Respiratory Failure
Pleural Effusion
Pericardial Effusion
Secondary:
Metastatic Lung Cancer
Anemia
Discharge Condition:
Expired
Discharge Instructions:
Not applicable, patient expired.
Followup Instructions:
Not applicable, patient expired.
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55,180
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13024
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Discharge summary
|
report
|
Admission Date: [**2111-1-7**] Discharge Date: [**2111-3-1**]
Date of Birth: [**2055-7-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
left upper extremity gangrene, cirrhosis, recurrent respiratory
failure
Major Surgical or Invasive Procedure:
Multiple paracenteses
Cardiopulmonary rescusitation
Hemodialysis
Ultrafiltration
Brachial artery bipass surgery
History of Present Illness:
Mr. [**Known lastname 29179**] is a 55 year-old man with HCV cirrhosis, ESRD, DM,
CAD s/p perioperative MI and PVD who was originally admitted for
upper extremity gangrene [**2111-1-7**] to vascular surgery service
and underwent left brachial to radial bypass on [**2111-1-12**]. The
procedure was complicated by perioperative MI and cardiac
arrest.
.
He was transferred to medicine on [**2111-1-21**] for ascites and
bradycardia. In the two days prior to admission to the MICU, he
was noted to have increased oxygen requirement (95% on 5L from
2L previously) and SBPs dropping from the 100s -> 80s. He
underwent a diagnostic paracentesis on the day of transfer after
receiving albumin 50g (initially planned for therapeutic tap
given increased abdominal distention); the tap was consistent
with SBP and he was started on ceftriaxone.
.
Of note, he has developed new ascites after having been told
that he "cleared" his Hep C years ago after tx with
ribaviron/interferon in [**2101**] at [**Hospital1 112**]. Noted to have a significant
alcohol history as well, but quit drinking approximately 21
years ago. Abdominal distension has been progressive over the
last month. Had tap on [**1-13**] negative for SBP; cytology not
sent. RUQ US on [**2111-1-20**] showed evidence of cirrhosis and
hypoechoic lesion concerning for HCC.
.
Then on [**1-24**] he was transfered to MICU for bradycardia,
hypotension, demand ischemia, and sepsis. He was intubated at
the time of transfer to MICU. In the MICU he was initially on
pressors. CVVH was initiated. He came off pressors on [**2111-1-26**].
He was extubated [**2111-1-27**]. Pressors were restarted on [**1-28**] and
the pt was reintubated on [**2111-1-29**] with worsening mental status.
.
Blood pressure measurement was a constant issue. BPs are
obtained on the right foreman and are approximately 10mmHg below
the a-line.
.
Repeat paracentesis showed SBP, culture negative, and he was
given meropenem, which he remained on for ESBL Klebsiella UTI.
He was also on empiric vancomycin at that time for possible VAP.
.
The patient's respiratory status remains dependent on the level
of abdominal ascites. O2 sats were as low at 33% from the
femoral and improved with paracentesis leading to a dx of
abdominal compartment syndrome. Sats improved with paracentesis.
Abd distension also worsens his respiratory effort and leads to
hypercarbia for which CPAP is used qhs. To prevent worsening of
respiratory status low volume paracentesis has been recommended
q2-4days.
.
He was extubated again on [**2-1**] and off pressors since [**1-31**]. CVVH
was discontinued and the pt tolerated HD [**2-3**]. Multiple goals of
care conversations have been had however the pt remains full
code.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations. Denies cough, or wheezes. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rashes. No numbness/tingling in
extremities. No feelings of depression or anxiety.
Past Medical History:
* CAD and MI s/p cardiac cath [**2105-1-21**] with diffuse, minor LAD
disease, OM1 80% and RCA 70-99%. His most recent Echo ([**12-24**])
showed There is mild symmetric left ventricular hypertrophy with
normal cavity size. There is moderate global left ventricular
hypokinesis with more prominent inferior severe hypokinesis
(LVEF = 30-35 %). The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position
PVD
* h/o parafalcine hemorrhage
* Hypertension
* Hyperlipidemia
* ?fatty liver
* ESRD on dialysis
* Diabetes Mellitus on insulin
* Chronic Hepatitis C (type 2 genotype)
* s/p cholecystectomy
* s/p L rotator cuff surgery
* [**2110-8-4**] R AKA, L BKA
* [**2110-7-29**] Revision R BKA
* [**2110-7-23**] B/L LE guillotine amputations
Social History:
30 pack year history, officially quit [**7-24**]. H/o heavy daily
alcohol consumption from [**2074**]-[**2090**] as patient was a roadie in
several bands during this time. Extensive drug history during
this time as well admitting to cocaine, heroin, and LSD. Was
living with his brother, has been in rehab since [**7-24**].
Family History:
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory. Siblings with CABG in
their 40s.
Physical Exam:
VS: Tc 98.3, Tm 98.6, BP 126/65 (93-141/43-76) via A line. BP on
right forearm 90s/50s (approximately 10 pts lower than a-line).
HR 96(86-103), RR 24([**10-14**]), Sat 100% on 2LNC (92-100%) on 2LNC
vs CPAP w/ 1L.
HEENT: non-icteric, R pupil nonresponsive, left minimally
responsive and pinpoint. OP with ulcer on left palate.
CV: RRR, no m/r/g
PULM: rhonchi left Upper lobe. Clear otherwise
ABD: bloody guaze on RLQ. NT, mild distension. + fluid wave.
LIMBS: right AKA, left BKA, dry gangreen on left 1 and 2nd
digit, right 4th digit. well healling bypass wound on left upper
arm. Picc in right upper arm. HD cath in left subclavian.
SKIN: stage II ulcer on coccyx.
NEURO: A+Ox2, CN intact except pupils as above, Able to move all
4 ext.
Pertinent Results:
LABS ON ADMISSION:
[**2111-1-7**] 05:30PM BLOOD WBC-9.7 RBC-4.54*# Hgb-11.2* Hct-38.6*#
MCV-85# MCH-24.7*# MCHC-29.1* RDW-16.7* Plt Ct-332#
[**2111-1-10**] 07:30AM BLOOD Neuts-76.1* Lymphs-13.8* Monos-6.7
Eos-3.0 Baso-0.4
[**2111-1-7**] 05:30PM BLOOD PT-13.1 PTT-28.5 INR(PT)-1.1
[**2111-1-7**] 05:30PM BLOOD Glucose-240* UreaN-25* Creat-2.9* Na-137
K-3.9 Cl-98 HCO3-23 AnGap-20
[**2111-1-12**] 04:00PM BLOOD ALT-16 AST-24 AlkPhos-87
[**2111-1-14**] 05:12AM BLOOD Lipase-8
[**2111-1-12**] 04:00PM BLOOD CK-MB-6 cTropnT-0.82*
[**2111-1-7**] 05:30PM BLOOD Calcium-8.6 Phos-4.2# Mg-1.7
[**2111-1-8**] 02:35PM BLOOD Vanco-27.9*
[**2111-1-12**] 11:25AM BLOOD Type-ART Temp-37 Rates-10/ Tidal V-550
FiO2-100 pO2-317* pCO2-55* pH-7.34* calTCO2-31* Base XS-2
AADO2-352 REQ O2-62 Intubat-INTUBATED Vent-CONTROLLED
Comment-ETT
.
LABS ON DISCHARGE:
[**2111-2-24**] 06:50AM BLOOD WBC-6.7 RBC-4.13* Hgb-10.8* Hct-37.0*
MCV-90 MCH-26.1* MCHC-29.1* RDW-18.2* Plt Ct-150
[**2111-1-31**] 04:53AM BLOOD Neuts-62.8 Lymphs-20.6 Monos-6.9 Eos-9.4*
Baso-0.3
[**2111-2-24**] 06:50AM BLOOD Glucose-115* UreaN-23* Creat-2.7* Na-138
K-5.0 Cl-101 HCO3-31 AnGap-11
[**2111-2-24**] 06:50AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.1
.
ASCITES FLUID
.
Test Name Value Units Reference Range
[**2111-1-23**] 03:00PM
ANALYSIS
WBC, Ascites 7000* #/uL 0 - 0
PERFORMED AT WEST STAT LAB
RBC, Ascites [**Numeric Identifier 5863**]* #/uL 0 - 0
PERFORMED AT WEST STAT LAB
Polys 58* % 0 - 0
PERFORMED AT WEST STAT LAB
Bands 2* % 0 - 0
Lymphocytes 10* % 0 - 0
PERFORMED AT WEST STAT LAB
Monocytes 10* % 0 - 0
PERFORMED AT WEST STAT LAB
Macrophage 20* % 0 - 0
.
IMAGING
.
[**2111-2-20**] CXR
FINDINGS: As compared to the previous radiograph, there is an
unchanged
course of the left-sided double-lumen central venous access line
on the
right-sided PICC line. Unchanged low lung volumes. Unchanged
moderate
cardiomegaly with minimal overhydration and retrocardiac
atelectasis. On
today's image, there is minimal blunting of the left
costophrenic sinus, so that the presence of a minimal left-sided
pleural effusion cannot be excluded. No other changes.
.
CT ABDOMEN WITH INTRAVENOUS CONTRAST:
.
There is left lower lobe atelectasis with minimal right-sided
atelectasis. Trace bilateral pleural effusions. There is severe
cardiomegaly and a central venous catheter is partially imaged,
with tip seen within the right atrium.
.
There are two arterial enhancing lesions within the liver. The
first is best seen on (3a:24) measuring 14 x 11 mm and the
second is best seen on (3a:45) measuring 8 x 11 mm with the
first located within segment VI/VII and the second located
within segment V/VIII of the liver. Both of these lesions have
homogeneous arterial enhancement and persistent enhancement in
portal venous phases, though with washout and more delayed
imaging, best appreciated on (6:20). Overall, enhancement
characteristics of these lesions are suspicious for
hepatocellullar carcinoma.
.
There is a nodular contour to liver, compatible with known
cirrhosis. There is no intra- or extra-hepatic biliary
dilatation. The main portal vein and its major branches are
patent. The patient is status post cholecystectomy. There is a
marked amount of ascites, splenomegaly measuring up to 13.8 cm,
and varices that are compatible with sequelae of portal
hypertension. Differential perfusion is noted within the spleen
in the area of hypoperfusion in the posterior edge of the spleen
seen in both arterial, and slightly delayed phases, though is
not apparent in longer delays and is thought to be related to
perfusion. This can be best appreciated on (3b:152).
.
Both adrenal glands are unremarkable. The pancreas enhances
homogeneously. The visualized portions of the intra-abdominal
small and large bowel are unremarkable with no bowel wall
thickening and no caliber changes to suggest acute obstruction.
Note is made of a small fluid-filled umbilical hernia. Both
kidneys appear atrophic in nature and demonstrate delayed
enhancement compatible with known end stage renal disease. There
is poor excretion of contrast There is an arterially enhancing
focus in the right kidney, of uncertain etiology, may represent
a focal lesion. There is extensive intra-abdominal ascites.
There is no intra-abdominal free air. There is no mesenteric or
retroperitoneal lymphadenopathy.
.
CTA EXAMINATION: The celiac axis has conventional anatomy and is
patent. The SMA is patent. The portal vein, SMV, and splenic
veins are patent. There is extensive atherosclerotic disease
involving the abdominal aorta and its major branches.
.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Bladder is difficult
to visualize, though likely collapsed anteriorly from
compression of severe
ascites(as no known surgical history provided) (501B:41), with
several foci of likely intraluminal air, of uncertain etiology.
The rectum, sigmoid colon, prostate, and seminal vesicles are
unremarkable with a rectal catheter in place. There is extensive
intra-abdominal ascites tracking through to the pelvis. There is
no pelvic or inguinal lymphadenopathy.
.
BONE WINDOWS: No suspicious lytic or sclerotic foci are
identified. There is extensive degenerative change involving the
thoracolumbar spine manifested by endplate sclerosis, marginal
osteophytic formation, and disc desiccation and loss of
intervertebral disc height.
.
IMPRESSION:
1. Two arterially enhancing lesions, the larger of which
measures 14 mm
located in segment VI/VII, and the second of which measures 11
mm located in segment V/VIII that demonstrate delayed washout
that are suspicious for
hepatoma.
2. Nodular appearance of the liver compatible with cirrhosis.
Sequelae of
portal hypertension with splenomegaly, massive ascites, and
varices.
3. Bladder is collapsed. Several intraluminal foci of air of
uncertain
etiology, recommend correlation with instrumentation, and
infection is not excluded as etiology.
4. Atrophic appearance of the kidneys compatible with known end
stage renal disease. 5mm area of arterial enhancement in the
right kidney may represent focal lesion such as AML or RCC and
if clinically indicated MR could be considered although this may
be limited by the small size of the lesion
5. Severe cardiomegaly.
.
[**2111-1-23**] CARDIAC ECHO
.
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is severe regional
left ventricular systolic dysfunction with akinesis of the
anterior, septal and apical segments, as well as the inferior
wall (multivessel CAD). Basal nferolateral segments contract
best (overall LVEF = 20%). No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Moderate right ventricular
systolic dysfunction. Mild mitral regurgitation. Moderate
tricuspid regurgitation. Mild pulmonary hypertension.
.
Compared with the prior study (images reviewed) of [**2111-1-13**],
there has been further deterioration of LV systolic function.
.
MICRO
.
[**2111-1-29**] 11:07 am URINE Source: Catheter.
**FINAL REPORT [**2111-2-3**]**
URINE CULTURE (Final [**2111-2-3**]):
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
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.
.
SENSITIVITIES: MIC expressed in MCG/ML
.
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- 16 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
55 y/o with HCV cirrhosis, ESRD, DM, CAD s/p perioperative MI
and PVD who was admitted for worsening PVD, underwent left
brachial to radial bypass on [**2111-1-12**] complicated by
perioperative MI, with abdominal compartment syndrome, recurrent
respiratory failure, spontaneous bacterial peritonitis, sepsis,
and refractory ascites.
.
MICU course: He was transferred to the MICU for management of
hypotension and likely sepsis. He was managed intermittently
with vasopressors and treated with mereopenem for ESBL
Klebsiella UTI and empirically for SBP, and his subclavian line
was removed because of concern for possible line infection. He
developed hypercapneic respiratory failure x 2 in the setting of
ascites and elevated abdominal pressures (peaked at 28) and was
extubated both times after large abdominal paracentesis
(volumes of 2L - 4L were removed). He also underwent CVVH
because of hypotension but was transitioned to hemodialysis
prior to transfer to medicine. Multiple family meetings were
held to discuss goals of care. Lines placed included a R PICC
on [**2111-1-28**] and a R femoval CVL and L femoral a-line on [**2111-1-29**].
.
Overall Floor Course:
Pt arrived to the floor remarkably asymptomatic and feeling
well. Throughout his course the patient became increasingly
dyspneic, and his ascites and abdominal distension increased.
The patient's symptoms were thought to be secondary to end-stage
NYHA Class 4 systolic congestive heart failure. The patient was
started on a 1L fluid restriction and began aggressive
ultrafiltration nearly daily for a goal of 1-2L negative per
session. Unfortunately, the patient's dyspnea and ascites
continued to worsen and the patient required Q2-4 day
paracenteses. The patient's dyspnea improved and he was
continued on nearly daily ultrafiltration, although
ultrafiltration was limited by hypotension and eventually
stopped since it was not felt to be successful in reducing
ascites fluid. The patient had two liver lesions that were
suspicious for hepatoma. Fortunately, the patient spoke with his
old hepatologist at [**Hospital1 112**] who said these same two lesions were
biopsied in [**2099**] and were negative for malignancy. A records
request was made at [**Hospital1 112**] to confirm this.
.
A goals of care family meeting was held where the patient and
family were told very clearly of his very poor prognosis and
progressive multi-organ failure. Despite this the patient was
hoping to get better and wanted to live to work on his charity
organization. Therefore, he was told that we would do our best
to help him achieve those goals.
.
Problem [**Name (NI) **]:
.
# Dyspnea: Multifactorial but primarily from [**Location (un) 7349**] Stage 4 CHF
(30-40% 1 year mortality) and cirrhosis (MELD score 22) leading
to refractory ascites and hypercarbic respiratory failure. CHF
suspected given volume status on exam and BNP > 70,000.
Hypercarbic respiratory failure occured at times due to
worsening ascites/abdominal distension. Respiratory dynamics
also aggravated by pleural effusions, muscular weakness from
critical illness, and underlying lung disease from smoking
history. Patient was maintained on oxygen for Sat > 90%, had
CPAP at night to prevent hypercarbia, underwent MWF hemodialysis
with occasional sessions of ultrafiltration, and was fluid
restricted to 1 liter per day as tolerated. Unfortunately his BP
did not allow for ACEi or BB or diuretic therapy. On discharge,
patient will require 3x/week HD with albumin and midodrine to
maintain BP. He will also require 1-2x/week paracenteses for
refractory ascites, felt to be from liver disease and cardiac
ascites.
.
# Hypotension: multiple components felt to be contributing.
Likely from poor cardiac output from systolic CHF as well as
from intravascular low volumes in setting of poor oncotic
pressure and low cardiac output. Patient was continued on
midodrine 5 mg PO before HD as well as albumin with HD, and will
require this on discharge to maintain BP. He was normotensive in
between HD sessions.
.
# Hypercarbic resp failure: two intubations throughout
admission. Respiratory effort limited by abdominal distension.
Respiratory dynamics also aggravated by pleural effusions,
muscular weakness from critical illness, and underlying lung
disease from smoking history. Respiratory status was improved by
frequent (2x/week) paracentesis.
.
# s/p cardiac arrest: patient had cardiac arrest on three
occasions, and felt to be related to volume shifts. His echo
confirmed severe systolic dysfunction (EF 20%) after his NSTEMI.
He was continued on aspirin 81, plavix, statin. He was not
started on BB or ACEi as he would not tolerate any further drop
in blood pressure. Volume status was controlled with HD 3x/week.
.
# HCV cirrhosis/ abdominal compartment syndrome / Liver mass /
refractory ascites: MELD score 22 (30% 1 yr mortality). Has
cirrhosis and ascites with 4L tap on [**1-13**] associated with
hypotension and NSTEMI. History of HCV treatment at [**Hospital1 112**]. 1.8
cm hypoechoic liver lesion on US [**2110-1-20**] concerning for HCC.
Apparently per patient's prior hepatologist, pt had these same
masses in [**2099**], which were biopsied and cancer negative. This
makes malignancy less likely. HCV Viral load normal suggesting
that the etiology of his subacute ascites (increased in last
month per pt) may be occult HCC obstructing a major vessel of
the portal vein. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39883**] unlikely given normal portal
doppler studies. Overall, likely that refractory ascites is
from worsening cardiac disease in setting of his NSTEMI and
potentially from worsening liver disease. Patient was continued
on lactulose/rifaximin. With regard to refractory ascites,
discussed case with liver team and no additional
medication/intervention felt to substantially improve patient's
symptoms. Also discussed possibility of daily UF, although per
renal, this has not proved to be an effective management
strategy.
.
# ESRD: ? from DM. ? hepato-renal. Initially on CVVH, but
discharged on HD regimen with albumin/midodrine.
.
# Anemia: likely in setting of CRI and stable throughout
admission
.
# sacral Decubitus ulcer: currently stage 2. Wound care was
consulted and performed q2h repositioning.
.
# PVD/Left brachial to radial bypass/Right 4th PIP
osteomyelitis: Also with R BKA and L AKA. For pain control,
patient was discharged with oxycontin standing, as well as IV
morphine and PO dilaudid prn.
.
# ESBL klebsiella urosepsis and positive SBP on tap on [**2111-1-23**]:
Treated empirically with vancomycin and meropenem (7 days).
.
# GOALS OF CARE: Numerous goals of care discussion were had with
patient, palliative care team, social work team, primary
medicine team, liver team, and renal team, given that patient
has multiple organ system failure. These are documented in chart
and OMR. Despite these conversations, patient confirmed his full
code status.
.
# Dispo: discharged to rehab with 3x/week HD and prn
paracentesis
Medications on Admission:
Dilaudid 1mg PO q3h prn arm pain (switched from fentanyl [**2-3**])
meropenem 500mg IV q24h on HD days (to be continued 7 days after
last foley pulled)
lidocaine patch 2 to left arm, 2 to lower back
midodrine 5mg PO TID
Rifaximin 400mg PO TID
lactulose 30ml PO TID
[**Month/Year (2) **] 81 mg PO daily
Sodium Chloride nasal spray
Insulin SS
clopidogrel 75mg PO daily
Heparin SC TID
glucagon prn
nephrocaps 1 cap daily
simvastatin 40mg PO daily
Discharge Medications:
1. shrinker Sig: One (1) once a day: 2 elastic shrinkers for
L AKA and 2 elastic shinkers for R BKA. .
Disp:*2 * Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Sliding Scale.
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-17**] Sprays Nasal
DAILY (Daily) as needed for dry nares.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
11. Bacitracin-Polymyxin B Ointment Sig: One (1) Appl
Topical DAILY (Daily).
12. Midodrine 5 mg Tablet Sig: One (1) Tablet PO PLEASE GIVE
30MIN PRIOR TO HD ().
13. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed) as needed for catheterization.
14. Lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO BID (2 times
a day) as needed for constipation.
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
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. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection every [**4-21**]
hours as needed for flank pain.
20. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
21. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO Q3H (every 3
hours) as needed for arm pain.
22. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
23. Procrit 40,000 unit/mL Solution Sig: One (1) Injection once
a week.
24. HD protocol
Albumin 25% (12.5g / 50mL) 25 g IV. Please give with dialysis in
morning.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
1) Non-ST elevation myocardial infarction
2) Acute on chronic systolic congestive heart failure
3) End stage liver disease
4) End stage renal disease
5) Spontaneous bacterial peritonitis
6) Hypercarbic respiratory failure
7) Cardiac arrest
8) Stage II decubitus ulcer
9) Urosepticemia
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 to take care of you here at [**Hospital1 18**]. You were
admitted for a bypass procedure for the arteries in your arm.
Unfortunately, you developed a heart attack after the procedure
and had 3 cardiac arrests. You also developed an infection of
the abdomen, which lead to respiratory failure only relieved by
tapping the fluid from your belly. You were suffering from
multisystem organ failure including your heart, liver, kidneys,
and vascular system that was progressing. Fortunately, you
remained stable and were able to go to a rehabiliation facility.
.
Your medications are listed on the discharge plan.
.
Please seek medical attention for fevers, chest pain, abdominal
pain, increasing fluid/volume build-up not relieved by dialysis
and paracentesis, shortness of breath, or any other concerns.
Followup Instructions:
You should follow up with your new PCP, [**Known firstname **] [**Last Name (NamePattern1) **], MD
([**Telephone/Fax (1) 250**]) within 1-2 weeks.
.
We have scheduled an appointment for you with your hepatologist,
Dr. [**Last Name (STitle) 39884**]. Please attend this appointment as directed:
Dr. [**Last Name (STitle) 39884**]
[**4-14**] 2:30
[**Last Name (NamePattern1) **]
[**Hospital 756**] Medical Specialties on [**Location (un) **]
Fax [**Telephone/Fax (3) 39885**]
.
You have an appointment with the vascular team. Provider
VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2111-4-16**] 10:00
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2111-4-16**] 10:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2111-3-1**]
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43,613
| 163,820
|
35418
|
Discharge summary
|
report
|
Admission Date: [**2185-1-18**] Discharge Date: [**2185-1-20**]
Date of Birth: [**2123-6-24**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
altered mental status, abdominal pain, fevers, tachycardia
Major Surgical or Invasive Procedure:
Therapeutic paracentesis [**1-19**] for 5L
History of Present Illness:
This is a 61 year old male with past medical history of
longstanding hepatitis C cirrhosis secondary to h/o IV drug
abuse complicated by jaundice, ascites, hepatic encephalopathy,
and possible 4mm HCC lesion found on MRI in [**8-25**] with serum
AFP=18 in [**6-25**], hypertension, and possible obstructive sleep
apnea presenting for further evaluation of altered mental
status, abdominal pain, fevers, and tachycardia to 180s. Per
his wife's report, he was been followed at the VA by his PCP
[**Name Initial (PRE) **] 4 months. In [**2184-5-14**], he developed hepatic
encephalopathy, ascites, and jaundice. An AFP in [**6-/2184**] was 18
and an MRI of his abdomen in [**8-/2184**] showed a possible 4mm HCC
lesion. He was referred to hepatology at the VA in [**2184-11-14**]
at which point he was given the diagnosis of cirrhosis. His
wife then transferred his liver care to [**Hospital1 18**] and he saw [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in 2/[**2184**]. Shortly thereafter, she noted her husband's
belly becoming more distended. He had an outpatient
paracentesis for 9L in [**12/2184**] but she says that the fluid
rapidly reaccumulated. He has been sleeping a lot at home and
she has been feeding him a low salt diet. As of the last few
days, she has noted that her husband has not been eating or
drinking anything because he was not hungry. At 2PM on the
evening of admission he started shaking and reported being very
cold. He had an episode of green emesis and was refusing to go
to the hospital. He had a large amount of explosive diarrhea
and then became confused shortly thereafter. He reported
abdominal tenderness as well. His wife called the Liver Center
who recommended urgent evaluation and she called EMS.
.
In the ED, initial VS were: T=101.7, HR=122, BP=129 systolic,
RR=28, 100% RA. On arrival, he was clearly encephalopathic with
asterixis, unclear thinking, and was also combative with nurses
and pulling out IVs. He was therefore intubated for agitation
and airway protection and a right triple lumen IJ was placed.
NG lavage revealed coffee grounds that cleared to bilious after
200cc of fluid and he was guaiac negative from below. EKG
showed Afib with RVR to the 160s with no evidence of focal
ischemia. CXR showed mild left lower lobe infiltrate. A
diagnostic para was done which was positive for SBP. He was
given Protonix and vanco/ceftazidime but no albumin. He did
receive 7 Liters of NS. Initial lactate was 7.7 which trended
down to 6.3 after 5L NS. He became hypotensive to the 80s prior
to transfer and was started on phenylephrine and his sedation
was changed from propofol to versed/fentanyl. Vitals prior to
transfer were: 98 rectally, 120s-130s, 130s/70s, 100% on vent.
.
On arrival to the MICU, he was intubated/sedated and the above
history was obtained from his wife.
Past Medical History:
-Hepatitis C with cirrhosis diagnosed in [**5-/2184**] after he
developed jaundice, ascites, hepatic encephalopathy. He has a
possible 4mm HCC lesion on MRI [**8-25**] with AFP=18 in [**6-25**]. He
experienced renal insufficiency in the past after a trial of low
dose diuretics. No varices. He was never treated for his
hepatitis C.
-Hypertension.
-Possible obstructive sleep apnea.
-PTSD
-Anxiety
Social History:
-Lives at home with his wife who he met 5 years ago
-[**Country 3992**] veteran, started smoking and h/o heroin abuse while in
the service
-h/o IV drug abuse, quit decades ago
-h/o ETOH abuse, quit many decades ago
-Tobacco: Smokes 1/2PPD until recently when he has cut back to 3
cigs/day since getting ill
Family History:
Cardiac disease in his sister and father.
Physical Exam:
Vitals: T: 98.8, BP: 115/82, P: 115, R: 23, O2: 91%
General: intubated/sedated
HEENT: Sclera icteric, dry MM, PERRL
Neck: supple
CV: Tachycardic, no murmurs, rubs, gallops
Lungs: Clear to auscultation anteriorly with diminished sounds
on the left, no wheezes, rales, ronchi
Abdomen: soft, distended but not taut, bowel sounds present
GU: Foley
Ext: warm, well perfused, [**11-15**]+ edema to knees bilaterally, no
clubbing, cyanosis
Neuro: intubated/sedated
Pertinent Results:
[**1-19**] ECHO: The left atrium is moderately dilated. No spontaneous
echo contrast is seen in the body of the right atrium or right
atrial appendage. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). There is considerable beat-to-beat
variability of the left ventricular ejection fraction due to an
irregular rhythm/premature beats. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Hyperdynamic left
ventricular systolic function.
.
[**1-19**] RUQ U/S:
IMPRESSION:
1. Cirrhotic liver without evidence of focal hepatic lesion.
2. No evidence of portal vein thrombosis.
3. Large amount of ascites.
4. Cholelithiasis without evidence of cholecystitis.
5. Simple right renal cyst.
.
[**1-19**] CXR:
IMPRESSION: ET tube terminating 3.4 cm above the carina. The
tube cuff is
expanded just beyond tracheal caliber. Unchanged small left
pleural effusion and bibasilar atelectasis.
Brief Hospital Course:
This is a 61 year old male with past medical history of
longstanding hepatitis C cirrhosis secondary to h/o IV drug
abuse complicated by jaundice, ascites, hepatic encephalopathy,
and possible 4mm HCC lesion found on MRI in [**8-25**] with serum
AFP=18 in [**6-25**], hypertension, and possible obstructive sleep
apnea presenting for further evaluation of altered mental
status, abdominal pain, fevers, and tachycardia to 180s
consistent with sepsis. Unfortunately, he passed away on the
morning of GNR sepsis.
.
#. GNR Sepsis: He met SIRS criteria with WBC=1.9 with 8%
bandemia, tachycardia, fever, and tachypnea with likely source
being SBP vs. PNA. Patient has evidence of SBP on diagnostic
para with 3200 WBCs and 60% polys and was growing GNRs in his
blood and his peritoneal fluid. He also may have had aspiration
pneumonitis versus beginnings of a PNA in his LLL on CXR. He
was treated empirically with Vanco/Cefepime/Levaquin/Flagyl to
cover SBP and PNA empirically. He received 9L of NS and was
given a large amount of albumin. He also required pressors with
vasopressin and phenylephrine as well as intubation for airway
protection. Despite maximal support, his lactate continued to
rise up to 10.2, his bandemia trended up to 20, and it became
clear that his prognosis was poor. His code status was
therefore transitioned to DNR/DNI from full code after a
discussion with his wife and he passed away on the morning of
[**1-20**] at 6:28AM.
Medications on Admission:
-methadone 75mg @ VA causeway clinic
-clonidine
-Klonopin
-Spironolactone
-Lactulose
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
|
[
"995.92",
"567.23",
"789.59",
"070.44",
"300.00",
"780.57",
"571.5",
"V70.7",
"038.40",
"304.00",
"V49.86",
"427.31",
"305.1",
"507.0",
"401.9",
"309.81",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"54.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7665, 7674
|
6028, 7489
|
346, 390
|
7733, 7750
|
4590, 6005
|
7814, 7832
|
4052, 4096
|
7625, 7642
|
7695, 7712
|
7515, 7602
|
7774, 7791
|
4111, 4571
|
247, 308
|
418, 3285
|
3307, 3711
|
3727, 4036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,884
| 163,701
|
30584
|
Discharge summary
|
report
|
Admission Date: [**2138-4-30**] Discharge Date: [**2138-5-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Hypotension, N/V. Details gleaned from ED/NH and [**Hospital3 **] Records.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **] F w/ h/o dementia and ? CHF presents from NH w/ [**12-17**]
day2 of [**Month (only) **] po intake, with 3 episodes of N/V over past 48
hours, her abdomen was noted to be distended. Initial SBP in 80s
but SBP 60 by eval, up to 100s after 1 L NS but continued to
trend down and received a total of 4 L in the ED. Guaiac neg
brown stool. Report of mild ileus on XR at NH today.
.
In the ED VS HR74 140/72->86/61 19 95%RA, given [**Last Name (un) **], flaygl, 4L
NS.
also given glucagon for bradycardia of 50s-->70s.
.
ROS: as per hpi, pt not able to provide further history.
Past Medical History:
Dementia
CHF
Angina
T2DM
Anxiety
CAD s/p AMI 97
s/p cholecystectomy
breast CA s/p L mastectomy
Social History:
Lives in a nursing home. PER OMRS No tobacco or alcohol use. She
is supported by her son, [**Name (NI) **] who is her HCP. Apparently
wheelchair bound
Family History:
NC
Physical Exam:
Vitals: T: 96.2 P: 65 BP: 96/25 R: 16 SaO2: 98 % on 2L NC
General: Awake, alert, NAD. Oriented to name but does not know
place. Thinks year in the 1900s and thinks she is 40 y.o.
Repeatedly asks why she is here and doesn't think she lives in a
nursing home.
HEENT: NC/AT, Pupils small but ERRL, EOMI without nystagmus, no
scleral icterus noted, MMM, no lesions noted in OP
Neck: supple, no JVD appreciated
Pulmonary: poor effort but no extra breath sounds noted
Cardiac: RRR, blowing III/VI systolic murmur heard over
precordium - even at her back
Abdomen: healed midline scar, soft, NT/ND, normoactive bowel
sounds, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally, bilateral heal ulcers, small
sacral decubitous ulcer
Skin: no rashes or lesions noted.
Neurologic:
-cranial nerves: II-XII intact
-motor: No abnormal movements noted.
-sensory: No deficits to light touch throughout
Pertinent Results:
[**2138-4-29**] 11:20PM WBC-13.3* RBC-3.39* HGB-10.3* HCT-29.7*
MCV-87 MCH-30.3 MCHC-34.7 RDW-14.2
[**2138-4-29**] 11:20PM ALT(SGPT)-7 AST(SGOT)-16 CK(CPK)-35 ALK
PHOS-67 AMYLASE-55 TOT BILI-0.4
[**2138-4-29**] 11:20PM LIPASE-26
[**2138-4-29**] 11:20PM GLUCOSE-118* UREA N-33* CREAT-1.8* SODIUM-140
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-30 ANION GAP-11
[**2138-4-30**] 12:47AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
.
abd [**4-29**]:
IMPRESSION: Non-obstructive bowel gas pattern. Prominent
degenerative changes along the lower thoracic and lumbar spine
with mild loss of height of L1 and L2, indeterminate in age.
.
cxr [**4-29**]:
IMPRESSION: No acute cardiopulmonary process.
.
echo [**4-30**]:
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with apical
akinesis/hypokinesis (no LV thrombus
identified). Overall left ventricular systolic function is
mildly depressed. Transmitral Doppler and tissue velocity
imaging are consistent with Grade I (mild) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are severely
thickened/deformed. There is moderate aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The left
ventricular inflow pattern suggests impaired relaxation.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
[**Age over 90 **] F presents from NH w/ N/V and hypotension, now resolved.
.
# Hypotension- The patient was admitted for hypotension that
resolved with multiple boluses of IV fluids. Likely hypovolemia
after viral gastroenteritis given history of [**Age over 90 **], vomiting
and diarrhea. Did not appear septic on admission and blood/urine
cultures are negative to date, but final blood cultures are
pending and should be followed at the nursing home. She was
initially on cipro and flagyl for possible GI infection, but as
she was afebrile and her blood pressure improved these were
stopped. She had normal LFT's. She likely had an element of
chronotropic incompetence given her toprol use. She was
restarted on a low dose of metoprolol which should be increased
as tolerated and her lisinopril and lasix were held and may be
restarted when her blood pressure can tolerate this. She should
have close blood pressure monitoring at rehab.
.
# Acute Renal Failure- Her creatinine was 1.8 on admission, but
normal at discharge. Her FeUrea was 21% on admission, so her
renal failure was likely prerenal as it resolved with IVF. As
above she had normal renal function at discharge.
.
# Diastolic CHF - Diastolic dysfunction on ECHO in-house. Given
the patient's hypotension her ACE inhibitor and lasix were held.
She appeared euvolemic during her course and with improvement
of her blood pressure she should have her lasix 40 mg daily and
lisinopril 5 mg daily restarted. Now appears relatively
euvolemic.
.
# Ulcers: The patient had ulcers on her heels and coccyx. For
her heels she should have the tissue dried with guauze and then
apply moisture barrier ointment to the periwound tissue with
each drg change. Apply a thin layer of DuoDerm Gel (wound gel)
to the open ulcers. Cover with dry gauze, ABD, Kerlix wrap and
change dressing daily. For her perineal/coccyx she should have
cleansing with Foam Cleanser, and application of Aloe Vesta
Moisture Barrier ointment to the affected area [**Hospital1 **] and prn. She
did well with this in the hospital per wound care
recommendations.
.
# Dementia - No issues during the course continued aricept, and
namemda
.
# Hypercholesterolemia- No issues with continuation of lipitor.
.
# CAD - She had elevated troponin with flat CK, so likely demand
from hypotension. She had no signs of ACS and was continued on
aspirin. She will continue lipitor, metoprolol and aspirin.
.
# Diabetes - Placed on RISS while inpatient with good control,
and was restarted on glyburide on discharge
.
# Anxiety- Continued on celexa, and zyprexa. She can be given
zyprexa as needed for agitation.
.
#) Communication: [**First Name8 (NamePattern2) **] [**Known lastname 72569**] [**Telephone/Fax (1) 72570**] (son)
.
Medications on Admission:
Lisinopril 5mg
Aricept 10mg QD
Liptor 10mg QD
Toprol XL 50mg QD
Glyburide 2.5 QD
Lasix 40 mg QD
Celexa 10mg QD
MVI QD
Omeprazole 20mg QD
Namemda 10 [**Hospital1 **]
Zyprexa 2.5 QD and PRN
Aspirin 325mg QD
Pureed Foods
Dulcolax 10mg PRN
MOM PRN
NTG SL PRN
Imodium PRN
Robitussin
Tylenol PRN
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-17**]
Tablet, Delayed Release (E.C.)s PO once a day as needed for
constipation.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain/fever.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual q 5 min x 3 as needed for chest pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 10283**] Center - [**Location (un) **]
Discharge Diagnosis:
1. Hypotension secondary to viral gastroenteritis
2. Acute renal failure
3. Diastolic CHF
4. CAD
5. Dementia
Discharge Condition:
stable, tolerating medications
Discharge Instructions:
1. You were admitted with hypotension and this was likely due to
viral gastroenteritis.
.
2. Notify your doctor [**First Name (Titles) **] [**Last Name (Titles) **], vomiting, fevers, chills,
shortness of breath and chest pain.
.
3. Follow-up with your doctor in 2 weeks
.
4. You will resume all medications except you are not on toprol
you are on metoprolol and your lasix and lisinopril are held and
should be restarted when your blood pressure is better.
Followup Instructions:
1. Follow up with your primary doctor in 2 weeks. Call Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] at [**Telephone/Fax (1) 10573**] for the appointment.
Completed by:[**2138-5-2**]
|
[
"250.00",
"424.1",
"412",
"V10.3",
"276.52",
"008.8",
"428.0",
"294.8",
"300.00",
"458.9",
"584.9",
"414.01",
"428.30",
"413.9",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8471, 8549
|
4088, 6849
|
336, 342
|
8702, 8735
|
2216, 4065
|
9241, 9435
|
1276, 1280
|
7190, 8448
|
8570, 8681
|
6875, 7167
|
8759, 9218
|
2096, 2197
|
1295, 2079
|
222, 298
|
370, 973
|
995, 1092
|
1108, 1260
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,392
| 135,536
|
54399
|
Discharge summary
|
report
|
Admission Date: [**2116-9-8**] Discharge Date: [**2116-9-14**]
Date of Birth: [**2064-10-4**] Sex: M
Service: MEDICINE
Allergies:
pollen and seasonal
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
fevers, arm pain
Major Surgical or Invasive Procedure:
Partial graft removal
Temporary HD line placement
Tunneled HD line placement- attempted [**2116-9-14**]
History of Present Illness:
Mr. [**Known lastname 100110**] is a 51M with ESRD on HD (T, TH, Sat), HTN, DMII who
presented to regularly scheduled [**Known lastname 2286**] yesterday where it was
noticed his left forearm AV graft was actively draining pus, so
he wassent in to the ED. Per patient, he was in his usual state
of health until Sunday when he noticed the region around his
fistula expanding and feeling warm and painful to touch, then
started to see whitish, thick fuild draining. He also noted
fevers to 101 and chills, as well as some watery diarhea. He
denies shortness of breath, chest pain, nausea, vomiting,
conspitation, or abdominal pain.
In the ED, initial VS were 97 76 136/48 15 97%. He was found to
be hyperkalemic to 7.7, was given 2g calcium gluconate, 30mg
kayexalate, and 1 amp sodium bicarb, 10 units insulin, and
dextrose. He was sent to the OR, where he had partial excision
of the left forearm AV graft with MAC anesthesia, 500cc
crystalloids and an EBL 280cc. He then went to IR and had
temorary RIJ line palced with a VIP port. He was sent from IR to
the MICU for emergent [**Known lastname 2286**], where they took off 1.9L with
ultrafiltration. His pre-[**Known lastname 2286**] weight was 195.7 kg (bed
weight), above his dry weight of 184 kg.
From the MICU he had an HD session Wednesday afternoon, he was
hypotensive and given a 250ml bolus NS, then arrived on the
medicine floor where he was comfortable and stable with BP
90/50.
Past Medical History:
- Non-insulin dependent diabetes mellitus
- History of line infections
- Peripheral neuropathy and peripheral vascular disease
- Leukocytoclastic Vasculitis
- Hypertension
- Obstructive sleep apnea
- Obesity
- GERD
- Anemia in setting of ESRD
- Secondary hyperparathyroidism in setting of ESRD
- Low-attenuation lesions in kidneys detected by CT in [**12/2111**]
- C. difficile infection in [**2110**] and [**2111**]
- S/p open cholecystectomy in [**2099**]
Social History:
Home: Lives alone in the [**Location (un) 4398**]
Work: Former electrician, after toe amputation had too much
difficulty going up and down ladders so on disability for the
last 15 years
Family: Born in [**Location (un) 4708**], moved to US at age 10, has multiple
family members in the area
Tobacco: Never
EtOH: Denies
Drugs: Denies
Family History:
NIDDM in both parents and two siblings. Mother with additional
high. Hyperlipidemia, hypercholesterolemia, hypertension, and
Alzheimer's.
Physical Exam:
ADMISSION EXAM
Vitals: 99.4 90/50 77 18 94RA BS 263
General: Alert, oriented, no acute distress, morbidly obese
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: obese, supple
CV: Regular rate and rhythm though very distant heart sounds, no
appreciable murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no appreciable
wheezes, rales, ronchi. Temporary line in Right IJ
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: Right toes amputated, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema. Left arm covered with kurlex with
stiches visible in forearm
DISCHARGE EXAM
Pt left AMA
Pertinent Results:
ADMISSION LABS
[**2116-9-8**] 09:00AM BLOOD WBC-7.4 RBC-3.01* Hgb-9.0* Hct-28.0*
MCV-93 MCH-30.0 MCHC-32.2 RDW-14.4 Plt Ct-180
[**2116-9-8**] 09:00AM BLOOD Neuts-65.4 Lymphs-23.8 Monos-8.0 Eos-2.3
Baso-0.5
[**2116-9-8**] 09:00AM BLOOD PT-11.9 PTT-30.6 INR(PT)-1.1
[**2116-9-8**] 09:00AM BLOOD Glucose-159* UreaN-89* Creat-15.0*#
Na-133 K-7.0* Cl-97 HCO3-20* AnGap-23*
[**2116-9-8**] 09:25PM BLOOD Calcium-8.3* Phos-2.7 Mg-2.2
DISCHARGE LABS
[**2116-9-14**] 04:33AM BLOOD WBC-6.1 RBC-2.63* Hgb-7.8* Hct-24.1*
MCV-92 MCH-29.7 MCHC-32.5 RDW-14.5 Plt Ct-240
[**2116-9-14**] 04:33AM BLOOD Glucose-197* UreaN-58* Creat-11.9*#
Na-132* K-4.3 Cl-94* HCO3-23 AnGap-19
[**2116-9-14**] 04:33AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.2
Micro
[**2116-9-8**] 8:55 am BLOOD CULTURE
**FINAL REPORT [**2116-9-14**]**
Blood Culture, Routine (Final [**2116-9-14**]):
ANAEROBIC GRAM POSITIVE COCCUS(I).
Isolated from only one set in the previous five days.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
Anaerobic Bottle Gram Stain (Final [**2116-9-10**]):
THIS IS A CORRECTED REPORT [**2116-9-10**], 7:45AM.
Reported to and read back by DR. [**Doctor Last Name **] [**2116-9-10**],
7:45AM.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
PREVIOUSLY REPORTED AS GRAM POSITIVE COCCI IN PAIRS ON
[**2116-9-10**],
0220.
ORIGINAL REPORT PHONED TO H. WARRAICH [**2116-9-10**], 0220.
FOREIGN BODY
**FINAL REPORT [**2116-9-11**]**
WOUND CULTURE (Final [**2116-9-11**]):
STAPH AUREUS COAG +.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Blood culture [**9-11**], 20 and 21 - NEGATIVE
Imaging:
[**2116-9-8**] Doppler of left forearm IMPRESSION: 1. Complex fluid
collection adjacent to the hemodialysis graft which may
represent abscess. 2. No DVT. 3. This study was not designed
to evaluate patency of the graft. Superficial portion of a
graft was noted to have lack of dopplerble flow. If desired,
dedicated exam can be performed in the vascular lab.
TTE [**2116-9-10**] IMPRESSION: Suboptimal image quality. The global
left ventricular function is probably normal. Overall, the
valves are not well seen, but pathologic regurgitation is not
seen. Mildly dilated ascending aorta.
[**2116-9-14**] CONCLUSION: Attempted conversion of a temporary HD
line to a tunneled HD
line, patient refused to proceed with the procedure and insisted
that even the
temporary access be removed. The patient left the procedure
with no vascular
access whatsoever. We hope he will be amenable to reattempting
the procedure
tomorrow, and should preferably have peripheral access obtained
before this
time for sedation.
Brief Hospital Course:
51 yo M w/ ESRD on HD p/w hyperkalemia and underwent emergent
[**Month/Day/Year 2286**] via temporary HD line and acute AV graft infection now
s/p graft removal who developed MRSA bacteremia and was started
on IV vancomycin with [**Month/Day/Year 2286**] and left AMA prior to having a
[**Month/Day/Year 2286**] line placed and has no [**Month/Day/Year 2286**] access at the time of
leaving the hospital.
# AV GRAFT INFECTION & BACTEREMIA: Pt presented with pus
draining from region near graft, likely hematoma formed when
graft being accessed then got infected. Pt is now s/p partial
excision of LUE AV graft and right temporarly line placement.
Started on IV Vanc/Cef [**9-9**], wound and blood culture showed GPC
in pairs, narrowed coverage to just IV Vanc. TTE had no findings
suggestive of endocarditis and given his low suspicion for
endocarditis, with 1/2 bottles growing GPCs, and all other
cultures came back negative, it was felt that a TEE was not
needed to pursue, he also had no new mururs on exam nor any
stigmata of endocarditis.
-continue vancomycin with HD
-he will continue to require dressing changes to the left
forearm daily
-will follow-up with Dr. [**First Name (STitle) **] of transplant surgery
# ESRD on HD- patient has significant access issues. He
receives [**First Name (STitle) 2286**] T/R/Sa. Had emergent [**First Name (STitle) 2286**] for hyperkalemia
on admission via a newly place temporary RIJ line. On [**2116-9-14**]
he was scheduled to ahve this changed to a tunnelled line. It
is unclear exactly what the events that occured in IR were, but
they were unable to easily obtain the tunnelled access and the
patient got upset and insisted that all lines be removed. He
returned to the floor that day without [**Date Range 2286**] access and
refused to have anything placed at [**Hospital1 18**] and insisted it be
performed at another center such as AV care. HIs otupatient
nephrologist was contact[**Name (NI) **] and we attempted to get outaptient
access placement scheduled for him for the next day, however due
to the hsort notice this was not possible. THe patient refused
to stay to have it performed by IR at [**Hospital1 18**], or to have it
scheduled as an Outpatient with IR the next day. He was
informed that he had no [**Hospital1 2286**] access when leaving AMA and
that he could die if he does not receivie [**Hospital1 2286**]. He expressed
understanding of this and insisted on leaving.
-patient needs [**Hospital1 2286**] access
# Type II DM: Patient had decreased po intake on admission in
the setting of his GPC bacteremia which as it was treated his
appetite came bakc and he was requiring more lantus than his
home dose of 20u and this was increased to 25 u.
# HYPERKALEMIA: Pt presented with K 7.0, likely secondary to
ESRD in the setting of missed HD session. Got emergent [**Hospital1 2286**]
in ICU. Currently 4.2.
# HTN: Held home nifedipine and lisinopril because pt has been
hypotensive during admission. Hypotension improving [**9-11**]. He
continued to be asymptomatically hypotensive to the low 90s
following dilaysis sessions so his home antihypertensives were
held.
-patient was instructed on discharge to hold his
antihypertensives until told to restart by an outpatient
provider
# PVD: Cont ASA 325mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nephrocaps 1 CAP PO DAILY
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Cinacalcet 60 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. NIFEdipine 60 mg PO DAILY
7. sevelamer CARBONATE 3200 mg PO TID W/MEALS
8. Aspirin 325 mg PO DAILY
9. Lantus 20 Units Bedtime
Insulin SC Sliding Scale using Novalog Insulin
Discharge Medications:
1. Calcium Acetate 667 mg PO TID W/MEALS
2. Cinacalcet 60 mg PO DAILY
3. Lantus 20 Units Bedtime
Insulin SC Sliding Scale using Novalog Insulin
4. Nephrocaps 1 CAP PO DAILY
5. Omeprazole 40 mg PO DAILY
6. sevelamer CARBONATE 3200 mg PO TID W/MEALS
7. Aspirin 325 mg PO DAILY
8. Vancomycin IV Sliding Scale
9. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Graft infection
ESRD
MRSA Bacteremia
Type II Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr [**Known lastname 100110**],
It was a pleasure taking care of you during your admission to
the [**Hospital1 18**]. You were admitted after your fistula got infected.
You had a partial removal of the fistula in the OR and then
multiple [**Hospital1 2286**] sessions with a temporary HD line. You were
found to have an infection at the graft site and in your blood,
and were started on IV antibiotics. After consulting with the
[**Hospital1 **] and Transplant teams we attempted to place a tunnelled
line but there was some difficutly and you were left without any
[**Hospital1 2286**] access which is very serious. You chose to leave
against medical advice as we do not have [**Hospital1 2286**] access for you
and this can be life threatening. If you develop any shortness
of breath, headache please present to the emergency department
as you may need emergent [**Hospital1 2286**].
You need to continue a 4-6week course of antibiotics (at
[**Hospital1 2286**]) to be deteremined by Dr.[**Last Name (STitle) **] team.
Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2116-9-12**]
7:30
Department: TRANSPLANT CENTER
When: MONDAY [**2116-9-21**] at 8:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ADVANCED VASC. CARE CNT
When: WEDNESDAY [**2116-10-21**] at 10:00 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: ENDO SUITES
When: FRIDAY [**2117-8-13**] at 11:00 AM
|
[
"588.81",
"443.9",
"790.7",
"V85.43",
"356.9",
"278.00",
"V49.72",
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"278.01",
"530.81",
"285.21",
"V45.11",
"041.12",
"E878.2",
"276.7",
"996.62",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.49",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11449, 11506
|
7356, 10647
|
296, 402
|
11613, 11613
|
3569, 7333
|
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|
2722, 2861
|
11089, 11426
|
11527, 11592
|
10673, 11066
|
11789, 12819
|
2876, 3550
|
240, 258
|
430, 1874
|
11628, 11765
|
1896, 2356
|
2372, 2706
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,126
| 190,056
|
53690
|
Discharge summary
|
report
|
Admission Date: [**2197-10-24**] Discharge Date: [**2197-11-17**]
Date of Birth: [**2121-3-31**] Sex: F
Service: MEDICINE
Allergies:
Propoxyphene / Pyridium / Bupropion / Darvon / Penicillins /
Claritin / Codeine / Moexipril / Shellfish
Attending:[**First Name3 (LF) 1845**]
Chief Complaint:
right chest pain
Major Surgical or Invasive Procedure:
right thoracentesis
History of Present Illness:
HPI: 76 y/o female with h/o HTN, dyspepsia, gerd presented
initially to [**Hospital1 18**] with one day of sharp respirophasic chest
pain over the last day. She developed symptoms of a URI
approximately one week prior to admission with cough, sore
throat, and rhinorrhea/post-nasal drip. The cough was
intermittently productive of a clear phlegm. She went to sleep
the night before admission with continued URI sx but awoke at
2am with sharp right sided chest pain, worse with deep
inspiration, radiating to her right shoulder blade and
occasionally horizontally across the cest and up retrosternally.
The pain occurs while ambulating and at rest (no distinct
difference), is not associated with eating, but does get worse
when leaning forward. She denies fevers/chills, n/v/d,
dysuria/hematuria, rashes. She has chronic constipation,
dyspepsia with early satiety, orthopnea and dyspnea on exertion
that has been present and increasing gradually over the last six
months.
The patient had a stress test in the past for left sided chest
pain, without ecg changes, no perfusion defects on MIBI.
She called her PCP who had her get a CXR that showed a right
sided pleural effusion and pleural opacities that was
followed-up with a CTA that failed to demonstrate PE but did
show r. pleural effusion and non-pathologic nodules. An ECG
showed no significant changes from baseline. Her D-dimer was
>[**2193**], wbc 13->11, and LFT's were all within normal limits. The
patient recieved toradol 15mg IV for pain with moderate effect.
Pt had CT that showed exudative right pleural effusion with
negativ ecytology. She was also scheduled for VATS given
multiple pleural based nodules. She also developed fever to
101.7, tachycardia, new wheezing and was thought to have pna
with component of RAD/COPD. Given this new wheeze, she was
started on solumedrol and [**Name (NI) 110238**] (pt without history of RAD). Pt
developed hypercarbic respiratory failure, initially responded
to nebs but then began to have decreased air movement despite
receiving racemic epi. Pt was then transferred to MICU for
mgt/observation of airway. Pt was seen by ENT in MICU who did
not visualize any anatomic obstruction. Pt put on facemask
bipap on admission to MICU.
Past Medical History:
PMH:
1.)HTN -- has been controlled on HCTZ
2.)Seasonal allergies
3.)GERD with hiatal hernia
4.)Dyspepsia
5.)?benign mass removed from [**Name (NI) 499**] [**2169**]
5.)Fibrous tumor encasing left ovary/sapinx removed [**2157**]
cta - no PE, r pleural effusion
Social History:
Lives alone in apt in [**Location 1268**], has a son who lives in VT,
retired, 20 pack year history (has now quit), minimal EtOh in
past (has now quit)
Family History:
Sister with NHL, Aunt with [**Name2 (NI) 499**] cancer, aunt with [**Name2 (NI) 499**] and
breast cancer, uncle with prostate cancer, father with ?cancer
Physical Exam:
VS: 98.7 HR=88 BP=143/71 RR=12 94% RA
Gen: awake, alert and oriented, comfortable, nad
HEENT: anicteric sclera, OP clear with moist MM
Neck: enlarged node right neck (stable as per pt), JVD=8cm, no
thyromegaly
CV: RRR, nl s1/s2, no m/r/g
Lungs: decreased BS RLL, no w/r/r, good air movement bilaterally
Chest wall: mild tenderness to palpation over lower right rib
cage
Abd: soft, diffuse mild tenderness, NABS
Extr: trace bilateral edema, warm
Pertinent Results:
[**2197-10-23**] 12:08PM BLOOD WBC-13.0*# RBC-4.35 Hgb-13.6 Hct-39.2
MCV-90 MCH-31.2 MCHC-34.6 RDW-12.6 Plt Ct-325#
[**2197-10-23**] 12:08PM BLOOD Neuts-65.6 Lymphs-22.7 Monos-6.9 Eos-4.2*
Baso-0.5
[**2197-10-23**] 12:08PM BLOOD Plt Ct-325#
[**2197-10-23**] 05:15PM BLOOD Glucose-128* UreaN-19 Creat-1.2* Na-140
K-4.0 Cl-99 HCO3-26 AnGap-19
[**2197-10-23**] 05:15PM BLOOD ALT-27 AST-28 AlkPhos-100 TotBili-0.4
[**2197-10-24**] 08:35AM BLOOD LD(LDH)-154
[**2197-10-25**] 08:46PM BLOOD Lipase-31 GGT-48*
[**2197-10-29**] 06:20AM BLOOD CK-MB-3 cTropnT-<0.01
[**2197-10-29**] 07:55PM BLOOD CK-MB-10 MB Indx-1.9 cTropnT-<0.01
[**2197-10-30**] 02:37AM BLOOD CK-MB-12* MB Indx-2.1 cTropnT-<0.01
[**2197-10-24**] 08:35AM BLOOD Albumin-4.3 Calcium-9.0 Phos-3.7# Mg-2.0
UricAcd-8.2*
[**2197-10-26**] 06:15AM BLOOD calTIBC-293 Ferritn-164* TRF-225
[**2197-11-6**] 06:00AM BLOOD VitB12-1329* Folate-10.8
[**2197-10-24**] 08:35AM BLOOD TSH-2.8
[**2197-11-1**] 11:27AM BLOOD TSH-0.78
[**2197-11-8**] 11:45AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2197-11-8**] 11:45AM BLOOD ANCA-NEGATIVE
[**2197-10-31**] 04:50AM BLOOD CK-MB-27* MB Indx-5.9 cTropnT-0.32*
[**2197-10-31**] 12:26PM BLOOD CK-MB-22* MB Indx-7.0* cTropnT-0.23*
[**2197-10-31**] 07:51PM BLOOD CK-MB-14* MB Indx-6.7* cTropnT-0.14*
[**2197-11-1**] 04:20AM BLOOD CK-MB-9 cTropnT-0.08*
[**2197-11-1**] 11:27AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2197-11-1**] 02:33PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2197-11-2**] 02:14AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2197-11-6**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2197-11-11**] 02:09PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2197-11-17**] 06:30AM BLOOD WBC-22.1* RBC-3.37* Hgb-10.5* Hct-30.9*
MCV-92 MCH-31.2 MCHC-34.0 RDW-14.0 Plt Ct-325
[**2197-11-13**] 09:45AM BLOOD Neuts-72* Bands-16* Lymphs-2* Monos-3
Eos-5* Baso-0 Atyps-1* Metas-0 Myelos-0 Plasma-1*
[**2197-11-17**] 06:30AM BLOOD Plt Ct-325
[**2197-11-12**] 05:30AM BLOOD PT-13.0 PTT-28.1 INR(PT)-1.1
[**2197-11-16**] 06:35AM BLOOD Glucose-102 UreaN-12 Creat-0.4 Na-139
K-3.7 Cl-100 HCO3-30* AnGap-13
[**2197-11-15**] 06:50AM BLOOD ALT-23 AST-24 AlkPhos-95 TotBili-0.4
[**2197-11-14**] 06:35AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.6
*
ECG Study Date of [**2197-10-23**] 4:58:42 PM
Normal sinus rhythm. ECG is within normal limits. Compared to
the previous
tracing of [**2197-1-20**] no diagnostic interval change.
*
CHEST (PA & LAT) [**2197-10-23**] 12:17 PM
New small right pleural effusion with possible subpulmonic
component.
New ill- defined peripheral opacities in right mid and lower
lung zone. In a patient with pleuritic chest pain, pulmonary
embolism should be considered. In the absence of infectious
symptoms, infection is unlikely. Therefore, a CT angiogram may
be considered for more complete assessment as communicated to
Dr. [**First Name (STitle) **].
*
CTA CHEST W&W/O C &RECONS [**2197-10-23**] 6:01 PM
FINDINGS: Soft tissue windows reveal a small to moderate sized
right pleural effusion and associated mild atelectasis. There
are several mediastinal lymph nodes, the largest of which is in
the precarinal space and measures 1.4 cm. Lung window images
reveal a rightsided pleurased nodular density and several small
nodules scattered in both lungs, the largest of which is in the
right lower lobe anterior to the pleural effusion and measures 8
mm. Atelectasis is seen at the right lung base. There is no
focal consolidation or pneumothorax. There is a small
pericardial effusion.
CT angiogram demonstrates no pulmonary embolus. The pulmonary
artery is somewhat prominent in size measuring up to 3.5cm. The
aorta is normal in caliber and there is no evidence of aortic
dissection. Calcifications are seen throughout the aorta.
The osseous structures and soft tissues are unremarkable. The
visualized portion of the upper abdomen is normal.
Coronal and sagittal reformatted images confirm the above
findings.
IMPRESSION: No pulmonary embolus. Right pleural effusion. Small
pericardial effusion. Enlarged pulmonary artery consistent with
pulmonary hypertension. Several small nodules within both lungs,
including pleural-based rightsided nodular density. The largest
of these is 8 mm, located in the right lower lobe. These are
nonspecific in nature . Differential diagnosis includes
inflammatory/ infectious process, less likely vasculitis or
neoplastic disease. Correlate clinically and with followup CT
scan.
*
ECHO Study Date of [**2197-10-24**]
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional
left ventricular wall motion is normal. 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.
Mild (1+) aortic regurgitation is seen. The mitral leaflets
appear
structurally normal with trivial mitral regurgitation. There is
borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global
and regional biventricular systolic function. Mild aortic
regurgitation.
Based on [**2190**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a moderate risk (prophylaxis recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
*
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2197-10-25**] 9:45 PM
No cholelithiasis or son[**Name (NI) 493**] signs of acute cholecystitis
*
PLEURAL FLUID Study Date of [**2197-10-25**]
NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells and lymphocytes.
*
CHEST (PA & LAT) [**2197-10-27**] 1:11 PM
No pneumothorax. Persistent small right pleural effusion.
Nodular density right mid zone for which follow up is
recommended.
*
CHEST (PORTABLE AP) [**2197-10-30**] 7:34 AM
Slightly increased right loculated pleural effusion with
adjacent opacity, likely atelectasis but right lower lobe
pneumonia cannot be excluded. Nodular opacities in the right
lung, as noted on previous CT scan.
*
CHEST (PA & LAT); CHEST (LAT DECUB)[**2197-11-9**] 1:38 PM
1. Persistent large layering right-sided pleural effusion. If
further detail of the opacities in the right hemithorax would be
helpful clinically, we reiterate the earlier recommendation for
follow-up CT when clinically appropriate.
2. Overall unchanged appearance of the chest.
*
CT CHEST W/O CONTRAST [**2197-11-10**] 12:11 AM
There is a small pericardial effusion, unchanged from the prior
study. There are coronary artery calcifications seen. There has
been interval development of collapse of the right lower lobe.
The previously seen right pleural effusion has increased in
size, and now is a large right pleural effusion. Within the
right pleural effusion is a focus of air -- Has the patient had
an attempted paracentesis? otherwise this could be a sign of
infection. There is a tiny left pleural effusion as well. In
addition, there is extensive nodular thickening of the pleural
surface which has developed in the interval in the right upper
lobe. The rapidity of this process makes this possibly secondary
to fibrin degradation products. There is a small calcified
granuloma again seen in the right middle lobe. Again seen is
precarinal lymphadenopathy measuring up to 1.7 cm. There are
small axillary lymph nodes, unchanged. No pneumothorax. Few
images though the abdomen demonstrate small gastrohepatic
ligament lymph nodes. BONE WINDOWS: No suspicious lytic or
blastic lesion.
IMPRESSION:
1) Interval collapse of right lower lobe with a large right
pleural effusion.
There is a focus of air in the fluid which could be secondary to
an attempted paracentesis, or else infection is a possibility.
2) Interval development of nodular pleural thickening of the
visualized right upper lobe.
*
PLEURAL BX F/S,PLEURAL CONTENTS.PLEURAL BX F/S. [**2197-11-10**]
1. Pleural biopsy (A-B): Metastatic non-small cell carcinoma
(see note).
2. Pleural contents (C-D): Metastatic non-small cell carcinoma
(see note).
Note: Immunostains show tumor staining for CEA (focal),
Cytokeratin (AE1/AE3, CAM 5.2) and S100 (scattered cells), but
is negative for MART-1, TTF-1, B72.3, and Calretinin.
*
ABDOMEN U.S. (PORTABLE) [**2197-11-14**] 9:21 AM
Normal appearance of the gallbladder; no gallstones. Normal
common bile duct
*
CT CHEST W/CONTRAST [**2197-11-15**] 3:01 PM
1. Circumferential nodular and irregular thickening of the right
pleural surface, with associated enhancement and pleural
effusion are consistent with neoplastic pleural disease and
malignant effusion. In regions, there appears to be invasion of
the pericardium.
2. There is atelectasis at the right lung base, although
superimposed infection cannot be excluded.
3. One of the right-sided chest tubes is malpositioned. Although
the field of view of the CT makes assessment of skin exit sites
difficult, it appears that the chest tube which has a more
anterior position, with only a short segment of the tubing
beneath the skin, is a malpositioned chest tube. Please note
that the chest tube which extends from the lung base to the lung
apex in a vertical configuration, as seen on the chest x-ray, is
appropriately positioned.
4. A focal lytic lesion within the L1 vertebral body could
represent a hemangioma. However, appearances are suspicious for
a metastatic lesion, particularly given the pleural disease
described above. Bone scan would be useful for further
evaluating this lesion, and for evaluation of other occult
skeletal metastases.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 76 year-old female with multiple medical
problems including HBV, fatty liver, colonic mass s/p resection,
HTN, hyperlipidemia, who was initally admitted on [**10-23**]
for increasing dyspnea over the six weeks prior to admission and
increased pleuritic chest pain on the right side.
*
1) DYSPNEA: After admission, a CXR was done which showed a right
sided pleural effusion. CTA was also done to rule out a
pulmonary embolus. This did not show a PE; however, showed
several mediastinal lymph nodes, the largest precarinal,
measuring 1.4 cm. There was also right-sided pleural nodular
densities and several small nodules bilaterally, the largest
located in the RLL anterior to the pleural effusion, measuring
~8mm. Right lung base atelectasis was present, with a
moderate-sized pleural effusion. No PE was seen, however. The
differential at that time was thought to be
inflammatory/infectious, less likely vasculitis or neoplastic. A
follow-up CT was recommended. On [**2197-10-25**], thoracentesis of the
right pleural effusion was performed by the interventional
pulmonology fellow and the pleural fluid obtained was consistent
with an exudative fluid with an elevated red count (trauma) and
lymphocytsosis. Cultures of the fluid were negative, and
cytology was negative for malignant cells. The patient then
developed fevers to 101.7 with new wheezing and was thought to
have a pneumonia with a component of reactive airway
disease/COPD. On [**10-28**], she was started on
vancomycin/flagyl/levofloxacin (these were later discontinued on
[**11-11**]). She was also started on solumedrol and MDI's. On
[**10-30**], Mrs. [**Known lastname **] then developed hypercarbic respiratory failure
and was found to have stridor/wheezing on exam which did not
improve with racemic epi. At this point, she was transferred to
the MICU. In the MICU, the patient was stabilized on BIPAP and
nebulizers. She was transferred back to the floor on [**11-5**].
After a few days on the floor, the patient again developed
increasing dyspnea. A CXR was performed which showed an
increase in the size of her right sided effusion. On [**11-9**],
another thoracentesis was attempted to take fluid off and make
the patient more comfortable; however, fluid could not be
aspirated. The patient's lung was imaged by the interventional
pulmonology (IP) fellow with US and thick fluid vs. consildation
vs. lung parenchyma was obseved. The IP fellow suggested that a
CT scan be performed for better characterization of the effusion
seen on CXR, as well as VATS to obtain tissue at the pleural
nodule for a diagnosis. The patient could not lie supine due to
significant respiratory distress, so she was transferred back to
the MICU for elective intubtaion to obtain CT scan and
subsequent VATS. The repeat chest CT on [**11-10**] showed an
increased right sided collection with worsening atelactasis of
right middle lobe and right lower lobe. There was also increased
nodular thickening of right upper lobe. On [**2197-11-10**], Dr. [**Last Name (STitle) 175**]
(thoracic surgery) performed a VATS and pleural biopsy. Two
chest tubes were placed during the surgery for drainage of her
effusion. The effusion was loculated, so thoracic surgery used
TPA to break up fibrinous locuations. Mrs. [**Known lastname **] did well
post-op with only minor pain at the incision site. This was
controlled with morphine. On [**11-12**], the patient was trasferred
back to the floor. She was maintained on nebulizers for
respiratory comfort and morphine for pain control. On [**11-15**], the
pathology from her pleural biopsy obtained during VATS revealed
a metastatic non-small cell lung cancer. Immunostains were
positive for CEA, cytokeratin, and S100, but negative for
MART-1, TTF-1, B72.3, and calretinin. The patient was notified
of the results and she reported that she did not want any
chemotherapy. After agreement by the patient, medical oncology
was consulted to review her case and present the possible
options to her before she made this decision final. After
seeing oncology, the patient still held to not wanted
chemotherapy. She said that she wanted to go home to [**State 3914**]
with her son, who is a retired nurse. Her son decided that he
would care for her in his home. He arranged to have hospital
bed sent to his home, and arranged to have physician who will
visit Mrs. [**Known lastname **] at home. An ambulance was arranged to
transport the patient from [**Location (un) 86**] to [**State 3914**].
*
2. PNEUMONIA: The patient had a CXR done on [**10-27**] which showed a
nodular density right mid zone. Given her fragile respiratory
status, this was treated as pneumonia with
levo/flagyl/vancomycin. The antibiotic course was continued
from [**10-28**] until [**11-11**].
*
3. NON-ST ELEVATION MI: During her admission, the patient had
episodes of chest pain. At one point, her cardiac enzymes
trended up to a high of trop = 0.32. EKG was without changes.
These cardiac enzymes subsequently trended down. Other episodes
of chest pain on this admission were not accompanied by EKG
changes or elevation of cardiac enzymes.
*
4. ACUTE RENAL FAILURE: During her admission, the patient had
ARF with a high creatinine of 3.6. The was likely of prerenal
etiology given her urine lytes at the time. With IV hydration,
her creatinine trended down, and on discharge was 0.5
*
5. ANEMIA: The patient had a low Hct throughout her admission
(low 30's to high 20's). Her stools were guaiac negative. She
was transfused to maintain Hct<30.
*
8. ABDOMINAL PAIN: Mrs. [**Known lastname **] periodically complained RUQ and
epigastric abdominal pain throughout her admission. Two RUQ
ultrasounds were obtained which were normal without evidence of
cholelithiasis or cholecystits. Her LFTs and amylase/lipase
also remained within normal limits. Her abdominal pain was
thought to be due to peptic ulcer disease. She was maintained
on her PPI.
*
9. DIARRHEA: She also complained of diarrhea towards the end of
her hospital course. She was tested for C. diff, which was
negative x 3. Her diarrhea was likely a side effect of her
antibiotics.
*
10. HTN: The patient was maintained on her outpatient regimen
for HTN.
*
11. PROPHYLAXIS: She was maintained on pneumoboots, SC heparin,
bowel regimen, and PPI.
*
12. CODE STATUS: Throughout her hospital admission, the patient
was full code. After she was given the diagnosis of NSCC, this
issue was re-addressed. After a discussion with the patient and
her son, she made the decision to change her status to DNR/DNI
and maintained that status on discharge from the hospital.
Medications on Admission:
HCTZ 25 qd
Pantoprazole 40 qd
Paxil 12.5 qd
Senna PRN
ASA 81 QD
[**Doctor First Name **] 60 PRN
Ca + Vit D
MVI
ALL: Shellfish
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
2. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 bottle* Refills:*0*
4. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) INH Inhalation Q12H (every 12 hours).
Disp:*60 INH* Refills:*0*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q4H (every 4 hours): with albuterol nebs.
Disp:*180 INH* Refills:*0*
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-13**] Sprays Nasal
TID (3 times a day) as needed.
Disp:*1 bottle* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*0*
8. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) INH
Inhalation Q3H (every 3 hours): [**Month (only) 116**] use more frequently if
necessary.
Disp:*240 INH* Refills:*0*
10. Multivitamin Capsule Sig: One (1) Cap PO QD ().
Disp:*30 Cap(s)* Refills:*0*
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. Bismuth Subsalicylate 262 mg/15 mL Suspension Sig: Fifteen
(15) ML PO TID (3 times a day) as needed for diarrhea.
Disp:*1 bottle* Refills:*0*
13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*1 bottle* Refills:*0*
16. Phenergan 25 mg/mL Solution Sig: Twenty Five (25) MG
Injection Q4-6H:PRN as needed for nausea.
Disp:*1 box* Refills:*0*
17. Morphine Sulfate 2 mg/mL Syringe Sig: 1-2 MG Injection
Q2H:PRN as needed for pain.
Disp:*40 MG* Refills:*0*
18. Roxanol Concentrate 20 mg/mL Solution Sig: 10-30 MG PO
Q4H:PRN as needed for pain.
Disp:*600 mg* Refills:*0*
19. Ativan 2 mg/mL Syringe Sig: 0.5-1 MG Injection Q4-6H:PRN as
needed.
Disp:*20 ML* Refills:*0*
20. Ativan 0.5 mg Tablet Sig: 0.5-1 MG PO Q4-6H:PRN.
Disp:*30 tablets* Refills:*0*
21. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
22. Senna 8.6 mg Capsule Sig: Two (2) Capsule PO BID:PRN as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
23. Dulcolax 10 mg Suppository Sig: Ten (10) mg Rectal QD:PRN as
needed for constipation.
Disp:*30 tablets* Refills:*0*
24. Equipment
please dispense (1)
Three in One Commode
Discharge Disposition:
Home With Service
Facility:
Visiting Nurse and Hospice
Discharge Diagnosis:
1) Metastatic Non-small cell carcinoma
2) Right Pleural Effusion
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the Emergency Room if you
experience difficulty breathing, chest pain, or fever/chills.
Followup Instructions:
Please follow up with your new doctor, Dr. [**Last Name (STitle) 110239**], after
discharge from the hospital. Please call for an appointment
([**Telephone/Fax (1) 110240**]).
|
[
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"553.3",
"401.9",
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"518.0",
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"V15.82",
"197.2",
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icd9cm
|
[
[
[]
]
] |
[
"34.04",
"99.04",
"34.91",
"96.04",
"93.90",
"96.71",
"93.96",
"34.51",
"88.43",
"34.24"
] |
icd9pcs
|
[
[
[]
]
] |
23164, 23222
|
13435, 20101
|
383, 405
|
23331, 23339
|
3807, 13412
|
23512, 23692
|
3148, 3303
|
20278, 23141
|
23243, 23310
|
20127, 20255
|
23363, 23489
|
3318, 3788
|
327, 345
|
433, 2679
|
2701, 2963
|
2979, 3132
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,869
| 176,694
|
12639
|
Discharge summary
|
report
|
Admission Date: [**2146-3-2**] Discharge Date: [**2146-3-18**]
Date of Birth: [**2100-8-2**] Sex: M
Service:
CHIEF COMPLAINT: Gangrene, left fourth toe.
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
male with a past medical history of insulin dependent
diabetes mellitus, now presenting with gangrene of left
fourth toe which started in mid-[**Month (only) 1096**]. He was admitted to
[**Location 39045**], [**Hospital **] hospital (home town), and started on
intravenous antibiotics. Amputation was recommended after an
angiogram and MRA were performed. He is now here for a
second opinion.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus since [**2105**] with
triopathy.
2. Legally blind.
3. Hypertension.
4. Coronary artery disease status post silent myocardial
infarction times two.
5. Status post kidney transplant in [**2126**].
6. Peripheral vascular disease status post right below the
knee amputation.
7. Hyperlipidemia.
8. Anemia.
PAST SURGICAL HISTORY:
1. Living related kidney transplant in [**2126**].
2. Open cholecystectomy in [**2138**].
3. Right below the knee amputation.
4. Left total knee replacement.
MEDICATIONS ON ADMISSION:
1. Imuran 125 mg q. day.
2. Lopid 600 mg twice a day.
3. ASA, 325 mg q. day.
4. Axid 150 mg twice a day.
5. Medrol 10 mg q. day.
6. Valium 5 mg twice a day.
7. Duricef 500 mg twice a day.
8. Toprol XL 25 mg q. day.
9. Demerol 25 mg q. day p.r.n.
10. Humulin N 30 units q. a.m.
11. Regular insulin sliding scale.
12. Epogen 8000 units subcutaneously on Monday, Wednesday and
Friday.
13. Nitroglycerin spray p.r.n.
14. Lasix 20 mg p.r.n.
15. Captopril 25 mg three times a day.
16. Phenergan p.r.n.
17. Iron sulfate 325 mg three times a day.
18. Colace 100 mg twice a day.
19. Neurontin 300 mg p.o. q. h.s.
ALLERGIES: Shrimp and iodine.
HOSPITAL COURSE: Mr. [**Name14 (STitle) 39046**] was admitted under the Vascular
Surgery Service. He was started on antibiotics. An
angiogram was performed which revealed high-grade stenosis of
the tibial peroneal trunk with two-vessel anterior tibial and
posterior tibial runoff below that includes feeding into
posterior tibial and dorsalis pedis artery. [**Last Name (un) **] consult
was obtained to optimize diabetic management. Renal,
Podiatry and Cardiology consults were also obtained.
He underwent a cardiac catheterization on [**3-7**], per
Cardiology recommendation which revealed three-vessel
disease. Coronary artery bypass surgery was recommended
prior to the Vascular Surgery. He underwent coronary artery
bypass graft times two (saphenous vein graft to left anterior
descending, saphenous vein graft to distal right coronary
artery), on [**3-8**]. His postoperative course was routine.
He then underwent a left below the knee amputation on
[**2146-3-14**]. He tolerated the procedure well. His
postoperative course was again routine. He was transiently
hypotensive on postoperative day two, although he was
asymptomatic. He responded to a fluid bolus. He normally
runs with systolic blood pressure of around 85 to 95 mm of
Mercury. He is now ready to go to rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Insulin 22 units subcutaneously a.m. and 6 units
subcutaneously p.m.
2. Regular insulin sliding scale.
3. Levaquin 500 mg p.o. q. day.
4. Lopid 600 mg p.o. twice a day.
5. Medrol 10 mg p.o. q. day.
6. Imuran 125 mg p.o. q. day.
7. ASA 325 mg p.o. q. day.
8. Lopressor 15 mg p.o. twice a day.
9. Colace 100 mg p.o. twice a day.
DISCHARGE INSTRUCTIONS:
1. The patient may not weight bear on upper extremities for
up to five weeks due to recent coronary artery bypass graft.
2. He may be fitted for prosthesis to the right stump.
3. He may get out of bed with maximum assistance.
4. Follow-up with Dr. [**Last Name (STitle) 1391**] in two weeks.
DISCHARGE DIAGNOSES:
1. Non-healing ulcer, left foot, status post left below the
knee amputation.
2. Coronary artery disease, status post coronary artery
bypass graft.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2146-3-18**] 10:51
T: [**2146-3-18**] 11:02
JOB#: [**Job Number 39047**]
|
[
"V42.0",
"440.24",
"285.1",
"401.9",
"412",
"250.71",
"414.01",
"369.00",
"V49.75"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.15",
"88.56",
"36.12",
"88.72",
"88.48",
"39.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
3874, 4297
|
3192, 3532
|
1214, 1861
|
1879, 3166
|
3556, 3853
|
1025, 1188
|
148, 176
|
205, 631
|
653, 1002
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,534
| 118,476
|
1073
|
Discharge summary
|
report
|
Admission Date: [**2135-1-2**] Discharge Date: [**2135-1-4**]
Date of Birth: [**2057-1-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Linezolid
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 77 year-old male with a history of DM, HTN, CHF (EF
45%), CAD s/p CABG, PAD s/p fem-[**Doctor Last Name **], a-fib, HL who presents with
hypoglycemia. The patient was in his usual state of health
until this evening when he was noted to confused and altered by
his wife. EMS was called and performed a fingerstick and
glucose was noted to be 26 and he was given 1 amp of D50 and
improved to 109.
In the ED, VS 98.2 72 140/62 16 96% 2L NC. Pt glucose on arrive
was 41 and was given his second amp of D50 and improved to 112.
He was rechecked in one hour and glucose was again low at 49.
He was then given his 3rd amp of D50, Octreotide 50ucg x1 and
started on a D5 gtt. He was given a total of 400cc NS and 1L
D5NS. The patient was also evaluated by toxicology who agreed
with the above management. Her lactate was normal at 1.5. He
was admitted to the ICU for close glucose monitoring.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity edema, cough, urinary frequency,
urgency, dysuria, lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash or skin changes.
Past Medical History:
- Diabetes mellitus, type II, HgbA1c 6.3%
- Peripheral arterial disease s/p fem-[**Doctor Last Name **] bypass [**2118**], repeat
angioplasty and left popliteal stent, non-healing LLE ulcers
- Hypertension
- Coronary artery disease s/p CABG x 4 in [**2119**]: s/p 3 drug
eluting stents
- Inferior MI [**10/2129**]
- Systolic heart failure, EF 45%
- Hypercholesteremia
- Atrial fibrillation
- Gastroesophageal reflux disease
Social History:
From Sicily, moved to USA [**2089**]. Former smoker, 2 packs per day
for 45 years, quit in [**2113**]. Previously drank wine, but stopped a
couple of months ago. Lives with wife and son. Retired
construction worker.
Family History:
Mother and father died of old age, both at [**Age over 90 **] years old. Sister
with "stomach" cancer. Brother with "water in his lungs".
Physical Exam:
Admission exam in [**Hospital Unit Name 153**]:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: 8cm JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2
PULM: bibasilar crackles, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/ +1 edema, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing.
Arriving to floor from [**Hospital Unit Name 153**]:
VS: Temp 97.5, BP 141/56, HR 69, RR 18, O2 96% on 2L NC
PAIN SCORE: 0/10
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, oropharynx clear
NECK: Supple, JVP 8 cm H20
CHEST: Bibasilar rales, no wheezing or rhonchi
CV: Irregularly irregular, normal s1 and s2
ABD: Soft, nontender, nondistended, bowel sounds normal
EXT: [**12-12**]+ BLE pitting edema, left hallux s/p amputation
SKIN: Chronic venous stasis changes LLE>RLE; ecchymoses in arms
NEURO: Alert, oriented to person, place, and [**2134-12-11**], CN 2-12
intact, strength 5/5 BUE/BLE, fluent speech, coordination normal
PSYCH: Calm, appropriate
Pertinent Results:
On Admission
[**2135-1-2**] 05:00PM WBC-7.5 HGB-11.6* HCT-37.2*
[**2135-1-2**] 05:00PM PLT COUNT-318
[**2135-1-2**] 05:00PM GLUCOSE-41* UREA N-52* CREAT-1.3* SODIUM-136
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-14* ANION GAP-17
[**2135-1-2**] 10:30PM GLUCOSE-89 NA+-135 K+-4.7 CL--111 TCO2-14*
[**2135-1-2**] 08:37PM LACTATE-1.5
[**2135-1-2**] 10:30PM TYPE-ART PO2-92 PCO2-26* PH-7.35 TOTAL
CO2-15* BASE XS--9 COMMENTS-VERY LOW D
[**2135-1-2**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2135-1-2**] 06:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2135-1-2**] 06:30PM URINE RBC-[**2-12**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2135-1-2**] 11:10PM URINE HOURS-RANDOM SODIUM-99 POTASSIUM-34
CHLORIDE-103
[**2135-1-3**]:
131 | 104 | 46
---------------<74
5.2 | 17 | 1.5
Ca: 8.6 Mg: 2.4 P: 3.3
PT: 15.9 PTT: 33.6 INR: 1.4
Urinalysis: Yellow, clear, Spec Gr 1.016, pH 5.0, Urobil Neg,
Bili Neg, Leuk Neg, Bld Mod, Nitr Neg, Prot 75, Glu Tr, Ket Neg,
RBC [**2-12**], WBC 0-2, Bact Rare, Yeast None, Epi 0-2
URINE CULTURE [**2135-1-2**]: Negative
CXR PA AND LATERAL [**2135-1-2**]:
Overall findings favor a diffuse pulmonary edema likely from
cardiogenic etiology. Slightly more confluent opacities may
simply reflect confluent edema or represent underlying
infiltrate or aspiration. Repeat radiography after appropriate
diuresis is recommended to assess for underlying infection.
CXR PORTABLE [**2135-1-3**]:
In comparison with the study of [**1-2**], there is minimal decrease
in
the diffuse bilateral pulmonary opacifications consistent with
congestive failure in a patient with cardiomegaly and evidence
of prior CABG procedure. The possibility of supervening
consolidation, especially at the left base, can certainly not be
excluded on this study.
ECHO [**2134-10-22**]: All [**Doctor Last Name 1754**] enlarged. Mild AR, Mild to Moderate
MR, Moderate TR. Severe pulmonary hypertension. LVEF 40-45%.
Brief Hospital Course:
77 year-old male with hypoglycemia [**1-12**] use of sulfonylureas at a
dose higher than he currently needs either because he is
inadvertently taking too much glyburide or he now requires a
lower dose. The patient is unable to state which medications he
takes, so it is very likely that he is not using his home
medications properly. He has not taken his Lasix at home for a
few weeks because he ran out. This explains in part why he has
crackles on physical exam and changes consistent with pulmonary
[**Month/Day (2) 1106**] congestion on CXR.
[**Hospital Unit Name 153**] Course: Patient was initially on a dextrose infusion, but
this is now weaned off. The patient is eating regular food by
mouth and his fingerstick blood sugars have been in the normal
range. The patient was also treated with 2 doses of IV Lasix
for clinical and radiographic evidence of volume overload.
PROBLEM LIST:
# DM, type II with Hypoglycemia: Patient was noted to have be
confused this evening and glucose was noted to be 29 by EMS. He
has subsequently received D50 amps x3, octreotide 50ucg x1
(suppresses endogenous insulin production) and D5 gtt. The most
likely etiology is glyburide overdose, but the patient does not
recall taking extra medications. Other possibility is glyburide
in elderly with declining kidnet function can cause
hypoglycemia. Other causes seem less likely including alcohol,
sepsis/infection, cortisol deficiency and even less likely
insulinoma or insulin autoimmune hypoglycemia. Metformin does
not cause hypglycemia and lactate is normal. He was closely
monitored with regular fingersticks and required several
treatments with D50. For a brief period, the patient was on a
dextrose infusion. Cortisol was 17.4 which is not consistent
with adrenal insufficiency. HbA1C was 6.3%.
- Hold Glyburide unless hyperglycemic (given that A1c is
6.3%,this was discontinued altogether. Would likely benefit from
ACE inhibitor, but will not start at this time given
hyperkalemia, this can be started as an outpatient if
electrolyties within normal limits.
# Systolic heart failure, EF 45%, mild exacerbation likely [**1-12**]
lasix non-compliance and dextrose infusion. Exam with crackles.
Per patient stopped taking furosemide past month. Improving with
Lasix 20mg IV x2. Restarted home Lasix 20mg PO Daily Metoprolol
continued. No ACE inhibitor for now given hyperkalemia. Have
arranged for cardiology follow-up
# Hyponatremia: Continue to monitor. 132 at the time if
discharge
# Non-gap Acidosis: Pt with Bicarb of 15 on labs. Pt without
nausea/vomiting and not on diamox. He did receive 1.5L of NS
that could cause a non-gap acidosis, but not likely to cause
such a dramatic drop. Urine lytes and urine gap c/w RTA likely
Type IV given DM. We monitored lytes [**Hospital1 **] and held further NS IVF
with a plan to diurese as tolerated. His acidosis was improved
at the time of discharge, repeat electrolytes can be checked as
an outpatient.
# HTN: Continued Metoprolol 50mg [**Hospital1 **].
# PVD s/p fem-[**Doctor Last Name **] bypass: Continued [**Doctor Last Name **] and Plavix
# CAD s/p CABG x 4 in [**2119**], s/p 3 drug eluting stents, stable,
no chest pain:
- Continued Aspirin, plavix. Simvastatin, and Metoprolol
# Atrial fibrillation, CHADS2 score 4
- Continued Aspirin and Metoprolol
- Not anti-coagulated given prior GI bleed and concern for
medication adherence; pt can readdress with [**Year (4 digits) 3390**]. [**Name10 (NameIs) **] tolerated
[**Name10 (NameIs) **] and plavix without bleeding.
# GERD: Continued Omeprazole
# Chronic kidney disease, stage 3, creatinine at baseline 1.5.
# DVT prophylaxis: Heparin Subcutaneous
# Code: FULL Code
# Communication: Wife, [**Name (NI) 7008**] [**Telephone/Fax (1) 7009**]; Son, [**Name (NI) 122**]
[**Telephone/Fax (1) 7010**]
# DISPO: Have requested home safety eval; medication changes
(stopping glyburide, restarting lasix, consideration of
restarting coumadin with [**Telephone/Fax (1) **]) discussed with son [**Name (NI) 122**] on day
of discharge
Medications on Admission:
Reviewed list with son, but patient's ability to take correctly
is highly in doubt.
- Glyburide 1.25 mg PO Daily
- Metoprolol 50 mg PO BID (possibly only taking once daily)
- Simvastatin 20 mg PO QHS
- Plavix 75 mg PO Daily
- Lasix 20 mg PO Daily (ran out 2 weeks ago)
- Aspirin 325 mg PO Daily
- Vitamin D 400 units 2 tablets PO Daily
- Iron 325 mg PO Daily
- Calcium 500 mg PO TID (patient does not take)
- Omeprazole 20mg PO Daily (patient does not take)
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Iron (ferrous sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Hypoglycemia
Systolic heart failure, acute on chronic
Diabetes type 2, poorly controlled with complications
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with low blood sugar. This is likely because
of your diabetes medication which you no longer need and may
have been taking too much of. You also had some extra fluid on
your lungs from congestive heart failure. Weigh yourself every
morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
****Please stop your glyburide.****
****Please take your lasix as prescribed (20mg daily)***
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: MONDAY [**2135-1-10**] at 11:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: TUESDAY [**2135-2-1**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: [**Hospital1 **] [**Location (un) 2352**] SUITE B
When: WEDNESDAY [**2135-3-2**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], DPM [**Telephone/Fax (1) 1142**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: WEDNESDAY [**2135-1-26**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"428.0",
"250.80",
"276.1",
"403.10",
"585.3",
"276.2",
"588.89",
"V45.81",
"427.31",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11218, 11276
|
5875, 6759
|
295, 302
|
11451, 11451
|
3818, 5852
|
12038, 13484
|
2285, 2426
|
10429, 11195
|
11297, 11430
|
9947, 10406
|
11602, 12015
|
2441, 3799
|
243, 257
|
330, 1589
|
6774, 9921
|
11466, 11578
|
1611, 2036
|
2052, 2269
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67,241
| 109,297
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38705
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Discharge summary
|
report
|
Admission Date: [**2171-2-16**] Discharge Date: [**2171-2-22**]
Date of Birth: [**2128-10-21**] Sex: M
Service: MEDICINE
Allergies:
Lorazepam
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
mediastinal mass
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 42 y.o male with no PMH who was originally transferred
from [**Hospital 5279**] Hospital for eval and tx of a new mediastinal mass
and PE. Pt reports was in USOH until ~4wks ago when he developed
a fever, non-productive cough, scratchy throat and severe SOB
(+orthopnea and DOE), facial+neck swelling, cyanotic ears/lips,
decreased appetite (wt loss 10-12lbs). He also reports sharp
R.sided lateral chest/rib pain, with occasional radiation down
his R.arm and a dull discomfort in his RUQ. He also reports a
white spot in his R.eye vision, that has since resolved. He
reported 2 episodes of n/v over this 4 wk period. He denies
travel, sick contacts, headache, blurred vision, odynophagia,
dysphagia, palps/d/c/melena/brpbr/dysuria/paresthesias
/weakness/skin rash.
He then presented to [**Location (un) **] Urgent Care [**2171-2-14**] where a
large lung mass was found on CXR. He was then admitted to [**Hospital 5279**]
Hospital.
There, CT chest showed a large [**Location (un) 21851**] invading the
R.mediastinum causing severe compression, but no occlusion of
the SVC. This mass was in contact with the pulmonary artery.
Labs showed AFP 1303, LDH 407, normal B-HCG. CT guided bx showed
malignant cells c/w poorly differentiated carcinoma (ddx
carcinomatosis of immature teratoma within mixed cell germ tumor
or poorly differentiated carcinoma with non-small cell
morphology.
Therefore, pt was transferred to [**Hospital1 18**] for mediastinoscopy and
further care. Pt now being transferred to the [**Hospital Ward Name **] for
the initiation of chemotherapy. Pt will require ICU given
possibility of tumor swelling causing complete SVC occlusion (IR
vs. vasc would need to stent). Onc felt comfortable starting
chemo if no liver lesions. Currently ?defect in falciform
ligament, radiology rec U/S. Pt with pan scan at OSH.
.
Currently, pt reports SOB, facial swelling, and R.arm swelling,
but pain is controlled.
Past Medical History:
none
Social History:
The patient has a significant other of 6+ years.
He worked for [**Doctor Last Name 634**] Electronics at a desk job, with no
particular toxic exposures. He reports that he smoked minimally,
[**1-19**] cigarettes per week, but nothing in >7yrs. He reports [**3-21**]
drinks a week, and denies drug use. He lives in [**Location (un) 3844**].
Family History:
Reviewed and noncontributory for any
malignancies. Mother had two minor strokes
Physical Exam:
VitalsT. 97.6, BP 129/77, HR 107, RR 24 sat 96% on 2L, 1607I/
1600 O
GENERAL: well appearing, anxious, NAD, able to speak in full
sentences
HEENT: nc/at, PERRLA, EOMI, anicteric, MMM, no OP lesions
neck:+facial plethora, neck swelling, supple
CARDIAC: s1s2 rrr no m/r/g
LUNG: b/l ae, no w/c/, decreased BS r.base
ABDOMEN:+bs, soft, +slight TTP Ruq, no guarding/rebound.
EXT: R.UE with ~2+edema, L.UE [**1-19**]+edema. LE without edema, no
c/c.
NEURO: AAOx3, CN2-12 intact, motor [**5-22**]
DERM:no rashes.
Pertinent Results:
[**2171-2-16**] 12:30AM PT-14.7* PTT-50.5* INR(PT)-1.3*
[**2171-2-16**] 12:30AM PLT COUNT-543*
[**2171-2-16**] 12:30AM WBC-8.9 RBC-4.27* HGB-11.1* HCT-34.2* MCV-80*
MCH-26.0* MCHC-32.4 RDW-13.0
[**2171-2-16**] 12:30AM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.2
[**2171-2-16**] 12:30AM estGFR-Using this
[**2171-2-16**] 12:30AM GLUCOSE-111* UREA N-5* CREAT-0.7 SODIUM-141
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14
[**2171-2-16**] 09:20AM PT-14.7* PTT-64.8* INR(PT)-1.3*
[**2171-2-16**] 09:20AM CEA-<1.0 AFP-1310*
[**2171-2-16**] 09:20AM HCG-<5
[**2171-2-16**] 09:20AM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-3.3
MAGNESIUM-2.2
[**2171-2-16**] 09:20AM ALT(SGPT)-80* AST(SGOT)-52* LD(LDH)-339* ALK
PHOS-138* TOT BILI-0.2
[**2171-2-16**] 09:20AM GLUCOSE-102* UREA N-5* CREAT-0.7 SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
[**2171-2-16**] 02:25PM PT-14.9* PTT-69.8* INR(PT)-1.3*
Chest CT scan Date: [**2171-2-11**] [x] outside film
Impression:
1.) large [**Location (un) 21851**] of the RUL invading the right aspect of
the mediastinum and causing severe compression but not occlusion
of the superior vena cava.
2.) PE involving the LLL artery
3.) Multiple nonspecific mediastinal lymph nodes are seen
without
change, the largest right peritracheal lymph node measuring
9x14,
not enlarged by criteria
.
Other
CT-guided needle biopsy [**2171-2-13**] (by dictation, original report
is
not available): flow cytometry negative for lymphoma, POSITIVE
markers: epithelial, pankeratin, BEREP4; NEGATIVE markers: CK-7,
CK-20, TTF-1, b-HCG, yolk-sac cocktail; impression -
differential diagnosis includes carcinomatosis component of the
immature teratoma within the mixed germ cell tumor and poorly
differentiated carcinoma with a non-small cell morphology.
.
MICROBIOLOGY:
none
.
EKG: ST, TWI III, TWF AVF, biphasic T v4-v6. na, no prior.
.
CXR: IMPRESSION: AP chest reviewed in the absence of any prior
chest imaging. Mediastinum is roughly midline despite a large
right pleural effusion accompanied by a sufficient right lung
atelectasis to suggest that this is a longstanding finding.
Smaller left pleural effusion has a very irregular contour along
the mediastinum posteriorly, which may indicate adenopathy.
Trachea is not particularly displaced and narrowed, so the
extent of
mediastinal mass is not appreciated on this study and would
require
cross-sectional imaging for assessment. With such a study one
can distinguish cardiac tamponade from SVC syndrome, which can
present with great clinical similarity. No pneumothorax. Dr. [**Last Name (STitle) **]
was paged.
.
ECHO [**2171-2-12**] OSH
-normal LV size, EF, RV normal, atrial normal, no valvular abn,
trace MR [**First Name (Titles) **] [**Last Name (Titles) **], impaired LV relaxation. No significant
pericardial effusion.
.
CT abd/pelvis OSH read: focal fatty infiltration is seen within
the liver adj to the falciform ligament. pancreas, spleen,
kidneys and adrenal glands are normal in appearance with
incdiental not of 2.5cm cyst from the lower pole of the
R.kidney, no calcified gallstones seen, no enlarged
intra-abdominal nodes seen. Moderately dilated loops of proximal
small bowel are seen with an abrupt caliber change inteh LUQ
beyond which the small bowel is decompressed. The colon overall
is normal caliber. Pelvis-large amt of stool present in rectum
and pelvic contents are otherwise unremarkable.
CXR [**2171-2-16**]:
AP chest reviewed in the absence of any prior chest imaging.
Mediastinum is roughly midline despite a large right pleural
effusion accompanied by a sufficient right lung atelectasis to
suggest that this is a longstanding finding. Smaller left
pleural effusion has a very irregular contour along the
mediastinum posteriorly, which may indicate adenopathy. Trachea
is not particularly displaced and narrowed, so the extent of
mediastinal mass is not appreciated on this study and would
require cross-sectional imaging for assessment. With such a
study one can distinguish cardiac tamponade from SVC syndrome,
which can present with great clinical similarity.
CXR [**2171-2-21**]:
There is no significant interval change in the large right
pleural effusion, although minimal decrease might be suspected
most likely due to postural changes. The right upper
paratracheal enlargement can be again appreciated.
The left lung is well aerated except for minimal basilar
opacities. The left midline tip is at the level of the mid
portion of left subclavian vein.
Scrotal U/S [**2171-2-18**]:
FINDINGS: There are small bilateral hydroceles. The right
testicle measures
2.45 x 1.93 x 3.54 cm. The left testicle measures 2.53 x 2.51 x
3.33 cm. The echotexture of the bilateral testes is extremely
heterogeneous with diffuse patchy areas of relative hypo- and
hyperechogenicity; however, there is no discrete mass identified
within either testicle. Vascularity within the testes appears
symmetric bilaterally. There is a 2.5-mm left epididymal cyst.
The appearance of the right and left epididymides is otherwise
normal.
IMPRESSION:
1. Diffusely and markedly heterogeneous testicular echotexture
bilaterally
without discrete masses identified. The findings are not
suggestive of a germ cell tumor of the testicle. The
differential diagnosis for the findings is broad, however,
including infectious or inflammatory process, possible drug
effect, or sarcoidosis. A diffuse infiltrative malignancy, such
as lymphoma, cannot be excluded, but if the known mediastinal
mass does not represent lymphoma, this seems unlikely. Clinical
correlation is recommended. MRI could be considered for further
evaluation if etiology remains uncertain.
2. Small bilateral hydroceles.
3. Tiny left epididymal cyst.
CT Head [**2171-2-20**]:
FINDINGS: There is no acute hemorrhage, edema, masses, mass
effect, or large territorial infarcts. No enhancing intracranial
lesions are seen. The
intracranial vessels enhance symmetrically, with no evidence of
large vessel cutoff.
Mucosal retention cysts are seen in the right ethmoid, left
maxillary, and
left sphenoid sinuses. The remaining paranasal sinuses and
mastoid air cells are clear. There are no fractures or
suspicious osseous lesions in the skull.
IMPRESSION: No evidence of intracranial metastases.
MRI Abdomen/Pelvis:
FINDINGS: On localizer images and coronal imaging, the known
large right
mediastinal mass is partly visualized. A large right pleural
effusion is
identified with areas of heterogeneous high signal on
T1-weighted images,
suggestive of proteinaceous or hemorrhagic components. There is
extensive
atelectasis of the right lower lobe.
Image quality is markedly degraded by patient's difficulty
suspending
respiration. A subcapsular area of signal loss is identified on
out-of-phase imaging in the anterior aspect of segment IVb of
the liver compared to the in-phase images, appearing to
corresponding to the focal area of low attenuation identified on
CT performed at outside hospital [**2171-2-11**]. The lesion exhibits
low signal in comparison to the adjacent hepatic parenchyma on
fat-suppressed T1 imaging, and is difficult to characterize on
post-contrast imaging due to motion artifact. No other focal
parenchymal lesions are seen in the liver. The portal vein and
hepatic veins are patent.
No intrahepatic or extrahepatic biliary duct dilatation is
identified. The
gallbladder is unremarkable in appearance. No gross abnormality
is seen in
the pancreas, spleen, kidneys or adrenal glands, but views are
suboptimal due to motion artifact. The arteries are suboptimally
visualized in arterial phase imaging, but the celiac artery and
superior mesenteric artery are patent. No free fluid is seen in
the upper abdomen. There is anasarca of the abdominal wall. No
abnormal signal is identified within the visualized bone marrow.
Multiplanar 2D and 3D reformations provided multiple
perspectives for the
dynamic series with kinetic information.
IMPRESSION:
1. Suboptimal visualization of the liver and other abdominal
organs due to
patient difficulty suspending respiration.
2. Area of abnormal hypoattenuation identified on CT likely
corresponds to an area of focal fatty infiltration, but precise
characterization cannot be made due to motion artifact. A repeat
MR study may be considered when the patient's respiratory status
improves.
3. Partial visualization of large right mediastinal mass and
large
right-sided pleural effusion with probable proteinaceous or
hemorrhagic
component.
RESULTS REPORTED AFTER DISCHARGE:
Cytology results
Right lung, fine needle aspirate and cell block
(CN-10-[**Numeric Identifier 85984**], procedure date [**2171-2-13**]):
POSITIVE FOR MALIGNANT CELLS,
consistent with a poorly differentiated epithelioid
neoplasm.
Note: The specimen consists of groups of pleomorphic
epithelioid cells with vesicular chromatin, small nucleoli
and scattered mitoses. See also corresponding core biopsy
report S10-4792 for further characterization.
Pathology results:
Right lung mass, needle core biopsies (CN-10-172, [**2171-2-13**],
[**Hospital 5279**] Hospital, [**Location (un) 5450**], NH):
Poorly differentiated adenocarcinoma, see note.
Note: Tumor cells are positive for keratin and BER-EP4, and
negative for TTF-1, PLAP, calretinin, CD30, CK20, and CK7. AFP
and HCG show high background. Limited tissue available for
study. The tumor shows focal mucin production and rare signet
ring cells. A metastatic lesion should be considered.
Brief Hospital Course:
Pt is a 42 y.o male with no PMH who presented with
SOB/fever/cough/weight loss/SOB and was found to have SVC
syndrome and a mediastinal mass.
#SOB/mediastinal mass-As per oncology note, differential
diagnosis includes carcinomatosis pattern of germ cell-teratoma
vs. poorly differentiated non-small cell. Chemotherapy started
in house day 1: [**2171-2-16**] with regimen of Dexamethasone 20 mg IV
DAILY Duration: 5 Doses, CISplatin 40 mg IV Days 1, 2, 3, 4 and
5, Etoposide 195 mg IV Days 1, 2, 3, 4 and 5. Pt tolerated
chemotherapy very well without evidence of tumor lysis syndrome.
Pt briefly started on ctx and azithro to cover post-obstructive
PNA on [**2171-2-16**], however, these were discontinued on [**2171-2-17**]
given no e/o PNA. He had minimal side effects of nausea which
was well controlled with Ativan, Zofran and standing Compazine.
CEA was <1 and CA [**80**]-9 was within normal at 4. HCG was <5.
Patient's alpha fetal protein level was 1310 on [**2-16**] and 1286 on
[**2-22**], leading the oncology team to be concerned that he would
need a different regimen as an outpatient, including possible
Bleomycin. Metastatic work-up did not reveal disease in the
head or abdomen though there were abnormal CT abdomen findings
as attached. A testicular ultrasound found only heterogenous
abnormalities, if anything, most consistent with lymphoma. For
final pathology and cytology, please see results section.
#SVC syndrome-caused by mass. Pt noted to have compressed SVC
on imaging, but without complete occlusion. Pt was treated with
heparin drip and transitioned to Lovenox. Neck and upper
extremity edema improved over course of admission, as did
headaches and vision changes. Cough was still present at
discharge.
#pulmonary emboli-Noted on outside hospital CT. Pt was
maintained on heparin as above. PE was thought to be most likely
from malignancy.
#transaminitis-noted on labs. Etiology could include malignancy
vs. infection vs. medication effect. Could also be due to
R.sided heart failure vs. metastatic process. CT abdomen
revealed focal fatty infiltration near the falciform ligament.
#anemia-unclear baseline. Could be due to malignancy.
# CODE: full confirmed.
# CONTACT: girlfriend [**Name (NI) 2270**] at [**Telephone/Fax (1) 85985**] or [**Telephone/Fax (1) 85986**]
cell. Pt reports she is HCP.
# Dispo: Patient to f/u with Dr. [**Last Name (STitle) 13551**] in [**Location (un) 3844**] on [**2-26**]
and with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] as needed after that.
Medications on Admission:
MEDICATIONS: none at home;
Meds on transfer:
Docusate Sodium 100 mg PO BID
1000 mL LR
Continuous at 50 ml/hr Order date: [**2-16**] @ 0950
Heparin IV
Alprazolam 0.5-1 mg PO/NG TID:PRN anxiety
Omeprazole 40 mg PO DAILY Orde
Azithromycin 500 mg PO/NG Q24H
CeftriaXONE 1 gm IV Q24H
zolpidem 5mg qhs
.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
Primary:
- germ cell-teratoma of the mediastinum
- superior vena cava syndrome
- pulmonary embolism
Discharge Condition:
mentating well, ambulating independently
Discharge Instructions:
You were transferred to [**Hospital1 69**]
from [**Hospital 5279**] Hospital for evaluation and treatment of a mass in
your chest that was obstructing the veins in your neck. You
also have a blood clot in your lungs. The blood clot and
obstructing of the veins in your neck were caused by a cancer in
your chest. You were in the intensive care unti and started on
chemotherapy. You were transfered to the regular oncology
floor. The swelling decreased and you started to feel better.
While you were here you were started on multiple new
medications. They are all of those on the attached list.
Be sure to take the Compazine (Prochlorperazine) even when you
are not nauseous in order to prevent nausea.
Followup Instructions:
You will follow-up on: [**2-26**] at 9:30am.
You will probably have to have your blood checked for alpha
fetal protein at that time.
You will also receive paperwork in the mail to return to Dr.
[**Last Name (STitle) 13551**].
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 85987**] MD
Address: NH ONCOLOGY-HEMATOLOGY
200 TECHNOLOGY DR
[**Last Name (STitle) 85988**] [**Numeric Identifier 85989**]
Phone: [**Telephone/Fax (1) 19102**]
You should call Dr.[**Name (NI) 31162**] office at [**Hospital1 **] if
different therapy is needed. Her number is, ([**Telephone/Fax (1) 31163**].
You will have to have your labs checked on Friday [**3-1**] and faxed
to:
Att: Dr. [**Last Name (STitle) 13551**] at ([**Telephone/Fax (1) 85990**]
Att: Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 38948**]
|
[
"285.9",
"V10.47",
"197.1",
"459.2",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15670, 15729
|
12793, 15321
|
288, 294
|
15873, 15916
|
3279, 12770
|
16673, 17500
|
2655, 2737
|
15750, 15852
|
15347, 15374
|
15940, 16650
|
2752, 3260
|
232, 250
|
322, 2253
|
2275, 2281
|
2297, 2639
|
15392, 15647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,362
| 194,132
|
8527
|
Discharge summary
|
report
|
Admission Date: [**2203-2-4**] Discharge Date: [**2203-2-10**]
Date of Birth: [**2133-5-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Respiratory failure, shortness of breath
Major Surgical or Invasive Procedure:
Intubation, extubation.
History of Present Illness:
This is a 69 year old female with a PMH of DM2, CAD s/p CABG,
diastolic CHF, COPD on 2L home oxygen, paroxysmal atrial
fibrillation, PE in the past, previously on coumadin but with
history of GI and RP bleed now with IVC filter and off coumadin,
recent history of respiratory failure requiring intubation in
[**9-/2202**] secondary to MRSA pneumonia with ARDS, who presented
initially to an outside hospital with chief complaints of acute
onset headache.
Per husband, she denied neck stiffness, vision changes, chest
pain, palpitations. Reported cough with nonproductive cough and
myalgias. Denies any BRBPR. No dysuria. She was found to have
fever of 100.6 and was hypoxic with O2sats in the 70% range on
room air and was started on bipap that was poorly tolerated.
She was given vancomycin/cefepime/IV solumedrol 125mg and
nebulizers for possible PNA and COPD exacerbation. ABG at that
time was 7.26, 85, 171 and patient was intubated. CXR was
obtained demonstrating pulm vascular congestion. CT head
demonstrated hydrocephalus, and when compared to CT from [**9-/2202**],
with more prominence ofthe ventricles. Was reportedly on
levophed briefly for SBPs reportedly in the ?60s/40s but which
normalized as levophed was weaned off. Transferred here for
further workup.
Upon transfer to [**Hospital1 18**], intial vital signs were T: 99.4, HR: 77,
BP: 123/61, R: 18, O2sat: 100% on the vent. Pulmonary exam was
notable for wheezing. Due to low grade fever, headache, and
history of meningitis and inability to obtain reliable history
or physical exam, there was concern for meningitis and patient
was given 2grams ceftriaxone and another dose of 10mg IV
dexamethasone with a failed attempt at LP in the ED. CT head
demonstrated hydrocephalus and neuro team was did not believe
that ventriculomegaly was etiology for headache. CXR with
pulmonary vascular congestion but no obvious pneumonia. Her
latest vent settings of AC with TV of 500X18 with FiO2: 60% and
PEEP of 8. Found to have large amount of secretions per
respiratory.
Per report, patient was started on fluconazole about a week ago
for treatment of a body rash.
Past Medical History:
-history of GI bleed
-Hx PE, pulm HTN, previously on Coumadin and s/p IVC filter but
discontinued after GI bleed in [**8-/2202**]
-PAF
-CAD s/p CABG
-diastolic CHF
-DMII
-peripheral neuropathy
-Hx TB (finished 1 yr treatment in [**7-29**])
-Hx meningitis
-Hx osteomyelitis of the spine
-Multiple lumbar compression fx
Social History:
Patient lives with husband, has personal care assistant. Prior
40 pack-year history of cigarettes, no alcohol. Wheelchair
bound due to back pain and fx's.
Family History:
Non-contributory.
Physical Exam:
VS: Temp: 100, BP: 113/76 HR: 86, RR: 18, O2sat: 100% AC
GEN: intubated, obese
HEENT: PERRL, difficult to assess JVD in setting of obesity
RESP: coarse breath sounds bilaterally, no wheezing on exam
CV: RR, S1 and S2 wnl, no m/r/g
ABD: obese, soft, nd, +b/s, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, no pedal edema
SKIN: no rashes
NEURO: intubated, pupils reactive as above.
DISCHARGE PHYSICAL EXAM
Vitals: Tm 100.0, Tc 99.0, 140s-160s/70s-80s, P70s-90, 22 95/2L
BG: 140s-226
GENERAL: Obese WF in mild distress, moaning
HEENT: Normocephalic, atraumatic. OP clear
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or gallops. JVP difficult to assess.
LUNGS: coarse BS BL, no rhonchi, rales, wheezes, good air
movement biaterally.
ABDOMEN: hyperactive BS, nondistended, soft, NTTP
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: grossly wnl, slight tremors
PSYCH: Listens and responds to questions appropriately
Pertinent Results:
Admission labs:
[**2203-2-4**] 08:00AM WBC-9.3 RBC-3.29* HGB-8.4* HCT-27.6* MCV-84
MCH-25.4* MCHC-30.3* RDW-15.5
[**2203-2-4**] 08:00AM PT-12.3 PTT-21.2* INR(PT)-1.0
[**2203-2-4**] 08:00AM PLT COUNT-292
[**2203-2-4**] 08:00AM FIBRINOGE-492*
[**2203-2-4**] 08:07AM GLUCOSE-212* LACTATE-0.7 NA+-137 K+-4.8
CL--93*
[**2203-2-4**] 08:00AM UREA N-46* CREAT-2.6*
[**2203-2-4**] 08:07AM freeCa-1.11*
[**2203-2-4**] 08:00AM LIPASE-47
[**2203-2-4**] 08:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-9* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2203-2-4**] 08:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2203-2-4**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-150
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2203-2-4**] 08:00AM URINE RBC-[**3-26**]* WBC-[**3-26**] BACTERIA-MOD YEAST-NONE
EPI-[**7-1**]
Discharge labs:
Micro:
[**2203-2-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-NEG
[**2203-2-5**] SPUTUM GRAM STAIN->25 PMNs and <10 epithelial
cells/100X field. NO MICROORGANISMS SEEN; RESPIRATORY
CULTURE-NEG; LEGIONELLA CULTURE-PRELIMINARY
[**2203-2-4**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-NEG; DIRECT INFLUENZA B ANTIGEN TEST-NEG
[**2203-2-4**] URINE Legionella Urinary Antigen-NEG
[**2203-2-4**] URINE CULTURE-NEG
[**2203-2-4**] BLOOD CULTURE-PENDING
[**2203-2-4**] BLOOD CULTURE-PENDING
IMAGING:
[**2203-2-9**] ABDOMEN (SUPINE & ERECT): pending
[**2203-2-7**] ABDOMEN (SUPINE & ERECT):
FINDINGS: Left lateral decubitus and supine views of the abdomen
were
obtained. The study is technically limited due to patient's body
habitus. An IVC filter and cholecystectomy clips are in place.
The patient is status post vertebroplasty. The bowel gas pattern
is normal. There is no obstruction, ileus or free
intraperitoneal air.
IMPRESSION: No obstruction or free intraperitoneal air.
[**2203-2-5**] CHEST (PORTABLE AP):
One view. Comparison with the previous study done [**2203-2-4**].
Bilateral
interstitial infiltrates likely representing edema persists. The
costophrenic sulci are indistinct. The patient is status post
median sternotomy and CABG as before. Cardiomegaly is unchanged.
An endotracheal tube and nasogastric tube remain in place.
IMPRESSION: No significant interval change.
[**2203-2-4**] CHEST (PORTABLE AP):
FINDINGS: Portable AP view of the chest was obtained. The
endotracheal tube is positioned approximately 2.8 cm above the
carina. The NG tube courses inferiorly below the left
hemidiaphragm though the distal side port is seen just below the
level of the GE junction. Patient is rotated to the right which
limits evaluation. Midline sternotomy wires are again noted with
fracture of the third sternotomy wire from the top. Mediastinal
clips are also noted. Cardiomegaly is unchanged with mild
central congestion and likely small bilateral pleural effusions.
IMPRESSION: Tubes positioned as detailed with NG tube tip
located just beyond the GE junction - advancement is
recommended. Otherwise, unchanged.
[**2203-2-4**] CT HEAD W/O CONTRAST:
FINDINGS: There is no evidence for acute intracranial hemorrhage
or large
mass. There is no shift of normally midline structures. The
basal cisterns are patent. There is preservation of [**Doctor Last Name 352**]-white
differentiation. Sulcal and ventricular prominence likely
reflects cortical atrophy which is likely secondary to
age-related involutional changes. Periventricular and
subcortical white matter hypodensity is likely sequela of
chronic small vessel ischemic disease.
Visualized bony structures are grossly unremarkable.
There is mucosal thickening and possible fluid in the anterior
and posterior ethmoid air cells. Air-fluid levels are seen in
the maxillary and sphenoid sinuses bilaterally which likely
reflects the patient's intubated status. There is partial
opacification of the mastoid air cells bilaterally which also
likely reflects the patient's intubated status and supine
positioning.
IMPRESSION: No acute intracranial process.
[**2203-2-4**] CHEST (PORTABLE AP):
FINDINGS: An endotracheal tube is visualized with tip
approximately 3.5 cm above the carina. A nasointestinal tube is
seen with tip below the diaphragm with side-port likely near the
gastroesophageal junction. The patient is rotated, limiting
evaluation of the cardiomediastinal contours. There is possibly
a right pleural effusion. There are ill-defined pulmonary
vascular markings, suggestive of pulmonary vascular congestion.
Note is made of an IVC filter, sternal wires, and mediastinal
clips.
IMPRESSION: Pulmonary vascular congestion and possible small
right pleural effusion. NG tube with tip below diaphragm with
side-port near GE junction; tube could be advanced slightly.
[**2203-2-4**] ECG: Normal sinus rhythm with right bundle-branch
block and secondary ST-T wave abnormalities. Compared to the
previous tracing of [**2202-9-27**] the right bundle-branch block has
returned.
Rate PR QRS QT/QTc P QRS T
70 144 120 460/477 38 95 75
Brief Hospital Course:
69 year old female with a PMH of DM2, CAD s/p CABG, diastolic
CHF, COPD on 2L home oxygen, paroxysmal atrial fibrillation, PE
in the past, previously on coumadin but with history of GI and
RP bleed now with IVC filter and off coumadin, recent history of
respiratory failure requiring intubation in [**9-/2202**] secondary to
MRSA pneumonia with ARDS, who presented initially to an outside
hospital with chief complaints of acute onset headache.
# Hypoxic/Hypercarbic Respiratory Failure: Patient was intubated
at OSH prior to transfer to [**Hospital1 18**]. Unclear etiology, but may be
multifactorial with differential including COPD exacerbation
given wheezing on exam in ED, emerging PNA (though not evident
on CXR and without leukocytosis), vs CHF exacerbation given
appearance of vascular congestion on chest radiograph. Less
likely differential includes PE. Had recent flu vaccine this
year, is flu negative here. ULegionella negative.
She was initially treated with levofloxacin and ceftriaxone and
started on vancomycin on [**2-5**] (she has a history of MRSA PNA).
Ceftriaxone was stopped on [**2-6**] as vanc and levofloxacin were
thought to be adequate. She will need a 8 day course (day 1 of
vanc [**2-5**] and day 1 of levofloxacin [**2-4**]). She was also treated
for COPD with a steroid pulse (60 mg po daily x 2 days, 40 mg x
3 days, to be tapered over 2 weeks total), and standing
albuterol and atrovent. She was extubated successfully on [**2-5**].
On [**2-6**] she was started on advair, spiriva, and continued on
albuterol prn. After extubation, she was transferred to the
medical floor where she was continued on the same regimen
(steroid taper, abx, advair, spiriva, albuterol prn). She was
supported with supplemental O2 and was able to be weaned to her
baseline of 2L. Her pulmonary exam continued to improve to the
point that she only had coarse BS BL without wheezing and some
minimal bibasilar crackles. She was discharged on her baseline
O2 requirement (2L). VNA will be helping her with nebulizer
teaching.
Of note, given possibility of interaction between Linezolid and
trazodone/paxil, pt was informed to hold other medications while
on linezolid.
# Headache: Her initial presenting complaint was headache. [**Month (only) 116**]
have been secondary to CO2 retention. Acute onset and severity
was initially concerning for acute intracranial process, however
CT scan was unremarkable with enlarged ventricles likely age
related changes. A differential of meningitis appeared less
likely given lack of confusion or nuchal rigidity but she had
already had several doses of antibiotics prior to arrival to
MICU, and an LP at this time would be of low yield.
Furthermore, an LP attempted and failed in ED due to poor
anatomy given multiple fractures. Neurology evaluated her in
the ED and initally in the MICU and recommended outpatient
neurology follow up upon discharge. By [**2-6**] her headache had
resolved.
# Acute Kidney Injury: Creatinine elevated to 2.6 on admission
from baseline of 0.9. Thought to be secondary to prerenal vs.
ATN (given transient hypotension at OSH). Her Cr improved since
admission with fluids and stabilization of her blood pressure.
Upon discharge, her Cr was 1.2. Her home lisinopril was held at
time of discharge to be restarted after 3 weeks to allow for
permissive hypertension for kidney perfusion (or to be restarted
earlier at the discretion of her PCP).
# Diabetes: She had elevated blood sugars in the setting of
steroids. She was initally treated with an insulin gtt which
was transitioned off on [**2-5**]. Her glargine was uptitrated on
[**2-6**] to 45 units qpm in the setting of BS > 400 after lunch.
She was maintained on a humalog SS and her fingersticks
continued to trend down with titration down of her steroids.
Upon discharge, she was to leave on her PO regimen, with a
glargine taper combined with her steroid taper. An email was
sent to her PCP regarding this regimen for adequate transfer of
care. The VNA was set up to check her BG at home the day after
discharge.
# Anemia/History of GI bleed: HCt 27 on admission to [**Hospital1 18**],
downtrended, but stabilized in the mid 20??????s. Baseline is
generally in the low 30s. No clinical evidence of bleeding.
Hemolysis labs were negative. Iron indices revealed Fe
deficiency anemia, however Fe was not started in house given
problems with constipation.
# Constipation: Pt was severely constipated at time of transfer
to the medicine floor. She was written for an aggressive bowel
regimen, however we were still unable to assist her in having a
bowel movement. The pt c/o distention and abdominal pain
multiple times, leading her to get KUBs which were c/w
constipation, not obstruction. She was started on enemas as
well (including a lactulose enema) and she was able to start
stooling on day of discharge. Of note, she was started on a
standing regimen of docusate, senna, and miralax, with PRN
lactulose as an outpatient. She was kept in house while she
started stooling to ensure she did not vagal in the setting of
large BMs.
# Diastolic CHF/Hypertension: Her home lasix was initially held
on admission, but then restarted on [**2-5**]. Metoprolol was
restarted on [**2-6**]. Lisinopril is still held due to her [**Last Name (un) **] (see
above). She was noted to have some crackles BL in lung exam, so
we were quite judicious with usage of fluids.
# PAF: Not on coumadin as an outpatient. She was continued on
ASA 81 mg daily. Metoprolol was initially held, but restarted
on [**2-6**]. The patient did not have any episodes of RVR.
# History of PE with IVC filter in place: Not on coumadin
secondary to history of recent GI bleed. Followed by GI team as
an outpatient. IVC filter in place. Low suspicion for PE
throughout course given lack of chest pain and good SaO2 on
baseline O2.
Medications on Admission:
- acetaminophen 650mg PO TID PRN
- alendronate 40mg PO as directed
- alprazolam 0.25mg PO TID
- aspirin 81mg PO daily
- calcium
- vitamin D
- fluconazole 100mg PO daily
- lasix 80mg PO daily
- glipizide 10mg PO BID
- combivent 2 puffs PRN
- lisinopril 5mg PO daily
- metoprolol succinate 12.5mg PO BID
- savella 25mg PO BID
- percocet 1 tab QID PRN pain
- pantoprazole 40mg PO daily
- paroxetine 10mg PO daily
- compazine PRN
- sitagliptin 25mg PO daily
- trazodone 50mg PO daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for fever, pain.
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. alendronate 40 mg Tablet Sig: One (1) Tablet PO asdir.
4. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO three times
a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. calcium carbonate Oral
7. cholecalciferol (vitamin D3) Oral
8. fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Savella 25 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Percocet Oral
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*30 Capsule(s)* Refills:*0*
17. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*30 Tablet(s)* Refills:*0*
18. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
19. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 disk* Refills:*2*
20. sitagliptin 25 mg Tablet Sig: One (1) Tablet PO once a day.
21. prochlorperazine maleate Oral
22. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
23. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
24. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
25. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation every 4-6 hours
as needed for shortness of breath or wheezing.
Disp:*30 capsules* Refills:*2*
26. Accu-Chek Compact Plus Care Kit Sig: use asdir
Miscellaneous asdir.
Disp:*1 kit* Refills:*0*
27. Accu-Chek Compact Test Strip Sig: One (1) strip
Miscellaneous QACHS for 21 weeks.
Disp:*QS * Refills:*0*
28. lancets Misc Sig: One (1) lancet Miscellaneous QACHS for
21 weeks.
Disp:*QS * Refills:*0*
29. Miralax 17 gram/dose Powder Sig: One (1) dose PO once a day.
Disp:*30 packets* Refills:*0*
30. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: [**11-20**]
units Subcutaneous at bedtime for 8 days: 30 units qhs x 3 days,
20 units qhs x 3 days, 10 units qhs x 3 days.
Disp:*QS * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass
Discharge Diagnosis:
Respiratory failure due to pneumonia and COPD exacerbation
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] from another hospital with a headache
and shortness of breath that required intubation and a stay in
the ICU. After you were kept safe and stable, we were able to
remove the breathing tube and we were able to transfer you to a
floor to continue treating you for a COPD exacerbation and
pneumonia with antibiotics, steroids, and breathing treatments.
You had very serious constipation that was treated with enemas
and medicines. Your kidneys also are recovering from a
temporary injury from low blood pressure.
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
- START using ADVAIR 250/50 1 puff twice daily
- START using SPIRIVA 1 capsule inhaled daily
- START using ALBUTEROL INHALER/NEBULIZER 1 PUFF/TREATMENT every
4-6 hours as needed for shortness of breath or wheezing
- START taking PREDNISONE 30 MG (3 tabs) for two more days, 20
mg (2 tabs) for 3 more days, and 10 mg (1 tab) for 3 more days
- START taking LINEZOLID/ZYVOX 600 MG by mouth twice daily for 3
days
- START taking LEVOFLOXACIN 750 MG daily for 3 days
- START taking DOCUSATE 100 MG by mouth twice daily
- START taking SENNA 1 tab by mouth twice daily
- START taking MIRALAX 1 PACKET daily
- START taking LACTULOSE 30 ml daily x 2 days, and then as
needed for constipation (1 day without bowel movement)
- START using GLARGINE INSULIN every night 30 units for 3 days,
20 units for 3 days, 10 units for 3 days
- STOP using COMBIVENT INHALERS
- STOP using LISINOPRIL for now (RESTART THIS MEDICATION ON
[**2203-2-26**])
Please be sure to follow up with your physicians as indicated
below and continue the rest of your medications.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**]
Phone: [**Telephone/Fax (1) 6699**]
Appointment: Thursday [**2203-2-17**] 11:00am
You can talk to Dr. [**Last Name (STitle) 6700**] regarding starting Lisinopril
earlier.
Completed by:[**2203-2-10**]
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6,210
| 148,106
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17303
|
Discharge summary
|
report
|
Admission Date: [**2155-5-12**] Discharge Date: [**2155-5-15**]
Date of Birth: [**2109-12-30**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: Patient is a 45-year-old man who
presents with a chief complaint of nausea, vomiting,
abdominal pain. He has a history of hypertension,
hypercholesterolemia, and drinks about four drinks of alcohol
per night of Vodka. Presents with abdominal pain for 3-4
days. He reports a four week history of fevers and chills,
but unmeasured temperatures, nausea, vomiting, nonbloody
bilious emesis 3-4 days ago. He noted onset of epigastric
pain that radiated to the periumbilical region and right
flank. This pain is constant, worse lying supine, best in
the fetal position. It is sharp/crampy pain. He has had
decreased po intake secondary to nausea, vomiting, and
anorexia. Presently hungry at the time of admission.
He presented to the Emergency Department secondary to pain.
The patient also reports increased abdominal girth. Pain
worse with movement. No known history of liver disease. No
prior EGD. No bright red blood per rectum or melena. No
icterus, no chest pain, no shortness of breath, no headache,
dysuria, rashes, diarrhea. Denies history of alcohol
withdrawal symptoms, seizures, DTs, no suicidal ideation,
homicidal ideation, no recent travel. No transfusions, no
homosexual behavior, no new social contacts, IV drug use, or
sick contacts. [**Name (NI) **] occasional confusion. He just returned
from a vacation to Turks and Caicos four months ago. Denies
any IV drug use or transfusions.
In the Emergency Department, he was given Phenergan 12.5 mg
IV x1, nicotine patch, Ativan 1 mg IV x1. Patient is noted
to have diffuse rash which was not noticed previously. It is
nonpruritic.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia. He was told he had very high
cholesterol, but never received treatment. His primary care
was supposed to followup with it, but he had never heard
back.
2. Hypertension.
3. Sinusitis.
4. Varicose vein stripping.
5. Status post appendectomy.
6. Seasonal allergies.
7. Questionable history of upper gastrointestinal bleed in
[**2154-12-18**] at [**Hospital6 4620**].
8. Subglossal duct drainage in the past.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Protonix 40 mg q day.
2. Inderal 20 mg [**Hospital1 **].
3. Tenormin 25 mg q day.
SOCIAL HISTORY: He started a new business. Last drink was
on Saturday, [**2155-5-10**]. He drinks 3-4 glasses of Vodka a day.
He smokes 1.5 packs per day. No drug use. He is separated
and has a girlfriend.
FAMILY HISTORY: [**Doctor Last Name 4702**] child, so unclear family history.
PHYSICAL EXAMINATION: On examination, his temperature was
100.7, blood pressure 170/72, pulse of 87, respiratory rate
16, sating 96% on 1.5 liters nasal cannula, 93% on room air.
In general, he is pleasant, thin man with mild tremulousness,
comfortable. HEENT: Pupils are equal, round, and reactive
to light. Extraocular movements are intact. No icterus.
Mild conjunctival erythema. Oropharynx is clear. Moist
mucous membranes. Lungs were clear to auscultation
bilaterally. Cardiovascular: Regular, rate, and rhythm,
normal S1, S2, no murmurs, rubs, or gallops. Abdomen:
Nondistended, positive bowel sounds, positive periumbilical
tenderness. Positive smooth liver edge 4 cm below the costal
margin, guaiac negative. Extremities: No clubbing,
cyanosis, or edema, warmth. Neurologic examination: He is
alert and oriented times three. Moves all extremities, no
asterixis. Derm: He has some spider angiomata facial/head
diffuse erythema, upper torso front, back blanching macules,
papular rash.
LABORATORIES ON ADMISSION: It was noted that he had a
lipemic specimen. His white count was 11, hematocrit of 45,
platelets of 127. His differential was 70% neutrophils, 7%
bands, 18% lymphocytes. His Chem-7: His sodium was 134,
potassium 4.9, chloride 100, bicarb 28, BUN 14, creatinine
0.8, glucose 103, calcium 8.7, and phosphorus of 2.8. His
INR was 1.0. His ALT was 54, AST of 69, alkaline phosphatase
is 185, and amylase 19, total bilirubin 1.7, lipase of 191.
Urinalysis: Specific gravity 1.014, 4+ urobilinogen, no
bilirubin, 15 ketones.
Chest x-ray: No opacities or effusions.
KUB: Mild dilated loops of the small bowel, maximum diameter
of 3 cm, no air fluid levels. The appearance was not
pathonomic for a small bowel obstruction. [**Month (only) 116**] represent
early bowel obstruction.
CT scan of the abdomen had uncinate process pancreatitis with
duodenal wall thickening and fluid tracking along the right
pericolic gutter to the pelvis, no abscess or evidence of
necrosis. Had a fatty liver, nonobstructing stones within
the upper pole of the left kidney and focal area of
hyperperfusion at the upper pole of the left kidney which
could relate to focal scarring.
Patient was admitted to Medicine.
HOSPITAL COURSE BY SYSTEMS:
1. Gastrointestinal: He had a pancreatitis that was only in
the uncinate process. It is of unclear etiology. He does
have an alcohol history, but also had significant
triglyceridemia on admission. His triglycerides were 6,237,
total cholesterol of 957, and HDL of 242, no LDL was
performed on that sample. Upon repeat, his total cholesterol
was 391, LDL of 299, triglycerides of 274, HDL of 37.
He was initially managed for his pancreatitis supportively
and po IV fluids, and gradually a diet was introduced with
good tolerance. He was eating full diet by the time of
discharge. He was started on [**Month (only) **] 40 mg po q day, and is
to followup for his hyperlipidemia with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] if he is
to have problems tolerating the elevated [**Name (NI) **] as an
outpatient and his triglycerides continue to be elevated.
Would recommend changing to pravastatin and a fibrate.
2. Alcohol abuse: Patient was monitored on a CIWA scale
initially, however, on [**2155-5-13**], patient started having
visual hallucinations, became extremely agitated, code purple
was called. He pulled out his IVs and was put in four-point
restraints. He had received 100 mg of Valium, 8 mg of Ativan
within the span of an hour and a half and still needing
restraints. He was transferred to the MICU for further
management.
He was monitored over the next 24-48 hours in the MICU, and
was called back out to the floor. At that time, he had only
received 40 mg of Valium per day prior. He was decreased to
10 mg on the night of admission, and had passed his acute
phase of his withdrawal symptoms at the time of discharge.
The patient has a history of benzodiazepine withdrawal. His
last benzodiazepine which was Ativan was [**Month (only) 547**] in [**2154**]. He
was given one more dose of Valium 5 mg to take on the evening
of discharge and 2 mg on the morning of discharge, and to
stop.
In terms of his alcohol abuse, he wanted to complete
outpatient detox, and had a meeting with [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**].
Outpatient detox is setup for him as well as psychotherapy
for his depression/anxiety. No SSRI was started at this
time, since he will be managed as an outpatient.
3. Cardiovascular: His dyslipidemia, unclear whether his
hypertriglyceridemia caused his pancreatitis or the reverse.
His triglycerides had come down, but this was in the setting
of being NPO. He was started on [**Last Name (NamePattern1) **] 40 mg q day as
above.
In terms of his blood pressure, he was on two medications,
Tenormin and Inderal. He was switched on to only atenolol
and was increased to 50 mg q day. We suspect that he was
placed on Inderal as well because at times he used to get
palpitations in the past with anxiety. We discussed with the
patient and decided to try and initiate just single
medication regimen as atenolol and to add Inderal back if he
continues to have symptoms of anxiety, and can be
re-evaluated as an outpatient.
4. Smoking cessation: He used the nicotine patch in
hospital. He would like to continue on a nicotine patch
perhaps just at nighttime. He was given 14 mg patch for 14
days, and also to followup with the primary care physician.
5. Low platelets, which has been stable likely secondary to
his alcohol use.
DISCHARGE DIAGNOSES:
1. Pancreatitis.
2. Alcohol withdrawal and delirium tremens.
3. Thrombocytopenia.
4. Hypertension.
5. Dyslipidemia with hypertriglyceridemia and
hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg q day.
2. Atenolol 50 mg q day.
3. [**Last Name (NamePattern1) **] 40 mg q day.
4. Thiamine 100 mg po q day.
5. Folate 1 mg q day.
6. Multivitamin one tablet q day.
7. Valium 5 mg on the evening of discharge and 2 mg on the
next morning postdischarge, and to then to stop.
8. Nicotine 14 mg transdermal q day.
FOLLOW-UP APPOINTMENTS: He is to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
on [**2155-5-22**] at 2:30 pm in the [**Doctor Last Name 780**] Building since he has
requested a new primary care physician. [**Name10 (NameIs) **] is also to call
for a follow-up appointment in the [**Hospital **] Clinic in [**1-20**] weeks.
He has also had teachings by Nutrition for a low cholesterol
and low sodium diet.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 1020**]
MEDQUIST36
D: [**2155-5-16**] 10:54
T: [**2155-5-19**] 07:23
JOB#: [**Job Number 48434**]
|
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[
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[
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[
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|
2387, 2582
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
157
| 107,880
|
27281
|
Discharge summary
|
report
|
Admission Date: [**2106-6-17**] Discharge Date: [**2106-6-24**]
Date of Birth: [**2025-12-3**] Sex: M
Service: MEDICINE
Allergies:
Succinylcholine / Aspirin
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Sepsis, respiratory failure
Major Surgical or Invasive Procedure:
Intubation, extubation, central line/PICC placement
History of Present Illness:
80y M, NH resident s/p recent subdural hematoma evacuation who
was in his USOH until 3.30am today when (per NH records) he
suddenly became hypotensive and hypoxic. A STAT ABG at the time
was 7.48/25/66/18.7, his SBP was in 70s and was treated with IV
NS, x2 bld cx were drawn and the pt was started on empiric Vanc
for presumed UTI. His labs were significant for: WBC 25.7 and Na
133. The pt was transferred to [**Hospital1 18**] to r/o sepsis and PE.
.
Per ED notes, this morning pt was also noted to have increasing
confusion, decreased urine output, fever and elevated white cell
count. He was tachycardiac, and had fever to 103, lactate 5 and
SBP to 80s. He was treated w/ IVF w/ inc in BP to 111/49, 1 dose
Vanc/levo/flagyl.
.
Recent admission ([**Date range (1) 61538**]) to ED for mental status changes and
hypotension in setting of UTI (pan-sensitive P.aeruginosa)
treated w/ 7d course PO Cipro.
.
On arrival to the [**Hospital Unit Name 153**], the pt was deep suctioned by the
Respiratory therapist and his secretions were significant for
food particles and bloody secretions.
Past Medical History:
DM- not on meds on diet control
Paget's disease
subdural hematoma s/p L craniotomy w/ hematoma evacuation ([**5-18**]
and [**5-21**]. Has some residual right sided weakness, aphasic,
cognitive impairment)
recent admission for UTI
h/o MSSA
acute infarct noted on MRI [**5-15**] (left posterior frontal region
indicative of an acute infarct).
Social History:
Lives alone in an apartment in [**Hospital1 392**], MA. Divorced, has nephew
and brother in local area, children in other states.
Former smoker
NO alcohol
Family History:
Non contributory
Physical Exam:
VS: T: 98.4, HR: 115, BP: 109/82, RR:30, O2 sats: 88% on 15L
high-flow
GEN: Elderly male, awake, sitting up in bed, in obvious
respiratory distress, audible wheezing.
HEENT: OP clear but very dry, no LAD, PERRLA
CV: (difficult to auscultate [**2-11**] diffuse, loud ronchi) RRR,
S1+S2, no obvious m/r/g
PULM: Diffuse rhonchi and wheezing throughout both lung fields.
ABD: soft, NT, ND, +BS, no HSM
EXTREM: no c/c/e. Warm periphery.
Neuro: Pt thinks he is in [**Hospital1 392**]. Once oriented to place, he can
recall it after 10 minutes, recalls DOB. Not oriented to time or
date. Tone LUE>RUE. Downgoing left plantar, equivocal right
plantar. Decreased bulk throughout.
Pertinent Results:
lactate 5->3
Phenytoin: 9.0
CHEM7: (83% N with 1 Band), Occ bacteria, occ yeast
CBC: WBC 52, HCT 31.7->29.8
UA: WBC [**10-29**]
.
Radiology:
CXR: RLL opacity-> PNA vs aspiration, extensive Paget's disease
of the right humerus, scapula and clavicle
.
ETT placement: 6cm above carina. It's below the clavicles.
.
[**2106-6-17**] 5:30 pm URINE Site: CATHETER
**FINAL REPORT [**2106-6-20**]**
URINE CULTURE (Final [**2106-6-20**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
.
[**2106-6-17**] 11:05 pm BRONCHOALVEOLAR LAVAGE
SPECIMEN COLLECTED VIA LAVAGE WITH STERILE WATER.
**FINAL REPORT [**2106-6-20**]**
GRAM STAIN (Final [**2106-6-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final [**2106-6-20**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2406**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
[**2106-6-18**] 12:00 pm BRONCHIAL WASHINGS
GRAM STAIN (Final [**2106-6-19**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2106-6-20**]): NO GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Brief Hospital Course:
80 year old male with DM, recurrent UTI, Paget's, s/p recent
subdural hematoma evacuation admitted to [**Hospital Unit Name 153**] w/ respiratory
failure found to have MRSA pna VRE urosepsis, now improved,
called out of [**Hospital Unit Name 153**] to medicine.
.
# Respiratory distress: Patient was in acute respiratory
distress on admission to the [**Hospital Unit Name 153**]. He was noted to have thick
bloody secretions on deep suctioning with visible food
particles. He was intubated and a bronchoscopy was performed on
[**6-18**] which showed inflamed friable mucosa with moderately thick
mucous in the LLL bronchus. No foreign body was visualized and
a BAL was sent for culture.
His acute respiratory distress was attributed to aspiration PNA
and urosepsis, however, his CXR on [**6-19**] was concerning for
possible ARDS. He was started on protective ARDS vent settings.
He was extubated successfully on [**6-20**]. His sputum culture
eventually grew MRSA and patient was continued on Linezolid for
coverage of MRSA PNA and VRE UTI. Pt also developed pulmonary
edema from fluids that were received, and received lasix for
diuresis with good effects. Pt's O2 was weaned as tolerated. At
the time of dicharge, pt was satting at 95% on RA.
.
# VRE urosepsis/aspiration, MRSA pneumonia: Patient was admitted
to the [**Hospital Unit Name 153**] for sepsis given hypotension, hypoxia, tachycardia,
fever and leukocytosis. The pt was noted to have a UTI. A
culture sent from the ED grew out enterococcus and patient was
noted to have bibasilar consolidations R > L accompanied by
small-to-moderate pleural effusions concerning for PNA. Patient
was started on Vancomycin, Levofloxacin, and Zosyn.
Blood cultures were sent from the ED remained NGTD. However,
urine cx returned positive for VRE, and patient was started on
Linezolid IV for coverage of his MRSA PNA and VRE UTI. The BAL
also came back + for MRSA which is covered by linezolid.
Attempted to d/c foley and pt unable to void after trial and
foley was replaced. Will need another voiding trial after
treatment of UTI.
.
# Hypotension: Patient arrived from the ED on Levophed. He was
aggressively fluid resuscitated and he was weaned off the
levophed on [**6-19**]. It was noted that the patient was developing
a non-gap hyperchloremic acidosis from the normal saline which
had been used for volume resusciation so his IVF was changed to
lactated ringers with good resolution. On [**6-18**] he failed his
[**Last Name (un) 104**] stim test and was started on stress-dose steroids. His
blood pressure stablized and his steroids were continued. IV
steroid was switched to po and po steroids tapered to off on
[**6-24**].
.
# Mental status changes: Patient is s/p subdural hematoma
evacuation. It is unclear what his baseline mental status is
although per report, he is able to follow commands, and there
was a notable decline which in part tiggered this admission.
Likely etiology of new decline in mental status is infection.
Given his past history of CVA, heparin SC was withheld. Patient
was continued on his seizure prophylaxis with Phenytoin
(currently 9.0; goal [**10-29**]) for his history of subdural
hematoma. He should be continued on this for an additional 2
weeks.
.
# DM: Patient was maintained on an ISS.
.
FEN: Patient was NPO while intubated. Nutrition was consulted
and tube feeding was initiated on [**6-18**]. Pt self discontinued his
NGT and a swallow study was performed. The video swallow showed
no aspiration but pt should have pills crushed for pocketing. In
addition, he does not have teeth and therefore should cont on
pureed solids. Pt was taking poor PO and had another family
discussion about PEG tube placement. Family does not want a PEG
tube but this should be readdressed with family if pt continues
to take poor PO. Daughter will address with her family. Pt was
started on Megace on [**6-24**].
*
PPx: Hepain SC, PPI, bowel regimen
*
Access: PICC
*
Code status: Full code (discussed with son, [**Name (NI) **], who lives in
[**Name (NI) 33977**])
*
Communication: son (W:[**Telephone/Fax (1) 66904**], C:[**Telephone/Fax (1) 66905**])
Medications on Admission:
Phenytoin for sz ppx
SC Heparin 5000U TID
Pantoprazole 40mg QD
Thiamine 100mg QD
MVI
Folic acid 1mg QD
Phenytoin 500mg QD (200mg [**Hospital1 **] and 100mg at noon)
Senna 1 Tab [**Hospital1 **] PRN
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Lopressor 25 mg [**Hospital1 **]
ISS
recently completed course Ciprofloxacin 500 mg Tablet Q12H on
[**2106-6-6**]
Discharge Medications:
1. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
2. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO
QAM AND QPM () for 2 weeks.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): until ambulatory then stop.
4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY
(Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg PO
AT NOON ().
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day) as needed for constipation.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): Please see sliding
scale. .
14. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 days.
15. Megestrol 40 mg/mL Suspension Sig: One (1) PO DAILY
(Daily).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) Flush Intravenous DAILY (Daily) as needed: 10 ml NS
followed by 2 ml of 100 Units/ml heparin (200 units heparin)
each lumen Daily and PRN. Inspect site every shift.
Order was filled by pharmacy with a dosage form of Syringe and a
strength of 100 U/ML.
17. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 3 days.
18. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release
(E.C.) PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnoses:
Aspiration/MRSA pneumonia
Sepsis
VRE urosepsis
.
Secondary diagnoses:
Hypertension
Discharge Condition:
Stable, afebrile
Discharge Instructions:
Call your doctor or come to emergency department if you develop
fevers, chills, nausea, vomiting, worsening cough, shortness of
breath, or any other worrisome symptoms.
Please call your PCP to make an appointment in [**1-11**] weeks after
you leave the rehab facility.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks.
Follow up with Dr. [**Last Name (STitle) 739**] with head CT on [**2106-7-1**].
PROVIDER: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-7-1**] 2:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"038.9",
"V09.0",
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"995.92",
"785.52",
"438.89",
"438.11",
"518.81",
"428.0",
"250.00",
"V58.43",
"507.0",
"276.2",
"482.41",
"255.4",
"438.0",
"276.8",
"285.9",
"787.2",
"599.0",
"401.9",
"780.79",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.14",
"33.24",
"96.6",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11873, 11952
|
5422, 9573
|
313, 367
|
12098, 12117
|
2763, 5399
|
12435, 12823
|
2039, 2057
|
10011, 11850
|
11973, 12041
|
9599, 9988
|
12141, 12412
|
2072, 2744
|
12062, 12077
|
246, 275
|
395, 1485
|
1507, 1849
|
1865, 2023
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,481
| 152,194
|
44196
|
Discharge summary
|
report
|
Admission Date: [**2100-11-1**] Discharge Date: [**2100-11-2**]
Date of Birth: [**2057-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / E-Mycin / Latex / Ondansetron /
Vancomycin / Levofloxacin / Zofran / Phenergan / Dilaudid /
Ceftriaxone / Sulfamethoxazole/Trimethoprim / Voriconazole /
Fluconazole / Caspofungin / Doxycycline / Propranolol /
Neurontin / Azithromycin / Xopenex Hfa / Optiray 300
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
admit for caspofungin desensitization
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42yo female with extremely extensive allergy history and history
of resistant [**Female First Name (un) **] yeast vaginitis treated with caspofungin a
few years ago, to which she developed chest tightness during
that course, who is now coming in for caspofungin
desensitization in order to treat a recurrent resistant yest
infection. Seen in [**Company 191**] [**10-1**] where vaginal swab sent off which
grew [**Female First Name (un) **]. This was found to be sensitive to caspofungin per
outside reference lab. Given her history of allergic reaction to
caspofungin, she is being admitted to the ICU for
desensitization and monitoring.
.
Of note, she develops phlebitic reactions to catheters kept in
beyonf the actual infusion (IVs, PICCs, etc). As a result, once
desensitized, she will need daily outpatient IV's placed at the
daycare infusion center in order to continue her caspofungin
course.
.
Review of systems is positive for a small laceration on the
bottom of her right foot. She cut her foot on a clean metal
edgue after tripping while putting together a new bed; no rust
or debris on the metal. No fevers, but small amount of erythema
and discharge at the cut. Review of systems is otherwise
negative.
Past Medical History:
presumed autonomic neuropathy for which she receives IVIG
bizarre phlebitic reactions to catheters kept in too long
atonic colon s/p resection
bronchospasm
Social History:
No tob, alcohol and illict drugs. Former NP in GI unit.
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
GENERAL: Pleasant, well appearing woman in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: small one cm superficial laceration on the bottom wof
right foot with erythema, but no warmth, edema or purulent
discharge
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-18**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
None
Brief Hospital Course:
The patient is a 42 year old female with caspofungin allergy and
resistant [**Female First Name (un) **] yeast vaginitis who presents for caspofungin
desensitization. Each of the problems addressed during this
hospitalization are described in detail below:
Caspofungin desensitization: was provided per desensitization
protocol. Premedication was provided with benadryl and
famotodine, epi was placed at bedside. The patient received 62g
"loading dose" today. Per protocol, she was observed for 2
hours after completion of loading dose for signs of anaphylaxis
or allergic reaction. No such reaction was observed. The
patient was discharged with the plan to receive 50mg daily via
daycares starting tomorrow [**2100-11-2**].
Foot laceration: The patient has a foot laceration. Per
discussion with PCP and ID, the patient did not require a
tetanus shot today. It was kept clean and dry.
Medications on Admission:
# Diphenhydramine 12.5 mg/5ml:Viscous Lidocaine 2%:Maalox swish
and spit 5 ml up to five times daily as needed for prn mouth
ulcers
# Epinephrine [EpiPen] 0.3 mg/0.3 mL (1:1,000) Pen Injector prn
# Estradiol [Estring] 7.5 mcg/24 hour Ring apply vaginally q3
months # Methylphenidate [Concerta] 18 mg Tab,Sust Rel Osmotic
Push 24hr
2 Tab(s) by mouth once a day
# Sucralfate 1 gram Tablet 1 Tablet(s) by mouth used topically
four times a day compound and diluted to 4% into an ointment
please make dye and fragrance free
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
2. Concerta 18 mg Tab,Sust Rel Osmotic Push 24hr Sig: Two (2)
Tab,Sust Rel Osmotic Push 24hr PO twice a day.
3. Estring 2 mg Ring Sig: One (1) Vaginal q3months.
4. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Intramuscular
PRN as needed for allergy symptoms.
5. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: Five (5) ml Mucous membrane five times a day as
needed for mouth ulcers.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: status post Caspofungin desensitization
Secondary: Foot laceration
Discharge Condition:
Vitals stable, asymptomatic
Discharge Instructions:
You were admitted to the hospital to undergo desensitization for
a drug called Caspofungin, which will be used to treat your
vaginal yeast infection. While the drug was being administered
using the desensitization protocol, you were observed closely by
ICU nurses and special precautions were taken in order to assure
safe desensitization. You tolerated the infusion of medicine
well and did not have any complications.
No changes were made to your medication regimen. You may return
to normal acitivity upon discharge from the hospital.
You have follow-up appointments for administration of the drug
Caspofungin. Please go to Pheresis center as instructed
starting tomorrow [**2100-11-2**].
You also will follow-up with your [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN and your
Primary Care Doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (see below).
Followup Instructions:
You need to go to Pheresis Center as instructed for
administration of Caspofungin.
You have the following follow-up appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2100-11-2**] 11:30 AM
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. Date/Time:[**2100-11-8**] 12:20 PM
Completed by:[**2100-11-7**]
|
[
"E849.0",
"892.0",
"337.9",
"V07.1",
"E885.9",
"112.1",
"564.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5063, 5069
|
3051, 3949
|
588, 594
|
5190, 5219
|
3022, 3028
|
6182, 6289
|
2109, 2127
|
4520, 5040
|
5090, 5169
|
3975, 4497
|
5243, 6159
|
2142, 2156
|
6314, 6652
|
511, 550
|
622, 1840
|
2171, 3003
|
1862, 2020
|
2036, 2093
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,121
| 188,856
|
24624
|
Discharge summary
|
report
|
Admission Date: [**2164-7-14**] Discharge Date: [**2164-8-7**]
Date of Birth: [**2125-4-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
CC:[**CC Contact Info 62177**]
Major Surgical or Invasive Procedure:
[**7-14**] Emergent craniectomy
External ventricular drain placement
[**7-18**] Tracheostomy
[**7-19**] PEG placement
History of Present Illness:
HPI: 39 y/o female transferred from OSH s/p being struck by
car.Report states that pt was walking off curb and hit by a car
that was not decelerating. Car drove away and patient was found
unresponsive by EMS and brought to [**Hospital 8641**] hospital. She was GCS
of 6 at scene with multiple attempts of intubation in route to
[**Location (un) 8641**]. When in ED at [**Location (un) 8641**], intubation was successful. CT of
head showed large R SDH, IPH, and frontal skull fracture. CT of
c-spine and torso were also done with no abnormal findings. She
was transferred to [**Hospital1 18**] by ambulance for further neurosurgical
workup.
Past Medical History:
unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
PHYSICAL EXAM:
BP: 166/102 HR: 96 R:22 O2Sats:100% on CMV/AC
Gen: GCS 5, intubated and unresponsive. Pt sedated with succ on
route to ED
HEENT: Pupils:5mm unresponsive bilaterally EOMs: unable to
examine, No hemptypanum bilaterally
Neuro:
Mental status: GCS 5, intubated and unresponsive. Pt sedated
with
succ on route to ED
Orientation: unable to access
Cranial Nerves:
I: Not tested
II: Pupils equally round and non-reactive to light, 5mm
bilaterally.
III, IV, VI: unable to access Extraocular movements
Motor: LUE- extensor posturing to noxious stimuli, LLE-
externsor
posturing to noxious stimuli. No movement on R
Positive Cough
Negative corneal reflexes bilaterally
Exam on discharge:
Awake, unable to access orientation
Pupils: 5-4mm Bilaterally
EOMs: not tracking or following commands
Face: symmetrical at rest
Motor: spontaneous and purposeful movements in the UE
bilaterally
withdraws briskly to noxious stimuli in LE bilaterally
2 beat clonus
Pertinent Results:
Labs on admission"
[**2164-7-14**] 02:50AM WBC-16.8* RBC-4.09* HGB-12.2 HCT-35.6* MCV-87
MCH-29.9 MCHC-34.3 RDW-12.7
[**2164-7-14**] 02:50AM PT-12.7 PTT-27.3 INR(PT)-1.1
[**2164-7-14**] 02:50AM PLT COUNT-320
[**2164-7-14**] 02:50AM FIBRINOGE-205
[**2164-7-14**] 02:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2164-7-14**] 02:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2164-7-14**] 02:50AM UREA N-9 CREAT-0.7
[**2164-7-14**] 02:57AM GLUCOSE-187* LACTATE-2.5* NA+-134* K+-3.6
CL--100
Labs on Discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2164-8-6**] 9.8 3.78 11.0 32.7 87 29.1 33.6 15.0 688
-------------------
IMAGING:
-------------------
CT HEAD W/O CONTRAST [**2164-7-14**] 1:12 PM
IMPRESSION:
1. Stable appearance of right frontal intraparenchymal
hemorrhage, scattered subarachnoid hemorrhage, interventricular
hemorrhage, and associated edema. Stable leftward shift of
midline structures.
2. Extensive pneumocephalus, roughly stable. Air also seen
within the
subcutaneous tissues overlying the site of craniectomy now with
interval
development of air tracking more inferiorly underneath the right
eyelid.
3. Slight improvement in mass effect upon the lateral right
ventricle and
suprasellar cistern.
4. Stable diastasis of the sagittal suture.
MR CERVICAL SPINE W/O CONTRAST [**2164-7-14**] 9:49 PM
FINDINGS: There is no disc or vertebral abnormality. The spinal
cord contour and signal pattern is within normal limits. No
pathology is seen in the area of the foramen magnum, except for
the question of possible small area of hemorrhage along the left
posterolateral aspect, suspected on prior head CT scan.
CONCLUSION: Negative cervical spine scan except for questionable
finding at the level of the foramen magnum.
CT HEAD W/O CONTRAST [**2164-7-15**] 4:57 AM
Essentially unchanged picture of right frontal intraparenchymal
hemorrhage with the minimal leftward-shift of midline structure.
Suggestion of interval slight decrease of pneumocephalus.
CT HEAD W/O CONTRAST [**2164-7-17**] 7:55 AM
Lateral ventricles less prominent than on study from two days
prior may
represent increasing ICP or cerebral edema. Unchanged near
complete
obliteration of a quadrigeminal cistern. Unchanged positioning
of
ventriculostomy catheter and unchanged appearance to right
frontal
intraparenchymal hemorrhage. No new areas of hemorrhage.
Intraventricular
hemorrhage seen on prior study is less apparent on this current
study
CT Head w/o contrast [**2164-7-20**]
Parafalcine, small left subdural, and residual right subdural
hematomas
display no significant interval change with stable appearance to
hemorrhagic and non-hemorrhagic bifrontal contusions with stable
post-surgical changes from prior right frontal and temporal
lobectomies. The ventricles appear increased in size compared to
the prior exam which likely reflects decreased cerebral edema,
as there is also improvement of [**Doctor Last Name 352**]-white differentiation.
Slight difference in the appearance of the tip location likely
also reflects ventricular reexpansion rather than repositioning.
There is improved visualization of the basilar cisterns. A small
amount of hemorrhage is again noted within the left occipital
[**Doctor Last Name 534**]. Increasing low-density left-sided subdural effusion is
noted which is likley more apparent related to decreased edema
within the brain parenchyma. Paranasal sinuses and mastoid air
cells are unchanged. Diastasis of the coronal suture is stable.
Approximately 4 mm of
rightward subfalcine herniation is noted.
IMPRESSION:
1. Improvement to ventricular size and basilar cisterns which
most likely
reflects decreased intraparenchymal cerebral edema. Slightly
increased size
to left subdural effusion may just be more apparent related to
improvement in parenchymal edema.
2. No significant interval change to previously described
subdural,
intraventricular, and intraparenchymal hemorrhages.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2164-7-23**]
3:31 PM
CONCLUSION:
1. There is no CT evidence of an acute pulmonary embolus.
2. Bibasal collapse.
3. There is a small amount of free air seen in the perihepatic
region
anteriorly within the abdomen. I note that the patient has had a
recent
insertion of a PEG tube; however, at this stage, there should be
no free air. Recommend clinical correlation. Has the patient
had further abdominal surgery? Is the patient's abdomen tense?
CT of the abdomen could be performed if clinically indicated to
further evaluate.
MRI Head [**7-25**]:
FINDINGS: Evidence of right frontal/parietal/temporal
craniectomy is again
seen. There are small epidural and subdural collections in the
craniectomy
bed, as seen on [**7-23**]. Small amounts of subdural blood products
are again seen posteriorly along both cerebral hemispheres, falx
and tentorium. There is dural enhancement at the level of the
craniectomy and at the level of the blood products, which is
expected in the immediate postoperative and trauma setting.
There is a small fluid-intensity left subdural collection along
the anterior left convexity as seen on [**7-23**], without associated
dural enhancement, which most likely represents a hygroma. There
is high signal on FLAIR images in the right parasagittal
occipital sulci (series 7, images [**11-25**]), likely related to
subarachnoid blood. Contrast enhancement associated with one of
these foci (series 10, image 11) is likely reactive. A small
focus of extra-axial, probably subarachnoid blood products is
also seen along the floor of the left anterior cranial fossa
(series 3, image 16, and series 9, image 64). Extensive blood
products are again seen along the right anterior/inferior
frontal and right temporal resection sites. There is no evidence
of
parenchymal contrast enhancement outside of the blood products
to suggest
cerebritis or cerebral abscess. There is a new 1 cm focus of
high signal on FLAIR images in the right thalamus compared to
[**2164-7-14**]. This lesion demonstrates high signal on the ADC
map today, much more conspicuous than on [**7-14**]. This may
represent evolution of a subacute infarction. Small lacunar
infarctions in the left pons and midbrain are unchanged. The
ventricles are stable in size. There is mild rightward shift of
the anterior falx and septum pellucidum, which is either stable
or minimally decreased compared to [**7-23**], allowing for
differences in modalities and the patient positioning. There is
increased opacification of mastoid air cells compared to the
previous study.
IMPRESSION:
1. Unchanged small epidural and subdural collections at the
right craniectomy site. Unchanged small amount of subdural blood
bilaterally. Unchanged small amount of subdural fluid along the
left convexity, most likely a hygroma related to recent surgery.
Dural enhancement at the craniectomy site and in the region of
the blood products is expected given the recent surgery and
trauma. However, superimposed infection of fluid collections
cannot be definitively excluded by imaging.
2. Small amount of right occipital parasagittal subarachnoid
blood, with a
small focus of associated contrast enhancement which is likely
reactive. If there is a clinical suspicion for a leptomeningeal
infection, correlation with a lumbar puncture is suggested.
3. No evidence of cerebritis or cerebral abscess.
4. Evolving signal abnormality in the right thalamus, likely a
small subacute infarction. Unchanged chronic lacunar infarctions
in the left thalamus and left midbrain.
5. Increased opacification of mastoid air cells compared to [**7-14**], [**2164**].
Chest X-ray [**7-25**]:
Tracheostomy tube tip is 3.2 cm above the carina. Bilateral
basal
consolidations greater on the right base are unchanged. On the
left is likely atelectasis. There is no pneumothorax. If any
there is a small right pleural effusion.
KUB [**7-26**]:
FINDINGS: A PEG tube is noted in the left upper quadrant and
projects
appropriately over the stomach. No dilated small bowel loops are
noted.
A large amount of stool is noted throughout the colon and,
particularly, in ascending and proximal transverse colons. No
free air is noted. An air-
fluid level is noted in the stomach.
IMPRESSION:
1. Fecal loading noted throughout the colon.
2. No radiographic evidence of obstruction or free air.
KUB [**7-27**]:
FINDINGS: In comparison with the study of [**7-26**], there is a large
amount of
fecal material throughout the colon as on the prior study. No
evidence of
small-bowel obstruction or free intraperitoneal gas. PEG tube
remains in
place.
Brief Hospital Course:
Pt was admitted to neurosurgical service and taken emergently to
OR for R craniectomy. Post op she was monitored closely in ICU.
In the OR, patient underwent a R hemicrainectomy with a left
frontal lobectomy and partial temporal lobectomy and and
external ventricular drain was placed to reduce intracranial
pressure. Patient was tachycardiac and has a history of benzo
and opiate substance abuse, she was given labetalol to control
heart rate.
On [**7-16**], her exam was improved with brisk movements, spontaneous
movements in the RUE and localization to noxious stimuli, left
upper exteremity was extension to noxious stimuli. Lower
extremities withdrew bilaterally to noxious stimuli. EVD was
open and draining clear CSF. Patient was febrile at 101.7 and
was pancultured.
On [**7-19**] the patient was stable enough to undergo a Peg placement.
Her EVD was also raised to 15 cm of water in an attempt to it
wean off. Overnight and early the next morning the drain stopped
functioning properly. It was flushed and there was still no CSF
draining that morning. A head CT revealed that the EVD was no
longer positioned in the lateral ventricle. Therefore, the EVD
was removed on [**7-20**].
The patient was transferred to the neuro stepdown unit on [**7-22**],
where her exam was stable. She has been withdrawing all
extremities , moving her lower extremity minimally . She was
also started on methadone d/t her history of substance abuse. On
[**7-23**], pt withdrew to noxious stimuli in upper extremities
bilaterally and her right lower extremity, but not moving the
left lower extremity to noxious stimuli.
On [**7-24**], the patient developed respiratory issues where her O2
saturation was in the 80s and was not cleared with suction. She
was transferred to the SICU for further management of her
airway. Infectious disease was consulted concerning her WBC or
30 and her antibiotic regimen. CXR was performed and a
consolidation was identified and antibiotics were started.
Cultures ultimately grew out ACINETOBACTER and STENOTROPHOMONAS.
Antibiotics were further narrowed for specific organisms per ID
recommendations.
On [**7-26**], she re-transferred to the NSURG stepdown unit when she
improved. She was noted to have significant abdominal distention
as well. KUB was performed and negative for any intraabdominal
air, but noted to have a significant amount of fecal material
present. She was started on a much more aggressive bowel regimin
and had several bowel movements resulting in impovement in
abdominal distention.
On [**7-30**], she was determined to be stable enough to transfer from
stepdown to the neurosurgical floor status. She continued to
work with PT and OT. The patient continued to be on a trach
mask. She continued her antibiotics (Cipro and Bactrim) which
were both scheduled to be given for a total of 8 days.
On [**8-2**] the patient was seen by endocrinology for hyponatremia.
She was determined to have SIADH but her sodium was trending up
by that day. Her sodium tablets were stopped and her free water
flushes were to be titrated based on her daily levels.
Patient shows improvement with free water restriction and
occupational therapy consult was called because of contracted
arms bilaterally. Her exam was much improved with spontaneous
movements in the upper extremities and withdrawing to noxious
stimuli and able to wiggle toes to stimuli. She will be
discharged to rehab to day.
Medications on Admission:
Medications prior to admission: unknown
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
3. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever/pain.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
11. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
for BM.
13. Levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID
(2 times a day).
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) for 2 days.
15. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension Sig:
Fifty (50) ML PO Q8H (every 8 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Traumatic brain injury
Hyponatremia
Pneumonia
Respiratory Failure resulting in need for tracheostomy
Discharge Condition:
Neurologically Stable
Discharge Instructions:
PLEASE USE ALLEVYN FOAM FOR 3 DAYS THEN DISCONTINUE FOR WOUND
CARE.
??????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.
??????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.
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:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast.
* you will need repeat TSH level repeated in [**4-16**] weeks.
Completed by:[**2164-8-7**]
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icd9cm
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24,577
| 178,132
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44010
|
Discharge summary
|
report
|
Admission Date: [**2166-3-26**] Discharge Date: [**2166-4-1**]
Service: Medicine, [**Hospital1 139**] Firm
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male with a past medical history of hypertension, atrial
fibrillation (status post pacemaker placement for symptomatic
bradycardia), obstructive sleep apnea, cor pulmonale, chronic
renal failure, and peripheral vascular disease who was
transferred from the Medical Intensive Care Unit to the floor
status post management of a hypercarbic respectively
decompensation.
The patient originally presented with knee pain on [**2166-3-26**]. He called Emergency Medical Service who found the
patient to be dyspneic and hypoxic with an oxygen saturation
of 70% on room air.
Of note, the patient had been complaining of increased lower
extremity edema and dysphagia for which he was seen in the
[**Hospital6 733**] Clinic on [**3-21**].
For his edema, the patient was told to double his Lasix dose.
His dysphagia was for solid foods, and the patient described
it as if "something was caught in my throat." The patient
was referred for Ear/Nose/Throat and had a swallowing study
done on [**3-25**] (one day prior to admission) with a barium
esophagogram showing a nonspecific motor disorder of the
esophagus with one episode of aspiration.
In the Emergency Department, the patient's oxygen saturation
was 70% on room air and improved to 90% to 95% on a
nonrebreather. His blood pressure was 96/50. An arterial
blood gas revealed a pH of 7.41, a PCO2 of 46, and a PO2 of
98. The patient did give a history of gradually increasing
dyspnea without chest pain. His mental status deteriorated,
and he was only nodding to questions. He received 40 mg of
intravenous Lasix, 120 mg of intravenously
methylprednisolone, albuterol and ipratropium nebulizers, and
aspirin 325 mg.
An electrocardiogram was done revealing ST elevations in
leads III and aVF and ST depressions in leads I and aVL. He
was taken to the Cardiac Catheterization Laboratory and
catheterization showed clean coronary arteries.
In the Catheterization Laboratory, the patient developed
further deterioration of his mental status as well as
hypoxemia and respectively acidosis with an arterial blood
gas of 7.25/61/67. He was placed on [**Hospital1 **]-level positive airway
pressure and transferred to the Medical Intensive Care Unit
for further management.
In the Medical Intensive Care Unit, the team felt that his
presentation was likely secondary to an aspiration event in
the setting of his lying flat in the Catheterization
Laboratory. He was placed on levofloxacin and metronidazole
as well as [**Hospital1 **]-level positive airway pressure. He was given
stress-dose steroids with intravenous hydrocortisone 50 mg
q.8h. As of [**3-27**], the patient was off of [**Hospital1 **]-level positive
airway pressure since 4 a.m. and stable with an arterial
blood gas of 7.38/46/82.
PAST MEDICAL HISTORY:
1. Status post pituitary adenoma resection;
panhypopituitarism.
2. Paroxysmal atrial fibrillation.
3. Cor pulmonale.
4. Obstructive sleep apnea.
5. Asthma.
6. Chronic renal failure (with a baseline creatinine of 1.2
to 1.5).
7. Hypertension.
8. Status post pacemaker placement for symptomatic
bradycardia.
9. Benign prostatic hypertrophy.
10. Peripheral vascular disease.
11. Gastroesophageal reflux disease.
12. Venous insufficiency.
MEDICATIONS ON TRANSFER:
1. Hydrocortisone 60 mg p.o. once per day.
2. Levofloxacin 250 mg p.o. every day.
3. Terazosin 5 mg p.o. q.h.s.
4. Levothyroxine 50 mcg p.o. once per day.
5. Albuterol as needed.
6. Amiodarone 200 mg p.o. once per day.
7. Protonix 40 mg p.o. once per day.
8. Regular insulin sliding-scale.
9. Flagyl 500 mg intravenously three times per day.
10. Heparin 5000 units subcutaneously q.12h.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone independently and is
capable of taking care of his activities of daily living. He
denies alcohol and tobacco use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
at the time of transfer revealed temperature was 96.1, blood
pressure was 114/49, heart rate was 60, respiratory rate was
25, and oxygen saturation was 95% on 5 liters nasal cannula.
In general, the patient was sitting upright in bed, in no
acute distress. Head, eyes, ears, nose, and throat
examination revealed surgical pupils, 2 mm bilaterally.
Sclerae were anicteric. The oral mucosa was moist. The neck
was without lymphadenopathy and with normal jugular venous
pulsation. Heart examination revealed a regular rate and
rhythm. Normal first heart sounds and second heart sounds.
Distant heart sounds. The lungs with occasional coarse
expiratory wheezes. Fair air movement. No rales. The
abdomen was obese, soft, nontender, and nondistended. Bowel
sounds were present in all four quadrants. Extremity
examination revealed 1+ pitting lower extremity edema to the
knees bilaterally with venous stasis skin changes.
Neurologic examination revealed alert and oriented times
three. Cranial nerves were grossly intact. Extremities with
full range of motion.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
transfer revealed white blood cell count was 13.9, hematocrit
was 36.7, and platelet count was 204. Sodium was 145,
potassium was 3.4, chloride was 107, bicarbonate was 25,
blood urea nitrogen was 17, creatinine was 2.1, and blood
glucose was 170. Calcium was 8.1, magnesium was 2, and
phosphate was 3.7. Total bilirubin was 1.4 and direct
bilirubin was 0.4. Creatine kinase was 104. Troponin I was
0.5. INR was 1.1 and partial thromboplastin time was 26.
Urinalysis revealed yellow/clear and small blood. Negative
nitrites, ketones, bilirubin, leukocyte esterase, 30 mg/dL of
protein, 3 to 5 red blood cells, 0 to 2 white blood cells,
and a few bacteria. Toxicology screen was negative for
aspirin, ethanol, acetaminophen, benzodiazepines,
barbiturates, and tricyclics.
PERTINENT RADIOLOGY/IMAGING: A chest radiograph on [**3-26**]
revealed an increased density at the left base, right
hemidiaphragm less distinct, perihilar edema consistent with
heart failure.
A chest radiograph on [**3-27**] showed decreased heart failure,
no infiltrates, and decreased bibasilar atelectasis.
An echocardiogram on [**3-26**] was a suboptimal study with
normal left ventricular wall thickness and cavity size. No
distinct wall motion abnormalities in the left ventricle.
The right ventricle was within normal limits. Trace aortic
regurgitation.
Catheterization on [**3-26**] revealed no significant
obstructive disease. No wall motion abnormalities. Ejection
fraction was 60%. Increased left ventricular end-diastolic
pressure at 17 mmHg. Moderate pulmonary hypertension of 38
mmHg.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. PULMONARY ISSUES: Initially, after transfer from the
Medical Intensive Care Unit the patient continued to have a
4-liter to 5-liter of oxygen requirement to maintain his
oxygen saturation. His episode of hypoxemia was felt to be
most likely secondary to an aspiration event followed by
flash pulmonary edema in the setting of diastolic cardiac
dysfunction.
With further diuresis, the patient's oxygen saturations were
improved and by [**4-1**] he was saturating greater than 92% on
room air. His furosemide was held starting on the evening of
[**3-29**] because he started to appear hypovolemic on examination
with dry mucous membranes and poor skin turgor.
He received a video oropharyngeal swallowing study which
demonstrated an intact swallowing mechanism with no evidence
of aspiration. A recommendation was made to avoid the use of
straws, however.
The patient continued to receive albuterol nebulizer
treatments while on the floor, and these were effective in
treating his episodic wheezing.
To rule out further heart failure, a chest radiograph was
obtained on [**3-31**] which demonstrated some bibasilar
atelectasis, but no evidence of heart failure. The patient
was completing a 10-day course of levofloxacin and
metronidazole for aspiration pneumonia.
2. LEG PAIN ISSUES: The patient notably had persistent pain
in both his lower extremities below the knees throughout his
admission. The legs were symmetrically slightly edematous
and tenderness to palpation anteriorly and posteriorly.
Lower extremity venous ultrasounds with Doppler studies were
obtained and revealed no deep venous thrombosis in either
lower extremity.
Given the patient's recent history of twisting his left
ankle, a plain film was obtained which revealed no evidence
of fracture or dislocation.
The patient described his pain as "tingling" as well as
"burning." This was felt to be perhaps secondary to a
neuropathy; although the patient did not have known
conditions that would predispose to a neuropathy such as
diabetes. Prior to discharge, the patient was empirically
started on low-dose gabapentin for treatment of presumed
neuropathy.
3. RENAL ISSUES: As aforementioned, at the time of transfer
from the Medical Intensive Care Unit, the patient had a
creatinine of 2.1. His fractional excretion of sodium was
0.19%. His acute-on-chronic renal failure was felt to be
secondary to prerenal azotemia in the setting of the
furosemide he was given as well as the dye load he received
in the Catheterization Laboratory. Another condition of the
differential diagnosis was acute tubular necrosis secondary
to the dye load he received.
The patient maintained good urine output throughout his time
on the floor, and his creatinine improved to a level of 1.4
at the time of discharge.
4. ENDOCRINE ISSUES: The patient was continued on
hydrocortisone 60 mg once per day as well as levothyroxine
for his panhypopituitarism. He had persistent mild
elevations in his fasting blood sugars which ranged between
150 and 200. He received a regular insulin sliding-scale for
this.
DISCHARGE DIAGNOSES:
1. Status post aspiration event and heart failure
exacerbation in the setting of diastolic cardiac dysfunction.
2. Chronic renal failure; status post acute-on-chronic
renal failure.
3. Bilateral peripheral sensory neuropathy.
4. Hypoproliferative normocytic anemia of undetermined
etiology.
6. Panhypopituitarism.
7. Diffuse deconditioning.
8. Paroxysmal atrial fibrillation.
9. Hypertension.
10. Chronic obstructive pulmonary disease.
11. Cor pulmonale.
12. History of pacemaker placement for symptomatic
bradycardia.
13. Obstructive sleep apnea (requiring [**Hospital1 **]-level positive
airway pressure).
14. Peripheral vascular disease.
CONDITION AT DISCHARGE: Condition on discharge was fair.
DISCHARGE STATUS: Discharge status was to [**Hospital3 94515**].
PRIMARY CARE PHYSICIAN: [**Name10 (NameIs) **] patient's primary care physician
is [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (telephone number [**Telephone/Fax (1) 250**]).
MEDICATIONS ON DISCHARGE:
1. Furosemide 40 mg p.o. q.a.m.
2. Gabapentin 100 mg p.o. q.h.s.
3. Albuterol nebulizer inhaled q.4-6h. as needed.
4. Atrovent nebulizer inhaled q.4-6h. as needed.
5. Vitamin D 400 units p.o. once per day.
6. Calcium carbonate 500 mg p.o. three times per day.
7. Flagyl 500 mg p.o. three times per day (through [**2166-4-4**]).
8. Levofloxacin 250 mg p.o. once per day (through [**2166-4-4**]).
9. Hydrocortisone 60 mg p.o. once per day.
10. Terazosin 5 mg p.o. q.h.s.
11. Levothyroxine 50 mcg p.o. once per day.
12. Amiodarone 200 mg p.o. once per day.
13. Protonix 40 mg p.o. once per day.
14. Regular insulin sliding-scale.
15. Heparin 5000 units subcutaneously q.12h.
[**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**MD Number(1) 200**]
Dictated By:[**Last Name (NamePattern1) 5596**]
MEDQUIST36
D: [**2166-4-1**] 15:13
T: [**2166-4-1**] 15:37
JOB#: [**Job Number 94516**]
|
[
"507.0",
"458.9",
"253.2",
"427.31",
"276.2",
"428.33",
"584.9",
"428.0",
"355.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9975, 10647
|
11055, 12030
|
6868, 9953
|
10662, 11028
|
148, 2947
|
3452, 3896
|
2970, 3426
|
3913, 6834
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,711
| 164,779
|
13653
|
Discharge summary
|
report
|
Admission Date: [**2114-3-2**] Discharge Date: [**2114-3-7**]
Date of Birth: [**2058-10-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Giant paraesophageal hernia.
Major Surgical or Invasive Procedure:
[**2114-3-2**] Esophagogastroduodenscopy, Lapaaroscopic Repair of
Hiatal Hernia, Laparotomy, [**Last Name (un) **] Gastroplasty, Toupet
Fundoplication
History of Present Illness:
Mr. [**Known lastname 41185**] is a 55-year-old gentleman who is self-referred for
management of his reflux and regurgitation. The patient states
that he has known that he has
had a hiatal hernia for at least 7 years. He had been diagnosed
with anemia approximately 2 years ago and for that had undergone
an upper endoscopy that by the patient's report showed a gastric
ulcer. This also showed a rather large hiatal hernia. Surgery
was not recommended at that time, and the patient had developed
worsening symptoms. This includes daily reflux regurgitation
for
solid food, dysphagia for solid food and liquids as well as a
hoarse voice. Of note, the patient was admitted twice last year
for pneumonia, although it is not clear to me if this
represented aspiration pneumonia or pneumonia related to the
patient's smoking history.
The patient states that his symptoms have been getting worse,
and over the past month or so, he has been troubled by daily
reflux regurgitation and more recently vomiting of nonbilious
food. He also complains of some difficulty breathing after
walking up 2 flights of stairs. The patient states that he
currently is on over-the-counter Prilosec. This has some mild
benefit, but
certainly, he notes his symptoms would be far worse if the
Prilosec were to be discontinued. The patient states that he is
troubled by significant dysphagia,
regurgitation and reflux and wishes to proceed with repair of
this giant paraesophageal hernia.
Past Medical History:
Anxiety/Depression
Diabetes Mellitus Type 2
Hypertension/Hyperlipidemia
Bronchitis
Kidney Stone/Calculi
Arthritis
P.S. Appendectomy, tonsillectomy, bilateral knee arthroscopy
[**2113**]
Social History:
He has a 15-pack-year smoking history. He had smoked for 16
years and quit, but recently resumed smoking about a year ago.
He is currently unemployed. He lives with his family. He is
not physically active, but is able to climb 2
flights of stairs without difficulty. He does not consume
alcohol.
Family History:
non-contributory
Physical Exam:
General: 55 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopathy
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp: scattered wheezes throughout
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Incision: lower abdominal mid-line with staples c/d/i no
erythema
Neuro: non-focal
Pertinent Results:
[**2114-3-1**] WBC-6.5 RBC-4.71 Hgb-13.2* Hct-38.7Plt Ct-387
[**2114-3-5**] WBC-11.0 RBC-3.17* Hgb-8.8* Hct-27.4 Plt Ct-275
[**2114-3-5**] Glucose-67* UreaN-28* Creat-0.9 Na-144 K-4.6 Cl-108
HCO3-28
[**2114-3-1**] Glucose-168* UreaN-20 Creat-0.9 Na-138 K-4.4 Cl-100
HCO3-28
Procedure date Tissue received Report Date Diagnosed
by
[**2114-3-2**] [**2114-3-2**] [**2114-3-6**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/cma??????
DIAGNOSIS: I. Hernia sac (A): Mature fibroadipose tissue,
consistent with hernial sac; numerous marginating neutrophils
are present, likely procedure-related.
II. Fundus, partial resection (B): Unremarkable segment of
gastric fundus.
BAS/UGI AIR/SBFT [**2114-3-3**]
UPPER GI GASTROGRAFIN STUDY: Approximately 100 cc of
Gastrografin were administered and sequential images were taken
of the upper GI tract. These demonstrate a free passage of
contrast material through the distal esophagus and stomach
without holdup at any location or evidence of leak.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2114-3-4**]
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Small right pneumothorax.
3. Moderate right pleural effusion, and near complete
atelectasis of the right lower lobe. Small left pleural
effusion.
4. Ground-glass attenuation airspace opacities at the lung
apices bilaterally, right greater than left, may represent
aspiration.
5. Post-surgical changes at the GE junction, consistent with
recent history of paraesophageal hernia repair.
CHEST (PA & LAT) [**2114-3-6**]
Transthoracic drain has been removed from the right chest and
mediastinum. A dilated stomach still projects above the plane of
the left hemidiaphragm in the midline, with precise relationship
to the left hemidiaphragm is indeterminate from this solitary
view. Small left pleural effusion is stable. Heart size is
exaggerated by the retrocardiac stomach, probably not enlarged.
A small region of radiopacity in the right mid lung may
represent a fissural fluid but should be followed to exclude
pneumonia. No pneumothorax.
Brief Hospital Course:
Pt admitted on [**3-1**] and taken to the OR for giant esophageal
hernia repair. An epidural was placed for pain control w/ good
effect. Surgery was uneventful. pt also had, NGT to sxn.
POD#1 NGT was d/c'd. Swallow study done with no leak and free
passage of barium. epdiural was split- bupivicaine and PCA
dilaudid was added to optimize pain contol. started on sips and
[**Last Name (un) 1815**] well.
POD#2 developed stridor, wheezing fractory to racemic epi and
nebs requiring hi flow O2. tansferred to ICU for ongong resp
monitoring. CTA [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] r/o PE which was neg.
CXR done revealing right effusion- pigtail was placed and
drained 850cc serosang fluid. Started on levaquin
prophylactically.
POD#3 Pt's symptoms improved over the next 24 hrs and was
transferred from the ICU to the floor.
POD#[**4-7**] pt ptogressed well w/o further resp issues. [**Last Name (un) 1815**] claer
liquid diet. ambulating well on roomair w/ sats >95%. Pigtail
drain was d/c'd and subsequently epidural was d/c'd and pt was
placed on po pain med w/ good effect.
pt was d/c'd to home on POD#6 and will follow up w/ Dr. [**First Name (STitle) **] in
2 weeks.
Medications on Admission:
CELEXA 10 mg--
CELEXA 20 mg--Tablet(s) by mouth 1xd
GLYBURIDE 5 mg--2 tablet(s) by mouth 2xd
LISINOPRIL 10 mg--1 tablet(s) by mouth 1xd
Loratadine --10mg 1xd
Metformin --1000mg po 2xd
PRILOSEC OTC 20 mg--20mg tablet(s) by mouth 1xd
SIMVASTATIN 40 mg--Tablet(s) by mouth 1qd
VICODIN 5 mg-500 mg--7.5/750 tablet(s) by mouth 2xd
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. 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:*11*
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
increase to 1000mg once blood sugars are consistently elevated >
130.
5. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Actos 15 mg Tablet Sig: One (1) Tablet PO QAM.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: take with narcotics.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H () as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO As needed as
needed for anxiety.
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation four times a day as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day:
then increase to regular dose of 10mg [**Hospital1 **] when appetite returns
to baseline.
Discharge Disposition:
Home
Discharge Diagnosis:
Hiatal Hernia s/p Laparoscopic Repair, [**Last Name (un) **] Gastroplasty,
Toupet Fundoplication
Anxiety/Depression
Diabetes Mellitus Type 2
Hypertension/Hyperlipidemia
Bronchitis
Kidney Stone/Calculi
Arthritis
P.S. Appendectomy, tonsillectomy, bilateral knee arthroscopy
[**2113**]
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Difficulty or painful swallowing
Avoid caffiene or carbonated beverages.
Remaining sitting for 30-45 minutes after meals
Chest-tube dressing remove and place bandaid until healed
You may shower
No bathing or swimming for 4 weeks
No driving while taking narcotics: continue stool softners with
narcotics.
Monitor fingerstick blood sugars: keep log and restarted your
full dose diabetic medications when blood sugars are
consistently elevated.
No Vicodan while taking oxycodone/acetaminophen
Abdominal staples to be removed when seen by Dr. [**First Name (STitle) **]
Continue inhalers as previous
DIET: Full liquid diet until seen by Dr. [**First Name (STitle) **]. [**Month (only) 116**] take small
pills.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] call for an appointment in
2 weeks.
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Telephone/Fax (1) 41186**]
Completed by:[**2114-3-7**]
|
[
"V64.41",
"750.4",
"401.9",
"E878.8",
"305.1",
"747.69",
"553.3",
"272.4",
"250.00",
"530.81",
"511.8",
"512.1",
"518.0",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.80",
"44.66",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
8028, 8034
|
5074, 6278
|
350, 503
|
8361, 8370
|
2978, 5051
|
9228, 9594
|
2548, 2566
|
6656, 8005
|
8055, 8340
|
6304, 6633
|
8394, 9205
|
2581, 2959
|
281, 312
|
531, 2004
|
2026, 2214
|
2230, 2532
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,912
| 170,266
|
32284
|
Discharge summary
|
report
|
Admission Date: [**2201-4-6**] Discharge Date: [**2201-4-17**]
Date of Birth: [**2146-5-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
vomiting, pain & swelling left side of abdomen
Major Surgical or Invasive Procedure:
[**2201-4-9**]: Arteriogram
History of Present Illness:
He presented to the ED on [**4-6**] in the afternoon with pain in
left flank, nausea and vomiting since 3am.
Past Medical History:
Onc History:
He presented to [**Hospital3 3583**] in mid [**Month (only) **] with
hematemesis. At that time, variceal bleeding was documented and
an ultrasound of the liver performed because of the development
of a variceal bleed
demonstrated two masses in the right lobe of the liver, the
larger measuring 9 x 7 and the smaller 2 x 2. The spleen was
also enlarged and there was evidence of splenorenal varices. A
CT scan was performed but was suboptimal, an MRI was also
performed with and without contrast at Shields MRI in [**Location (un) **].
This demonstrated a large complex mass in the right lobe of the
liver, an approximately segment V which measured approximately
12x10 cm. The findings were considered consistent with
hepatocellular cancer. There was also a modest amount of ascites
and small bilateral pleural effusions. At that time, an alpha
fetoprotein level was 8.4. Hepatitis C antibody was reactive and
hepatitis B surface antigen was negative. A liver biopsy was
apparently done at [**Hospital3 3583**] and the findings were
consistent with iron overload. He was subsequently referred to
the liver [**Hospital 1326**] Clinic. They saw him on [**2200-10-31**]. Review
of the scans demonstrated an approximately 12 cm mass that was
felt to be outside of the criteria for liver transplantation.
There was also some concern for multiple nodules within the
liver. At least two of which had some early enhancement
characteristics consistent with also possible hepatocellular
cancer all in the right lobe. He was felt not to be a candidate
for resection.
.
He was advised that chemoembolization was probably the best form
of treatment for his likely HCC. Of note, he was seen in a
second opinion consultation at [**Hospital6 1129**]
last week and they also concurred with the recommendation of
chemoembolization.
.
Other PMH:
chronic Hep C
hemachromatosis as per onc history
abdominal pain, on protonix
tachycardia
Social History:
He has a long history of alcohol. However, at a maximum, he
would drink about a six-pack of beer a day. He quit in [**10-2**]. He
normally has one to two beers a day. He is married. He has three
children, two females, ages thirty-five and thirty-one, and one
son, age nineteen. All three are alive and well. The
nineteen-year-old son has been tested for hemochromatosis and
was told seven years ago that there was no evidence of this
disease. He is a nonsmoker with a very remote history of
tobacco.
Family History:
substantial history of hemochromatosis. He has a 52-year-old
brother
diagnosed with hemochromatosis on the basis of a blood test. He
also has one sister who is also got hemochromatosis, the
sister's daughter and his brother's son also have the disease.
He has been tested genetically and told he was a carrier. A
liver biopsy performed in [**Month (only) **] at [**Hospital3 3583**] apparently
confirmed iron overload, two other sisters are without the
disease.
.
Both of his parents are deceased. His father died of unknown
causes, since he did not live with the family. Mother died of
emphysema. There is no other family history of cancers.
Physical Exam:
T HR 84 BP 96/66 RR 16 O2 100% 2L
A&O x3, in pain, pale
EOMI, somewhat jaundiced
Lungs clear
Cor RRR
Abd soft, NT/ND, Rectal negative
L flank with soft tissue swelling/++p
skin warm & dry
psych nl mood,
Pertinent Results:
[**2201-4-6**] 03:15PM FIBRINOGE-133*
[**2201-4-6**] 03:15PM PT-18.1* PTT-33.1 INR(PT)-1.7*
[**2201-4-6**] 03:15PM PLT COUNT-42*
[**2201-4-6**] 03:15PM WBC-5.2# RBC-2.26* HGB-8.0* HCT-22.7*
MCV-101* MCH-35.3* MCHC-35.1* RDW-18.6*
[**2201-4-6**] 03:15PM CALCIUM-9.6 PHOSPHATE-4.8* MAGNESIUM-1.9
[**2201-4-6**] 03:15PM LIPASE-41
[**2201-4-6**] 03:15PM ALT(SGPT)-44* AST(SGOT)-74* ALK PHOS-81 TOT
BILI-3.0*
[**2201-4-6**] 03:15PM GLUCOSE-116* UREA N-25* CREAT-1.0 SODIUM-133
POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-24 ANION GAP-17
[**2201-4-6**] 10:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2201-4-16**] 06:30AM BLOOD WBC-3.8* RBC-2.80* Hgb-9.3* Hct-26.7*
MCV-95 MCH-33.1* MCHC-34.8 RDW-20.9* Plt Ct-35*
[**2201-4-14**] 06:20AM BLOOD PT-12.8 PTT-27.9 INR(PT)-1.1
[**2201-4-16**] 06:30AM BLOOD Glucose-101 UreaN-9 Creat-0.5 Na-134
K-3.6 Cl-96 HCO3-30 AnGap-12
[**2201-4-16**] 06:30AM BLOOD ALT-25 AST-41* AlkPhos-61 TotBili-4.3*
[**2201-4-16**] 06:30AM BLOOD Albumin-2.7*
[**2201-4-15**] 06:05AM BLOOD Mg-1.6
Brief Hospital Course:
He presented to the ED on [**4-6**] in the afternoon with pain in
left flank, nausea and vomiting since 3am. He was given IV
fluid, morphine/fentanyl and Zofran. A CT demonstrated
1.large hematoma extending along the entire left posterolateral
chest and abdominal wall with unusual cystic structure at the
level of the seventh lateral rib with layering hematocrit level
and layering contrast within this cyst, suggesting this to be
the source for hemorrhage, although no imaging (of this region)
was performed during the arterial phase to establish
extravasation. While no mass or cystic structure was seen in the
soft tissues on prior chest CT, this raised the question of an
underlying lesion such as hemorrhagic metastasis to the soft
tissues in this patient with known HCC.
2. Multifocal hepatocellular carcinoma again noted and grossly
unchanged from the prior CT abdomen of [**2201-1-28**]. Again possible
tumor thrombus in the left portal vein was noted.
3. Slight increase in ascites. Splenomegaly and multiple varices
unchanged.
4. Enlargement of the right adrenal gland, more prominent than
on the CT abdomen of [**2201-1-28**].
5. Moderate right and small left pleural effusions with
associated atelectasis.
6. 3-mm nodules in the right and left lower lobes were
concerning for metastasis.
7. Multifocal ground-glass opacities in the right lung
concerning for non- specific pneumonitis, possibly due to
aspiration.
He received 4 units of prbc, 2 units of plts, cryo and FFP.He
was admitted to the SICU under the care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. He
continued to bleed despite receiving Factor VII. IR embolization
was performed of the throacoacromial artery. Hct continued to
drop and another arteriogram was performed which did not show
any significant bleeding source. Factor VII was again given with
stabilization of HCT.
Once hct stabilized, he was transferred out of the SICU to the
med-[**Doctor First Name **] floor. Diet was advanced. Acute pain service was
consulted recommending tizanidine. Pain was controlled with this
and oral pain medication (MS contin [**Hospital1 **] and prn percocet).
Hepatology followed closely. Per criteria prognosis was poor and
palliative care was consulted. The patient decided on DNR/DNI
status after discussion of poor prognosis. VNA/Hospice services
were coordinated to provide services and the family organized to
provide assist/supervision for the patient once home. Scripts
were provided for pain medications and anti-emetics.
He did experience urinary retention on the day his foley was
removed ([**4-15**])necessitating replacement of the foley. Of note,
he had significant lower body edema for which he was given
lasix. Lasix 40mg qd was ordered as a home dose. The foley was
to remain in place.
Medications on Admission:
aldactone 50'', inderal 10', ambien 12.5HS prn, protonix 40',
sucralfate 1'''
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*7 Tablet(s)* Refills:*0*
2. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
5. Propranolol 10 mg Tablet Sig: One (1) 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. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*30 ML(s)* Refills:*2*
10. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Cranbery Area Hospice
Discharge Diagnosis:
Multifocal HCC
Left chest hematoma
urinary retention
cirrhosis
risk for GI bleeding/thrombocytopenia
Discharge Condition:
poor
Discharge Instructions:
Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if worsening
edema/pain
Return to the ER if vomiting blood or other concerning symptoms
and you wish to be treated.
You will be going home with a Foley and leg bag. You will be
taught how to manage this and the home nurses will help you.
Followup Instructions:
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], Thursday [**4-23**]. Please call [**Telephone/Fax (1) 673**] for
appointment
Completed by:[**2201-4-17**]
|
[
"922.2",
"788.20",
"338.3",
"286.7",
"198.89",
"275.0",
"E928.9",
"155.0",
"922.1",
"197.0",
"571.2",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"99.07",
"99.05",
"99.06",
"88.44",
"99.04",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
8993, 9045
|
5018, 7831
|
360, 390
|
9189, 9196
|
3902, 4995
|
9553, 9734
|
3014, 3659
|
7959, 8970
|
9066, 9168
|
7857, 7936
|
9220, 9530
|
3674, 3883
|
274, 322
|
418, 529
|
551, 2480
|
2496, 2998
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,872
| 183,384
|
33289
|
Discharge summary
|
report
|
Admission Date: [**2191-5-18**] Discharge Date: [**2191-5-19**]
Date of Birth: [**2148-2-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 77283**] is a 43 year-old man with a history of alcohol abuse
who presented the ED with chest pain, now being admitted to the
ICU with alcohol withdrawal.
.
Most recently admitted [**Date range (1) 77285**] with alcohol withdrawal
initially requiring valium [**Name (NI) 60563**] (unclear total amount).
.
Starting three days prior to admission he began drinking a
bottle of vodka daily. On the day of admission he drank a
bottle of vodka between 10am and noon because he "wanted to harm
himself". Later he began having palpatations and some
difficulty breathing. He took a cab to [**Hospital1 18**].
.
In ED vitals showed T 98.2, BP 103/60, HR 83, RR 16, sat 98% on
room air. Was intoxicated in the ED (EtOH 280) with chest pain.
ECG was unremarkable. [**Hospital1 60563**] of 20; recieved a total of 40mg of
valium.
Past Medical History:
1. Alcohol abuse
- Multiple detox admissions including [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and [**Location (un) 12091**],
HRI Triangle program
2. Mood d/o nos
- Admitted ([**3-13**]) after Seroquel overdose while intoxicated
3. Hypertension
4. Hyperlipidemia
5. Diabetes
6. GERD
Social History:
Works as a corporate tax accountant and is concerned that he may
have lost his job after admitting EtOH to his boss. Broke up
with boyfriend [**Name (NI) **] several months ago after dating for about a
year, but continues to be friends and finds [**Name (NI) **] to be very
supportive. Lives in apt with 2 roommates. He has had a problem
with EtOH use for many years, including DUI. Also history of
blackouts though denies DTs/seizures. He reports cocaine use in
past; in [**2187**] he used regularly and was in research program that
helped him quit. States that other than recent one-time heroin
use, used heroin in distant past. Denies other substances.
Denies IVDA. Used many substances in the past including
cocaine, ecstasy, crystal meth.
Family History:
Father died of MI at age 55; also had history of paranoid
schizophrenia. Mother died of MI at age 67. Sister in has
history of psychotic breaks requiring 2 psych hospitalizations
but currently doing well.
Physical Exam:
VITALS: HR 96
GEN: Well appearing. In no distress. Mildy tremulous.
HEENT: Anicteric. Dry MM.
CV: Regular. Tachycardic. No murmurs.
PULM: Clear. No wheeze.
ABD: Soft. Mildly TTP in epigastrum.
EXT: Warm. No edema.
NEURO: Alert. Oriented to person, "[**Hospital1 18**]", "[**2191-5-18**]"
Pertinent Results:
[**2191-5-18**] 02:15PM BLOOD WBC-11.8*# RBC-4.93 Hgb-14.9 Hct-43.0
MCV-87 MCH-30.3 MCHC-34.8 RDW-14.2 Plt Ct-463*#
[**2191-5-19**] 04:15AM BLOOD WBC-8.9 RBC-4.37* Hgb-14.1 Hct-37.9*
MCV-87 MCH-32.2* MCHC-37.1* RDW-13.9 Plt Ct-352
[**2191-5-18**] 02:15PM BLOOD Neuts-55.0 Lymphs-37.6 Monos-5.4 Eos-0.4
Baso-1.5
[**2191-5-18**] 02:15PM BLOOD Plt Ct-463*#
[**2191-5-19**] 04:15AM BLOOD Plt Ct-352
[**2191-5-18**] 02:15PM BLOOD UreaN-15 Creat-0.9 Na-142 K-4.0 Cl-104
HCO3-22 AnGap-20
[**2191-5-19**] 04:15AM BLOOD Glucose-164* UreaN-14 Creat-0.8 Na-138
K-3.5 Cl-101 HCO3-24 AnGap-17
[**2191-5-18**] 02:15PM BLOOD ALT-45* AST-33 CK(CPK)-160 AlkPhos-80
TotBili-0.3
[**2191-5-19**] 04:15AM BLOOD ALT-41* AST-33 AlkPhos-76 TotBili-0.8
[**2191-5-18**] 02:15PM BLOOD Lipase-22
[**2191-5-18**] 02:15PM BLOOD CK-MB-2
[**2191-5-18**] 02:15PM BLOOD cTropnT-<0.01
[**2191-5-18**] 08:25PM BLOOD CK-MB-2
[**2191-5-18**] 08:25PM BLOOD cTropnT-<0.01
[**2191-5-18**] 08:25PM BLOOD Calcium-8.9 Phos-2.5* Mg-1.9
[**2191-5-19**] 04:15AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.8
[**2191-5-18**] 02:15PM BLOOD ASA-NEG Ethanol-260* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**5-18**] Port CXR
UPRIGHT AP VIEW OF THE CHEST: The lungs are clear without focal
opacity. No
appreciable pleural effusion or pneumothorax is present. The
cardiomediastinal silhouette, hilar contours and pulmonary
vasculature are
normal.
IMPRESSION: No acute cardiopulmonary abnormality.
[**2191-5-19**] 04:15AM BLOOD WBC-8.9 RBC-4.37* Hgb-14.1 Hct-37.9*
MCV-87 MCH-32.2* MCHC-37.1* RDW-13.9 Plt Ct-352
[**2191-5-19**] 04:15AM BLOOD Glucose-164* UreaN-14 Creat-0.8 Na-138
K-3.5 Cl-101 HCO3-24 AnGap-17
[**2191-5-19**] 04:15AM BLOOD ALT-41* AST-33 AlkPhos-76 TotBili-0.8
[**2191-5-19**] 04:15AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.8
Brief Hospital Course:
43M with history of alcohol abuse, presenting with chest pain
and mild ETOH withdrawal.
1. Alcohol dependence/intoxication/withdrawal. History of prior
admissions for withdrawal, most recently in [**3-14**]. [**Date Range 60563**] <10 at
the time of arrival to MICU and likely was more intoxication
than withdrawal as only required 20 of diazepam.
- Thiamine/folate/MVI given
2. Chest pain. Cardiac enzymes negative x2. CXR negative. ECG
unremarkable. Was in the setting of intoxication and appears
unlikely to be secondary to angina.
- f/u w/ PCP for possible outpatient stress
3. Depression/SI. Seen by psychiatry who did not feel he was at
risk and could be discharged. Recommended SW consult.
- Continued home citalopram
4. Hypertension. Continued home Toprol
5. Hyperlipidemia. Continued home tricor.
6. Diabetes. Weight related; diet controlled.
7. GERD. Continued home H2 blocker.
Medications on Admission:
1. Toprol XL 100 mg daily
2. Tricor 145 mg daily
3. Celexa 20 mg daily
4. Famotidine 20 mg daily
5. MVI
6. Thiamine
7. Folate
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol intoxication
2. Chest pain
Discharge Condition:
Good, no suicidal ideation, hemodynamically stable
Discharge Instructions:
You came into the hospital with palpitations while drinking
alcohol. You expressed thoughts of hurting yourself, therefore
you were evaluated by the psychiatry service. When you sobered
up, you denied any intention to harm yourself and the
psychiatrists thought you were safe to return home. You were
seen by social work, and provided with contact information for
outpatient detox options.
.
While in the hospital you had testing that showed no evidence of
a heart attack.
.
Please take your medications as directed. Please talk to your
primary care doctor about your drinking.
.
Call Dr. [**Last Name (STitle) 6420**] [**Telephone/Fax (1) 5723**] and seek medical attention if
you develop:
*** Recurrent chest discomfort, shortness of breath, thoughts of
hurting yourself or anyone else, or if you have any other
symptoms that worry you.
Followup Instructions:
Please follow up with your primary care [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name3 (LF) **]
R. [**Telephone/Fax (1) 5723**] in the next week.
|
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8,619
| 123,362
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50228
|
Discharge summary
|
report
|
Admission Date: [**2159-6-2**] Discharge Date: [**2159-6-10**]
Date of Birth: [**2073-6-26**] Sex: F
Service: MEDICINE
Allergies:
Zithromax
Attending:[**First Name3 (LF) 1650**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 85 year old Russian-speaking woman w/PMHx of
CAD s/p CABG, systolic and diastolic CHF, afib on coumadin, CRI
(basleine creatinine ~1.5), complete heart block s/p permanent
pacer, hip fracture [**11-15**] after a fall who presents with SOB.
History is taken with help of her son as an interpreter. Her son
noticed that occasionally at rehab she was on oxygen
intermittently but was not requiring oxygen at home. She has
been at [**Hospital 100**] Rehab since [**Month (only) **] and came home 1 day prior to
admission. Her lasix dose was being adjusted at rehab. She has
been progressively short of breath with worsening LE edema for
the past few weeks but markedly worse since in the past [**3-9**]
days. No chest pain or pressure. No lightheaded or dizzy
feelings. No fevers or chills. She has a non-productive cough. +
Orthopnea which is chronic. She uses a walker at home and has
had worsening DOE. Her son thinks she was adhering to a low salt
diet.
.
In the ED, initial VS 99.8 73 139/60 16 100% 15L NRB, weaned to
97% on 2L. BNP was 23,00. CXR showed CHF. She received 60mg IV
Lasix and a foley catheter was placed. ECG was paced. Vitals
prior to transfer: 98.7 72 138/57 18 98%/2 L nc.
Past Medical History:
1. CAD - s/p 2V CABG [**4-/2145**] to OM/CX and to RCA. Recath [**8-/2145**] -
occluded RCA [**Last Name (LF) **], [**First Name3 (LF) **] OM [**First Name3 (LF) **] disease, previously diseased
LCx and LAD free of disease (followed by Vainov/[**Doctor Last Name **])
2. Chronic Systolic Heart Failure EF 30-35%
3. Atrial fibrillation on warfarin and amiodarone
4. s/p DDD pacer for 2:1 AV block
5. Hypertension
6. Hyperlipidemia
7. Peptid Ulcer Disease
8. Glaucoma
9. Hypercalcemia [**2-7**] hyperparathyroidism - s/p parathyroid
resection in '[**28**]'s now with recurrence; noted to have new large
complex left-sided thyroid nodule (inconclusive biopsies) -
followed by Endocrine
10. s/p TAH/BSO
11. Osteoporosis
12. h/o neurogenic bladder, urethral stricture
13. Hyperplastic colonic polyps
14. h/o mod MR, mild PAH, LAE (TTE [**2144**])
15. Congestive heart failure, systolic, EF 40%
16. Hypothyroidism
Social History:
She lives alone in an apartment in [**Location (un) 86**] and cares for herself.
Son and daughter live nearby. Husband died last year. She denies
any tobacco or EtOH use. Retired ENT physician from [**Country 532**].
Family History:
Non-contributory
Physical Exam:
VS: T97.2 BP 108/80 HR 72 RR 20 96% on 3L.
GENERAL: Well-appearing woman in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, JVD ~13cm. Visibly pulsatile
carotid pulse in the neck. no carotid bruits.
HEART: RRR, harsh [**2-11**] ejection murmur at RUSB. + chest heave.
LUNGS: Resp unlabored. Diffuse wheezes and crackles through left
lung field. Right is more clear.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, 2+ peripheral edema to thighs bilaterally, L
perhaps slightly greater than R, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
.
Discharge Exam:
VS: 97.0 131/63 71 28 95%2L
GENERAL: NAD, thin, pale elderly woman
HEENT: PERRL, EOMI, MMM, OP clear.
NECK: Supple, no JVD
HEART: RRR, harsh [**2-11**] ejection murmur at RUSB
LUNG: Stable diffuse rhonci and crackles at 1/2way up, good
airmovement.
ABD: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, 1+ peripheral edema to thighs bilaterally.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD
Pertinent Results:
Blood Counts
[**2159-6-2**] 10:00PM BLOOD WBC-7.6 RBC-4.23# Hgb-12.7# Hct-38.1#
MCV-90 MCH-30.0 MCHC-33.4 RDW-16.7* Plt Ct-252
[**2159-6-4**] 12:00PM BLOOD WBC-14.4*# RBC-4.67 Hgb-13.6 Hct-42.9
MCV-92 MCH-29.2 MCHC-31.8 RDW-16.1* Plt Ct-233
[**2159-6-5**] 05:05AM BLOOD WBC-17.1* RBC-4.19* Hgb-12.4 Hct-37.4
MCV-89 MCH-29.6 MCHC-33.2 RDW-16.6* Plt Ct-191
[**2159-6-10**] 04:18AM BLOOD WBC-7.8 RBC-3.79* Hgb-11.0* Hct-33.2*
MCV-88 MCH-29.0 MCHC-33.1 RDW-15.6* Plt Ct-169
Coags
[**2159-6-2**] 10:00PM BLOOD PT-22.5* PTT-26.7 INR(PT)-2.1*
[**2159-6-10**] 04:18AM BLOOD PT-33.8* PTT-30.8 INR(PT)-3.4*
Chemistry
[**2159-6-2**] 10:00PM BLOOD Glucose-126* UreaN-35* Creat-1.8* Na-144
K-3.6 Cl-106 HCO3-27 AnGap-15
[**2159-6-4**] 07:20AM BLOOD Glucose-86 UreaN-30* Creat-1.5* Na-143
K-3.6 Cl-103 HCO3-33* AnGap-11
[**2159-6-7**] 07:08AM BLOOD Glucose-89 UreaN-50* Creat-1.7* Na-149*
K-3.4 Cl-110* HCO3-29 AnGap-13
[**2159-6-10**] 04:18AM BLOOD Glucose-82 UreaN-36* Creat-1.5* Na-145
K-3.9 Cl-106 HCO3-30 AnGap-13
Cardiac
[**2159-6-2**] 10:00PM BLOOD proBNP-[**Numeric Identifier 104764**]*
[**2159-6-2**] 10:00PM BLOOD cTropnT-0.01
[**2159-6-3**] 07:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2159-6-4**] 07:20AM BLOOD CK-MB-2 cTropnT-0.02*
Reports
[**2159-6-2**] CXR:
Cardiomegaly with mild congestive heart failure. Probable small
bilateral pleural effusions and left basilar atelectasis.
.
[**2159-6-4**] CXR:
Increasing confluent opacities within the left mid lung zone and
right lower lung zone may represent pulmonary edema given the
rapid onset with the differential being infection or aspiration.
.
[**2159-6-5**] TTE:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
mid- and distal anterior and septal akinesis, as well as
inferior hypokinesis and probable akinesis of the true LV apex
(segment incompletely visualized). The remaining segments
contract normally (LVEF = 35%). No masses or thrombi are seen in
the left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Moderate regional left ventricular systolic dysfunction, most
c/w multivessel CAD. Mild aortic regurgitation. Moderate to
severe mitral regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2158-1-4**],
there is more prominent anterior/septal regional LV dysfunction
and the overall LVEF is lower. The other findings are similar.
.
[**2159-6-6**] Video Swallow:
Several episodes of penetration and aspiration with
administration of thin
liquids. The study and the report were reviewed by the staff
radiologist.
Brief Hospital Course:
HOSPITAL COURSE
85 year old Russian-speaking woman p/w worsening systolic CHF,
course complicated by aspiration pneumonia, s/p abx and
diuresis, ready for discharge to rehab
.
ACTIVE ISSUES:
# Acute on Chronic Systolic Heart Failure: Patient was admitted
with SOB and hypoxia with signs of fluid overload on
exam/imaging and an markedly elevated BNP. Course was
complicated by a stay in the CCU for a lasix drip to treat
hypoxia in the setting of failure. Patient was subsequently
diuresed with improvement in resp status and transfer back to
the floor. Diuresis was also complicated by an episode of
hypotension thought to be secondary to over diuresis and
scheduling of medications; decreased dosing of spironolactone
and isosorbide mononitrate, and spread out administration of
medications to decrease risk of hypotension during the daytime.
The remaineder of her CHF regimen (carvediolol, digoxin and
losartan) was continued unchanged.
.
# Recurrent Aspiration PNA: During hospital course patient was
found to have RLL infiltrate. Vanco/cefepime was started for
treatment of presumed aspiration PNA. Video swallow showed
unpreventable silent aspiration with all fluid consistencies.
Per family meeting, patiend wished to continue eating and to be
rehospitalized if she aspirates in the future. At discharge
patient was planned for cotinuation of antibiotics until
[**2159-6-11**] .
.
# Medication changes due to age: Ativan, hydroxyzine, ambien,
meclizine were stopped given patients age and risk of causing
delirium.
.
INACTIVE ISSUES:
# CAD: continued aspirin, carvedilol
.
# Anemia: Continued iron sulfate.
.
# Afib on Coumadin: Pacer dependent, on coumadin and amiodarone
(INR goal [**2-8**]). CHADS2=2.
.
# Glaucoma: Continued Latanoprost.
.
#Hypothyroidism: Continued levothyroxine
.
TRANSITIONAL ISSUES:
1. Code status - Patient remained DNR/DNI
2. Pending Labs - No labs/studies were pending at time of
discharge
3. Transition of Care: Patient was discharged to [**Hospital 4542**] Rehab
Facility in [**Location (un) 38**].
4. Barriers to Care: The family was made aware of the
unpreventable silent aspiration and a family meeting was held.
The patient requested that she be allowed to eat and understood
the potential risk for ongoing aspiration and
re-hospitalization. She has asked to be rehospitalized and
treated with antibitiotics.
Medications on Admission:
Xalatan 0.005 % eye drops 1 drop qHS
Patanol 0.1% eye drops 1 drop each eye [**Hospital1 **]
Carvedilol 6.25mg PO daily
Protonix 40mg PO BID
Senna 8.6mg 2 tabs [**Hospital1 **]
Vitamin D2 50,000 units PO every other week
Aspirin 81mg PO daily
Ativan 0.5mg PO PRN anxiety
Calcitriol 0.25mg PO daily
Losartan 12.5mg PO daily
Digoxin 125mcg sig: .5 tabs PO QOD
Imdur 30mg PO daily
Amiodarone 200mg PO daily
Meclizine 12.5mg PO daily
Nitroglycerin 0.4mg SL PRN
Hydroxyzine 5mg PO qHS PRN itching
Spironolactone 25mg PO daily
Ambien 5mg PO qHS PRN insomnia
Levothyroxine 50mcg PO daily
Ferrous Sulfate 325mg PO daily
Warfarin 1mg daily (per son)
Lasix 60mg PO daily
Discharge Medications:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Patanol 0.1 % Drops Sig: One (1) drop Ophthalmic twice a day:
Each eye.
3. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
5. senna 8.6 mg Capsule Sig: Two (2) Capsule PO twice a day.
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO every other week.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. digoxin 125 mcg Tablet Sig: One Half Tablet PO EVERY OTHER
DAY (Every Other Day).
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tab
Sublingual once a day as needed for chest pain.
13. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
16. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
17. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush: PICC.
18. cefepime 2 gram Recon Soln Sig: Two (2) g Injection Q24H
(every 24 hours) for 1 doses: Last day [**6-11**].
19. Outpatient Lab Work
Vancomycin trough [**2159-6-8**] before PM dose. Fax results to Rehab
physician for titration of Vancomycin, goal trough = 15-20.
20. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Neb Inhalation every six (6) hours.
21. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO QPM (once a
day (in the evening)).
22. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
23. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q48H (every 48 hours) for 1 doses: last day [**6-11**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY:
-Acute on Chronic Diastolic Heart Failure
-Aspiration Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
- Patient w stable ronchorus breathing, satting mid90s on 2
liters
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You were hospitalized for treatment of
shortness of breath. Your symptoms were a result of your
worsening of your heart failure (your heart having trouble
pumping), in addition to an infection in your lungs. Fluid was
taken off from your lungs with medications, and you were given
antibioitics.
.
Your pneumonia was likely caused by difficulty swallowing, with
saliva, liquids, and food falling into your lungs. The swallow
team evaluated you and was unable to make diet recommendations
to that would prevent this aspiration process. By continuing to
eat, you will continue to have the risk of aspirating. They
recommended that you see a speach therapist to help teach you
proper eating techniques. You indicated that you would like to
continue eating.
.
During this hospitalization the following changes were made to
your medications:
-STARTED IV Vancomycin to treat for pneumonia
-STARTED IV Cefepime to treat for pneumonia
-STARTED nebulizer treatments
-DECREASED isosorbide mononitrate
-DECREASED spironolactone
-STOPPED Ativan, Ambien, Meclizine, Hydroxyzine as this can
cause disorientation in patient's your age
Followup Instructions:
Your care after discharge will be overseen by the extended care
facility physician. [**Name10 (NameIs) **] extended care physician should schedule
[**Name Initial (PRE) **] follow-up appointment with your primary care physician 2 weeks
after discharge from the extended care facility.
Department: Voice, Speech, and Swallowing
Phone: [**Telephone/Fax (1) 3731**]
Please call and book a follow up appointment within 2 weeks of
discharge. If you have any questions or concerns please call the
office.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 1653**]
|
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"518.81",
"365.9",
"263.9",
"414.00",
"V45.81",
"584.9",
"428.43",
"V49.86",
"276.0",
"403.90",
"585.9",
"244.9",
"507.0",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12189, 12288
|
7003, 7179
|
290, 296
|
12405, 12405
|
3894, 6980
|
13865, 14461
|
2733, 2752
|
10074, 12166
|
12309, 12384
|
9388, 10051
|
12655, 13842
|
2767, 3441
|
3457, 3875
|
8826, 9362
|
230, 252
|
7194, 8534
|
324, 1551
|
8551, 8805
|
12420, 12631
|
1573, 2482
|
2498, 2717
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,144
| 107,460
|
49696
|
Discharge summary
|
report
|
Admission Date: [**2202-10-11**] Discharge Date: [**2202-10-20**]
Date of Birth: [**2145-7-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Mitral and tricuspid regurgitation
Major Surgical or Invasive Procedure:
[**2202-10-11**] - Redo Sternotomy, Mitral valve replacement(27mm St.
[**Male First Name (un) 923**] Mechanical), tricuspid valve Repair(30mm CE Annuloplasty
Ring)
History of Present Illness:
Mrs. [**Known lastname 9996**] is a 57-year-old woman who is five years status
post bovine pericardial aortic valve replacement who presents
with increasing mitral
regurgitation, tricuspid regurgitation and hepatic enlargement.
It was elected to proceed with mitral valve replacement,
tricuspid repair.
Past Medical History:
mitral regurgitation
tricuspid regurgitation
s/p aortic valve replacement
systemic lupus erythematosis
systemic hypertension
pulmonary hypertension
raynaud's disease
s/p cholecystectomy
lupus nephritis
rheumatic heart disease
portal hypertension
anemia
Social History:
Patient is married with one son, denies tobacco, minimal EtOH
Family History:
Grandmother died from a CVA at age 50. Father died at age 70
from complications of diabetes.
Physical Exam:
awake and alert
Lungs- clear
cor-R at 70. crisp cardiac sounds, no murmur
exts- 2- edema legs, not tense
Abdomen- soft, nontender, normoactive bowel sounds
wounds- clean and dry. sternum is stable.
Pertinent Results:
[**2202-10-11**] ECHO
Pre Bypass
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter. There are simple atheroma in the descending
thoracic aorta. A bioprosthetic aortic valve prosthesis is
present. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. There is mild valvular
mitral stenosis (area 1.5-2.0cm2). Moderate to severe (3+)
mitral regurgitation is seen. Severe [4+] tricuspid
regurgitation is seen. There is no pericardial effusion.
Post Bypass
The patient is AV-paced and on an infusion of epinephrine .04
mcg/kg/min.. Left and right ventricular function is preserved.
The aorta is intact. There is [**2-7**]+ tricuspid regurgitation. The
mean gradient of the tricuspid valve was < 5mmHg. The mitral
valve mechanical prosthesis is in good position with a mean
gradient <6mmHg.. There is a mild mitral perivalvular leak.
Remaining exam is unchanged. These findings were communicated
intraoperatively to Dr. [**Last Name (STitle) **].
[**2202-10-19**] 05:30AM BLOOD WBC-14.1* RBC-2.77* Hgb-8.5* Hct-25.4*
MCV-92 MCH-30.8 MCHC-33.5 RDW-16.4* Plt Ct-283
[**2202-10-20**] 10:50AM BLOOD PT-24.7* INR(PT)-2.4*
[**2202-10-18**] 05:25AM BLOOD PT-40.7* PTT-36.2* INR(PT)-4.4*
[**2202-10-18**] 01:35AM BLOOD PT-38.1* PTT-35.9* INR(PT)-4.1*
[**2202-10-17**] 07:00PM BLOOD PT-60.6* PTT-35.9* INR(PT)-7.2*
[**2202-10-17**] 04:58PM BLOOD PT-57.5* PTT-33.6 INR(PT)-6.8*
[**2202-10-17**] 01:00PM BLOOD PT-49.3* PTT-35.9* INR(PT)-5.6*
[**2202-10-17**] 06:35AM BLOOD PT-45.7* PTT-81.8* INR(PT)-5.1*
[**2202-10-16**] 10:04AM BLOOD PT-20.1* PTT-55.1* INR(PT)-1.9*
[**2202-10-16**] 03:45AM BLOOD PT-17.1* PTT-56.5* INR(PT)-1.5*
[**2202-10-15**] 05:50AM BLOOD PT-16.9* PTT-50.2* INR(PT)-1.5*
[**2202-10-14**] 04:33AM BLOOD PT-17.7* PTT-38.3* INR(PT)-1.6*
[**2202-10-14**] 03:08AM BLOOD PT-18.7* PTT-104.1* INR(PT)-1.7*
Brief Hospital Course:
Mrs. [**Known lastname 9996**] was admitted to the [**Hospital1 18**] on [**2202-10-11**] for elective
surgical management of her mitral and triccuspid valve disease.
She was taken directly to the operating room where she underwent
a redo sternotomy with a mitral valve replacement using a 27mm
St. [**Male First Name (un) 923**] mechanical valve and a tricuspid valve
repair/annuloplasty. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. She weaned fro bypass on epinephrine and propafol.
She was AV paced due to underlying complete heart block.Within
24 hours she awoke neurologically intact and was extubated. The
pressor was weaned,however, she remained in heart block with a
ventricular rate in the 30s. On POD 3 she was in sinus rhythm
with first degree block in the 50s and stable. She was
transferred to the floor.
Diuresis was continued, to remove fluid overload that existed
preoperatively as well as secondary to the surgery. She
developed atrial flutter subsequently. The EPS service saw her
and cardioversion was planned. On POD6 her INR was greater than
6 and 2 units of FFP were administered, with a fall of the INR
to 4.
The following day her INR was 3.1 and she received 1mg of
Coumadin. cardioversion with 200jouoles successfully converted
her to SR which persisted at discharge. her INR was 2.4 the day
of discharge and 2 mg of Coumadin was ordered.
Her weight fell with diuresis and edema improved. She remained
stable and felt well. She was ready for discharge and diuretics
will be continued.
Arrangement were made for her follow-up for Coumadin dosing with
her primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **]. She will take 2mg
[**10-20**] and 16 then have a PT/INR checked on[**10-22**] and talk with
Dr. [**Last Name (STitle) **] for further orders. She is to return in 2 weeks for
staple removal.
Medications on Admission:
lasix 20', plaquenil 200", lisinopril 40', lopressor 100",
diovan 160', ASA 81', ferrex 150", MVI
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO bid ().
Disp:*60 Capsule(s)* Refills:*2*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*1*
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
11. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: [**Name8 (MD) **] MD for instructions as directed.
Disp:*100 Tablet(s)* Refills:*2*
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p mitral valve replacement and tricuspid annuloplasty
mitral regurgitation
tricuspid regurgitation
s/p aortic valve replacement
hypertention
Pulmonary hypertension
systemic Lupus erythematosis
H/O Rheumatic heart disease
Raynaud's disease
congestive heart failure
Rheumatoid arthritis
Esophagheal spasm
Lupus nephritis
Anemia
Mild hepatic portal fibrosis
s/p cholecystectomy
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Scheduled appointments:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2202-11-24**] 4:45
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2202-12-9**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2202-12-21**] 3:30
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-6**] weeks and for Coumadin dosing.
Completed by:[**2202-10-20**]
|
[
"427.32",
"E934.2",
"397.0",
"403.90",
"997.1",
"585.9",
"443.0",
"710.0",
"394.1",
"V42.2",
"790.92",
"398.91",
"426.0",
"416.8",
"285.1",
"E878.1",
"582.81",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"39.61",
"35.33",
"99.07",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
7483, 7541
|
3710, 5688
|
358, 524
|
7962, 7969
|
1556, 3687
|
8702, 9426
|
1229, 1323
|
5836, 7460
|
7562, 7941
|
5714, 5813
|
7993, 8679
|
1338, 1537
|
284, 320
|
552, 857
|
879, 1133
|
1149, 1213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,284
| 139,707
|
46371
|
Discharge summary
|
report
|
Admission Date: [**2150-7-30**] Discharge Date: [**2150-8-12**]
Date of Birth: [**2069-8-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
This is a 80yo M with h/o CAD s/p CABG, systolic CHF, aortic
stenosis, Afib, DVT, and pulmonary fibrosis who presents with
hemoptysis, shortness of breath, and hypoxia.
He went to pulmonary clinic today with hemoptysis. He has had
intermittent hemoptysis for about 2.5 weeks. It has been
gradually increasing in severity, initially mild but now
moderate. Today he coughed up 1 teaspoon every few hours.
Denies fever/chills, but endorses increasing O2 requirement.
Typically he only wears O2 at night but now has been wearing it
during the day due to desats to the 80's. Also reports
decreased peak flows on his spirometer. Denies changes in
weight recently. Denies peripheral edema or orthopnea. Denies
PND. Denies chest pain.
In the ED, initial VS were 99.5 90 95/61 18 97% 2L. On exam, pt
has no tachypnea but does have bibasal crackles. HR is
irregular, and no JVD or edema appreciated. Labs revealed INR
3.4 and BNP elevated at 3789. No elev WBC, no bands and Cr of
1.7 (Cr 1.6 in [**3-/2150**]) was noted. CXR showed evidence of RUL
pneumonia. EKG showed A. fib, 90, left axis deviation, no STEMI.
TnT was neg. Pt was given Aspirin 325 and Lasix 40 mg IV to
which he diruresed 1L. Pt then received 1L NS bolus for SBP 80s.
BP now 102. Bld cx and urine cx were sent. Antibiotics for
community acquired pneumonia were started (CTX/Azithro). Pt had
no hemoptysis while in ED. and resp status remained stable. PE
was considered but CTA was not done due to creatinine of 1.7,
discussed this with Dr. [**Last Name (STitle) **]. On transfer, VS were 99.2 92 18
97/60 94% 4l. Given 3L fluid total.
Past Medical History:
CAD, s/p MI, s/p CABG [**2125**], anatomy unknown
chronic systolic CHF, LVEF 40-45% [**2149-6-4**]
Aortic stenosis (valve 1.0-1.2cm2 on [**2149-6-4**])
Paroxysmal atrial fibrillation
Hypertension
Hyperlipidemia
Pulmonary fibrosis: ?secondary to amiodarone
Pulmonary hemorrhage [**2148**]
DVT [**2146**]
Testicular cancer
Colon cancer s/p left hemicolectomy
Corticosteroid-induced hyperglycemia
Shingles and post-herpetic neuralgia
T7 compression fracture
Social History:
He lives with his wife in [**Name (NI) 86**] for five months of the year and
is in [**State 2690**] for the remainder. He is a retired chemistry
teacher. He does not smoke, rarely drinks. He has three children
and grandchildren.
Family History:
Non-contributory. No family history of early MI or arrhythmias.
Father had heart disease.
Physical Exam:
Vitals: Afebrile 107 91/61 25 93%4L
General: Alert, oriented, chronically ill appearing male in no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP elevated to midneck, no LAD
CV: Irregularly irregular with III/VI systolic murmur at LUSB
without radiation to the carotids
Lungs: Velcro crackles bilaterally R>L
Abdomen: soft, protuberant, 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:
[**2150-7-30**] 05:10PM WBC-7.7 RBC-4.32* HGB-12.0* HCT-34.3* MCV-80*
MCH-27.8 MCHC-35.0# RDW-18.5*
[**2150-7-30**] 05:10PM NEUTS-70.6* LYMPHS-15.9* MONOS-10.8 EOS-2.3
BASOS-0.4
[**2150-7-30**] 05:10PM PLT SMR-LOW PLT COUNT-96*
[**2150-7-30**] 05:10PM PT-34.0* PTT-35.0 INR(PT)-3.4*
[**2150-7-30**] 05:10PM proBNP-3789*
[**2150-7-30**] 05:10PM cTropnT-<0.01
[**2150-7-30**] 05:10PM GLUCOSE-124* UREA N-46* CREAT-1.7* SODIUM-139
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-33* ANION GAP-12
Reports:
ECG [**2150-7-30**]: Atrial fibrillation with a controlled ventricular
response. Left axis deviation. Non-specific intraventricular
conduction delay. There are Q waves in the inferior leads
consistent with myocardial infarction. There is a late
transition in the anterior leads consistent with possible prior
anterior wall myocardial infarction. Non-specific ST-T wave
changes. Compared to the previous tracing of [**2149-6-19**] atrial
fibrillation has replaced sinus rhythm and the QRS duration is
longer.
CXR [**2150-7-30**]: 1. New patchy opacity within the periphery of the
right upper lung field concerning for an infectious process.
Followup radiographs after interval treatment are recommended to
ensure resolution of this finding. 2. Pulmonary fibrosis. 3.
Interval vertebroplasty of multiple compression deformities
within the thoracic and lumbar spine.
LENIs [**2150-7-31**]: No evidence of deep vein thrombosis in either
leg.
CT Chest [**2150-7-31**]: 1. New diffuse bilateral ground glass
opacities superimposed upon underlying pulmonary fibrosis. The
differential diagnosis is broad including hemorrhage, widespread
infection (including PCP or viral pneumonia), acute exacerbation
of underlying interstitial pneumonia, and asymmetric edema. 2.
Pulmonary fibrosis with a basal predominance which is
incompletely assessed on this CT. 3. Pulmonary artery
enlargement suggests underlying pulmonary hypertension but this
finding has lower specificity for hypertension in the setting of
diffuse interstitial lung disease. 4. Multiple thoracic
vertebral compression fractures some of which have progressed
from CXR of [**2149-6-19**]. 5. Extensive atherosclerotic
disease.
TTE [**2150-8-1**]: Mildly dilated left ventricle with severely reduced
left ventricular systolic function. Moderately dilated and
depressed right ventricle. At least moderate to severe mitral
regurgitation, directed posteriorly. Moderate to severe
tricuspid regurgitation. Severe pulmonary artery systolic
hypertension.
Brief Hospital Course:
80yo M with h/o CAD s/p CABG, systolic CHF, aortic stenosis,
Afib, DVT, and pulmonary fibrosis who presents with hemoptysis,
shortness of breath, and hypoxia.
#. Hemoptysis/Hypoxia: On admission there was a wide
differential diagnosis for his hemoptysis including pneumonia,
PE, CHF/MR, bronchiectasis, DAH, or trauma. He was initially
treated for CAP with ceftriaxone/doxycycline, although he did
not have elevated WBC or fevers. He underwent CT chest which
showed bilateral ground glass opacities that could represent
hemorrhage, infection, interstitial pneumonia, or edema. He
then underwent bronch which showed some bloody secretions
potentially consistent with DAH vs infection vs bland bleed in
the setting of ILD. He was started on prednisone for worsening
lung disease. He had a TTE on [**2150-8-1**] that showed worsening of
his LVEF to 20-25% and worsening MR, and he was transferred to
the CCU team for further management.
#. Acute on chronic renal failure: Creatinine 1.7 on admission
which improved with diuresis and medical management.
#. Hypotension: He had blood pressures in the 80s/50's while
mentating well with good urine output. These values were felt
to be close to his baseline blood pressures.
#. Paroxysmal Atrial fibrillation: In Afib with rates 100's on
admission. He was continued on his home dronedarone and
metoprolol.
#. acute on chronic systolic CHF: He was diuresed with IV lasix
for volume overload as above and his hypoxia mildly improved.
#. Thrombocytopenia: Platelets 96 from baseline of 140-150 on
admission. They remained stable during his stay.
#. CAD s/p CABG: No ECG changes to suggest ischemia on
admission. He was continued on his home beta blocker, statin,
and aspirin.
#. Hyperlipidemia: Continued on his home statin
#. H/o post-herpetic neuralgia: Home pregabalin
Medications on Admission:
Dronedarone 400mg po bid
Furosemide 40-80mg po daily
Lidocaine-Prilocaine 2.5%-2.5% cream daily daily as soon as
possible
Metoprolol Succinate 25mg po daily
Pantoprazole 40mg po daily
Miralax 17g po daily
Pregabalin 75mg po qam, 150mg po qpm
Simvastatin 20mg po daily
Spironolactone 25mg po daily
Warfarin
Aspirin 81mg po daily
Calcium carbonate-Vitamin D3 600-400unit po bidac
Glucosamine/Chondroitin-MV-Min3
MVI 1 tab po daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*60 Tablet(s)* Refills:*1*
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:*1*
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
4. pregabalin 75 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
5. pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. glucosamine-chondroitin Oral
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*90 Tablet(s)* Refills:*2*
14. warfarin 1 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*0*
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses: dose adjusted by outpatient heart failure
providers.
16. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*1*
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day: with meals.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
18. Outpatient Lab Work
please have INR's checked on [**8-13**] and [**8-17**] and call results to
PCP [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 2946**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (Phone: [**Telephone/Fax (1) 2205**]) and Dr. [**First Name11 (Name Pattern1) **]
[**Last Name (NamePattern4) 4511**], MD (Phone [**Telephone/Fax (1) 62**])
19. Home Oxygen
Please provide home Oxygen at 1-2L per minute continuously. For
goal oxygen saturation >90%
20. Outpatient Lab Work
please have INR's checked on [**8-13**] and [**8-17**] and call results to
PCP [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 2946**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (Phone: [**Telephone/Fax (1) 2205**]) and Dr. [**First Name11 (Name Pattern1) **]
[**Last Name (NamePattern4) 4511**], MD (Phone [**Telephone/Fax (1) 62**]). Please check Chem 7 on
[**8-17**] as well and call into above numbers.
21. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] VNA
Discharge Diagnosis:
PRIMARY:
Pulmonary fibrosis
SECONDARY:
coronary artery disease
acute on chronic systolic congestive heart failure
atrial fibrillation
chronic deep 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:
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital for coughing up blood. This was
ultimately believed to be caused by pulmonary fibrosis. You were
treated for pneumonia initially but then steroids were added.
REGARDING YOUR MEDICATIONS...
START:
-Pantoprazole 40mg daily
-Prednisone 40mg daily
-Alendronate 5 mg daily
-Vitamin D 800 units each day
-Calcium 500mg three times a day with meals
-Metoprolol Tartrate 12.5 mg three times per day
STOP:
-METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr
daily
-DRONEDARONE [MULTAQ] - 400 mg Tablet - 1 Tablet(s) by mouth
twice
a day
CHANGE:
-Lasix 20 mg daily
-Coumadin 2.5mg daily (please have your INRs checked as
prescribed and faxed to your PCP and cardiologist)
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
Otherwise, please followup with your primary care physician
[**Name Initial (PRE) 176**] 7-10 days regarding the course of this hospitalization.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2150-8-20**] at 10:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
[**Hospital Ward Name 4094**]: Pulmonary Medicine
When: THURSDAY [**2150-8-20**] at 11:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) 610**] [**Name8 (MD) **] RN [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2150-8-28**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 2946**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 2205**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 2204**]
within 1 week. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.**
.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2150-9-5**]
|
[
"V10.05",
"427.31",
"516.3",
"V10.47",
"250.00",
"272.4",
"053.19",
"428.0",
"424.2",
"424.1",
"416.8",
"403.90",
"584.9",
"414.01",
"733.00",
"585.3",
"733.13",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
10991, 11050
|
5897, 7728
|
313, 327
|
11258, 11258
|
3346, 3346
|
12592, 14355
|
2703, 2795
|
8207, 10968
|
11071, 11237
|
7754, 8184
|
11434, 12569
|
2810, 3327
|
263, 275
|
355, 1963
|
3362, 5874
|
11273, 11410
|
1985, 2441
|
2457, 2687
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,017
| 169,236
|
32698
|
Discharge summary
|
report
|
Admission Date: [**2187-12-25**] Discharge Date: [**2187-12-28**]
Date of Birth: [**2114-9-24**] Sex: M
Service: MEDICINE
Allergies:
Tetanus Antitoxin
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
b/l saddle pulmonary embolism
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 yo with h/o HTN, hyperlipidemia presented to [**Hospital **]
hospital with sudden onset of pain b/w shoulder blades at 11AM,
while walking from car to house. He felt as though he would pass
out but made it inside. He suddenly lost consciousness without
warning signs or symptoms, falling to the ground and hitting
head on floor (carpet). Pt thinks he had LOC for 20 min. When he
awoke, he felt he was breathing rapidly. He took 2 baby aspirin
and waited about 1.5 hours until his wife came home and brought
[**Last Name (un) **] to the OSH. At [**Hospital1 **], he was found to have large
bilateral main pulmonary emboli, as well as right popliteal DVT.
A CT head was negative for bleed. He was given IVFs, 100mg of
Lovenox , ASA 325, and 5mg of Coumadin at 3PM. He was
transferred to [**Hospital1 18**] for further management.
.
He denies any recent travel (did travel by airplane to Novia
Scotia in [**Month (only) 216**]). No family or personal h/o DVT or PE. He had a
colonoscopy 2 yrs ago which was unremarkable and states his PCP
likely checks his PSA regularly.
.
At [**Hospital1 18**] ED, T 98.3, HR 74, BP 171/82, RR 22, 100% 2L. Labs
revealed a creatinine of 1.4 (baseline unknown) and TropT 0.17.
He was admitted to the MICU on [**12-25**] where he was put on a
heparin drip w/ bridge to coumadin. His INR on admission was 1.1
and on transfer was 1.3. During this time his Troponins trended
down 0.17 -> 0.11 -> 0.05. He was hemodynamically stable and
transferred to [**Wardname 27095**].
.
Past Medical History:
HTN
Hyperlipidemia
OSA, not on CPAP
s/p Cardiac Cath 2 yrs ago (no intervention)
Social History:
Never smoked. Occasional EtOH use. No illicits. Married, lives
with his wife in [**Name (NI) 47**]. Deals poker and blackjack.
Family History:
No family h/o of DVT or PE. Mother died at 85 from heart
condition, Father died of dementia.
Physical Exam:
Admission Physical Exam
Vitals: 98.7 51SB 110/91 (106-146/ 46-91) 16 95% RA
Gen: well appearing, no apparent distress
HEENT: EOMI, MMM, granulation tissue on bridge of nose
Neck: No JVD, supple
Lungs: L CTA, R crackles @ bases
Heart: RRR nl S1S2 no M/R/G, brady
Abdomen: soft, non-distended, non-tender
Ext: 2+DP pulses b/l, no edema, no calf tenderness
.
Pertinent Results:
[**2187-12-25**] 09:00PM GLUCOSE-141* UREA N-42* CREAT-1.4* SODIUM-143
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15
[**2187-12-25**] 09:00PM estGFR-Using this
[**2187-12-25**] 09:00PM CK(CPK)-98
[**2187-12-25**] 09:00PM CK-MB-NotDone cTropnT-0.17*
[**2187-12-25**] 09:00PM WBC-12.7* RBC-4.04* HGB-13.1* HCT-38.9*
MCV-96 MCH-32.4* MCHC-33.6 RDW-13.6
[**2187-12-25**] 09:00PM NEUTS-74.0* LYMPHS-20.4 MONOS-4.5 EOS-0.9
BASOS-0.1
[**2187-12-25**] 09:00PM PLT COUNT-140*
[**2187-12-25**] 09:00PM PT-12.7 PTT-33.7 INR(PT)-1.1
Brief Hospital Course:
73 y.o. man with sudden onset back pain and LOC. Found to have
b/l main pulmonary artery PEs and R popliteal DVT.
.
# Pulmonary embolism - OSH PECT indicated bilateral main
pulmonary artery emboli. Pt lost consciousness indicating some
hemodynamic instability, but has had normal vital signs since.
OSH head CT indicated no evidence of acute hemorrage or
cerebrovascular changes. Troponin leak on admission indicated
heart strain (as evidence on admission EKG) or ischemia and is
correlated w/ worsened prognosis. His troponin trended down over
time and there was no evidence of STEMI on repeat EKG [**12-26**].
Patient was put on heparin gtt scale for a coumadin bridge.
.
In investigating source of clot, it may be possible that
sustained time sitting may be responsible but there is no
obvious source; in context of no recent immobility or travel,
must consider two other arms of Virchow's triad: endothelial
damage and hypercoagulable state. Patient has no history of
smoking or DM, although he does have a h/o HTN and
hyperlipidemia which may have contributed to endothelial damage.
Patient had normal colonoscopy 2 yrs ago; will hold off checking
PSA to look for Trousseau's syndrome. The question of whether Mr
[**Known lastname 76191**] has a hypercoagulable state, whether genetic or acquired,
can be worked up as outpatient. Given slow increase in INR,
patient was discharged with lovenox 100 q12H with sufficient
quantity to get him to his PCP appointment on the following
Wednesday after his Friday discharge.
.
# DVT - R popliteal DVT found at outside hospital. Denies travel
or family hx of thromboembolic disease. Anticoagulation as above
and no need for repeat LENIs or IVC filter unless fails
anticoagulation.
.
# Renal failure- Creatinine 1.4 on admission, was 1.3 at outside
hospital. Unknown baseline. Pt. did get CTA with dye load at
OSH. Urine lytes were drawn and FeNA = 0.008% and BUN/Cre = 28
indicating prerenal state. This was likely due to a combination
of IV contrast given at OSH and dehydration. Creatinine came
down to 1.1 by the day of discharge.
.
# Hypertension - BP @ basline hypertension 150s/80s. Will
restart home HTN HCTZ, but held lisinopril for concern about
renal function. Will not use BBlockers as baseline HR is 40-60
(apparently has long h/o this per patient and is consistently
asymptomatic). On discharge, given hypertension in the hospital
and normal renal function, his home dose of lisinopril was
restarted.
.
# Hyperlipidemia - continue lipitor at home dose
.
# Hyperglycemia: FSBG 134-174. HBA1c is 5.8 indicating no
evidence of hyperglycemia. Getting RISS and FSBG QID in MICU and
O/N on floor. In AM FSBG well controlled 113,107, no h/o
diabetes, and no evidence of current glucose intolerance.
Elevated BG likely due to acute stress secondary to PE and D5W
that heparin drip was administered in. His RISS and QID
fingersticks were discontinued.
.
# MAINTENANCE
FEN - Cardiac diet
Prophylaxis- heparin gtt, bowel regimen, restart ASA 81.
Access: 18g and 20g IV
Dispo: PT consult
FULL CODE
Medications on Admission:
Lipitor 20mg
Lisinopril 5mg daily
HCTZ (5 or 10 pt. can not remember)
ASA 81mg daily
Benztropine (2.5 patient can not remember)
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*10 injection* Refills:*0*
5. Benztropine 1 mg Tablet Sig: unknown Tablet PO once a day:
You may restart this medicine in consultation with your
physician. [**Name10 (NameIs) **] have not received it here in the hospital.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please draw PT, PTT and fax results to [**Telephone/Fax (1) 7400**] (Dr. [**Last Name (STitle) **].
[**Location (un) **] office)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
pulmonary embolism
deep vein thrombosis
.
Secondary Diagnosis:
hypertension
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hosptial for a pulmonary embolism and
deep vein thrombosis.
.
You were treated with anticoagulants and were discharged once it
became evident that your pulmonary and cardiovascular status had
improved.
.
We incidentally found that your creatinine, a measure of renal
function, was elevated on routine labs, suggesting somewhat
decreased kidney function. This returned to [**Location 213**] by the time
of your discharge. This likely does not reflect an ongoing
problem but it's something that you and your doctor can check on
from time to time. If your urine becomes foamy, bloody, brown,
or you start having much more or much less urine, let your
doctor know.
.
You have started two medicines: enoxaparin (lovenox), coumadin
(warfarin). You'll be taking the lovenox injections while the
coumadin takes effect, which may take a few days. Please go to
your doctor's laboratory to get your blood drawn (with the
prescription sheet for PT, [**Name (NI) 18090**]. Call your doctor's office to
find a good time for you to go there on Monday for a blood draw
([**Telephone/Fax (1) 7401**]).
.
It will be important to have close laboratory follow-up in order
to know that your coumadin levels are appropriate and to know
when to stop the lovenox. Coumadin is a medicine that requires
careful monitoring, and you'll need to work with Dr [**Last Name (STitle) 5263**] and
nurses who help follow the laboratory values; they'll tell you
when you need to adjust the dose or schedule of coumadin in
order to maintain a good level.
.
Lovenox and coumadin both thin your blood so that you have fewer
blood clots, but this also means that you will be more likely to
bleed for longer times. If you have minor cuts you'll need to
apply pressure to them for a longer time in order for them to
clot. You will also find that you bruise more easily. If you
have significant injuries, seek medical attention immediately,
and let your care providers know that you are on blood-thinning
medication.
.
Various things can change your coumadin levels. Antibiotics can
have the effect of increasing the effect of the coumadin. Dark
green vegetables (like collard greens, kale, and spinach) can
sometimes decrease the effect of the coumadin; eat a constant
level of these foods day-to-day, or avoid them. We are also
giving you an information sheet about coumadin and you should
continue to talk to your doctor about how to keep your coumadin
working well and not thinning your blood too little or too much.
.
It is not yet clear why you had this event of deep vein
thrombosis and pulmonary embolism. You may need further testing
to see if there is an underlying tendency for your blood to clot
more than usual. Dr. [**Last Name (STitle) 5263**] can work on this with you; he may or
may not want you to consult a hematologist (a specialist in
blood problems).
.
Please take all medications as prescribed.
.
Please keep all of your follow up appointments.
.
If you have new back or chest pain, bleeding that does not stop,
fevers >101.5 F, or new breathing difficulty, or other symptoms
that concern you, call your doctor's office or go to an
emergency department.
Followup Instructions:
We have made the following appointment for you with your primary
care physican, Dr. [**Last Name (STitle) 5263**] [**Telephone/Fax (1) 7401**]: Wednesday, [**1-2**]
at 11:45 am. Your coumadin dose and follow-up for your
hospitalization will be addressed at this appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"276.51",
"403.90",
"790.29",
"585.9",
"327.23",
"453.41",
"415.19",
"272.4",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7300, 7306
|
3171, 6219
|
310, 316
|
7459, 7465
|
2602, 3148
|
10672, 11078
|
2116, 2210
|
6399, 7277
|
7327, 7327
|
6245, 6376
|
7489, 10649
|
2225, 2583
|
241, 272
|
344, 1851
|
7409, 7438
|
7346, 7388
|
1873, 1955
|
1971, 2100
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,534
| 147,302
|
35880
|
Discharge summary
|
report
|
Admission Date: [**2163-12-29**] Discharge Date: [**2164-1-6**]
Date of Birth: [**2111-11-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left upper lobe carcinoid tumor.
Major Surgical or Invasive Procedure:
[**2163-12-29**]: Sleeve left upper lobectomy (reanastomosis of
left lower lobe bronchus to left mainstem bronchus),
mediastinal lymph node dissection, intercostal muscle flap
buttress.
[**2163-12-31**]: Flexible bronchoscopy.
History of Present Illness:
52yoF ex-smoker (23 pk-yr) w/ asthma found to have LUL
endobronchial lesion.
Initially presented in [**9-23**] c/o L pleuritic pain. + productive
cough but no hemoptysis. Pt treated w/ Moxifloxacin x 20 days
for
PNA. Since, no CP/cough/fever/chills.
CT [**9-23**] suspicious for L hilar mass w/ post-obstructive PNA of
lingula. Followup CT [**10-23**] showing slightly smaller L hilar mass
w/ improvement of PNA. S/p bronchoscopy [**2163-11-22**] showing L
endobronchial lesion (typical carcinoid) completely occluding
LUL, partially occluding L MS bronchus.
Baseline significant dyspnea, unable to ambulate 1 flight of
stairs w/o stopping x years. Denies weight loss.
Past Medical History:
Asthma x '[**46**]
morbid obesity
hypertension
OA of knee
GERD
OSA
Crohns (off Asacol since '[**57**])
tinnitis
s/p tonsillectomy '[**26**]
s/p correction of deviated septum
s/p CCY '[**60**]
s/p hammer toe [**Doctor First Name **] '[**60**]
Social History:
Widow. Tobacco 24 pack year. Quit [**2148**]. ETOH: non
Family History:
non-contributory
Physical Exam:
VS: 99.3 98.9 86 126/76 18 95RA
Gen: NAD, A+OX3, supine on bed
CV: RRR
Resp: Crackles left lower lobe, good inspiratory effort
Abd: Obese, NT/ND, +BS
Ext: 1+ edema
Pertinent Results:
[**2164-1-1**] 09:32PM BLOOD WBC-9.2 RBC-3.46* Hgb-9.8* Hct-28.8*
MCV-83 MCH-28.4 MCHC-34.1 RDW-14.2 Plt Ct-309
[**2164-1-1**] 04:14AM BLOOD WBC-11.5* RBC-3.28* Hgb-9.2* Hct-27.3*
MCV-83 MCH-28.0 MCHC-33.8 RDW-14.3 Plt Ct-250
[**2163-12-30**] 03:40AM BLOOD WBC-14.4* RBC-3.73* Hgb-10.7* Hct-30.7*
MCV-82 MCH-28.8 MCHC-35.0 RDW-14.3 Plt Ct-303
[**2163-12-29**] 03:02PM BLOOD WBC-21.4*# RBC-4.32 Hgb-12.0 Hct-35.1*
MCV-81* MCH-27.9 MCHC-34.3 RDW-14.2 Plt Ct-405
[**2164-1-4**] 07:45AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-138
K-4.2 Cl-99 HCO3-32 AnGap-11
[**2164-1-2**] 03:50PM BLOOD Glucose-141* UreaN-10 Creat-0.9 Na-138
K-3.8 Cl-99 HCO3-30 AnGap-13
[**2164-1-1**] 04:14AM BLOOD Glucose-120* UreaN-16 Creat-0.8 Na-135
K-4.0 Cl-102 HCO3-26 AnGap-11
[**2163-12-29**] 03:02PM BLOOD Glucose-164* UreaN-25* Creat-1.0 Na-140
K-4.4 Cl-104 HCO3-25 AnGap-15
[**2163-12-30**] 03:40AM BLOOD Glucose-116* UreaN-33* Creat-1.9* Na-137
K-4.3 Cl-100 HCO3-29 AnGap-12
[**2164-1-4**] 07:45AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.9
[**2164-1-1**] URINE CULTURE (Final [**2164-1-2**]): NO GROWTH.
[**2163-12-31**] BRONCHOALVEOLAR LAVAGE FINAL REPORT [**2164-1-3**]
GRAM STAIN (Final [**2164-1-1**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2164-1-3**]):
>100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
Blood Cultures x 4 No growth to date
CXR:
[**2164-1-5**] (after pneumostat placed): A very small left apical
pneumothorax has, in retrospect, improved from the prior study.
Widespread subcutaneous emphysema persists. With the exception
of the change in pneumothorax, there are no other relevant
changes since the recent radiograph of earlier the same date.
[**2164-1-6**] No obvious PTX (difficult to assess due to subQ air),
[**Doctor Last Name **] tube in place
[**2164-1-3**] Slight increase in size of small left apical
pneumothorax.
[**2164-1-3**] Generalized atelectasis in the left lung persists.
Small left apical pneumothorax is larger today than yesterday,
apical pleural tube in place. Persistent subcutaneous emphysema
in the left axilla and anterior chest wall. Right lung clear.
Heart size top normal, still shifted to the left of
midline,reflecting atelectasis on the left.
[**2164-1-1**] Two left-sided chest tubes are again seen with diffuse
left-sided
subcutaneous emphysema extending to the right side of the neck
and in the
right lateral chest wall. The amount of subcutaneous emphysema
makes it
difficult to assess for a focal infiltrate on the left.
[**2163-12-31**]: Marked increase in amount of subcutaneous emphysema.
[**2163-12-30**]: The left apical pneumothorax is still present, appears
to be unchanged or slightly increased. There is slight increase
in the subcutaneous air in the left hemithorax. The right lung
is unremarkable. There is no appreciable pleural effusion seen.
Cardiomediastinal silhouette is unchanged. Left-sided cardiac
atelectasis is slightly worse but still minimal.
[**2163-12-29**]: : Small left apical pneumothorax
Brief Hospital Course:
Mrs. [**Known lastname 3646**] was admitted on [**2163-12-29**] for Sleeve left upper
lobectomy (reanastomosis of
left lower lobe bronchus to left mainstem bronchus), mediastinal
lymph node dissection, intercostal muscle flap buttress. She
was extubated in the operating room, monitored in the PACU prior
to transfer to the floor. She had 2 chest tubes anterior apical
with a persistent airleak and a posterior basilar were to
waterseal. The acute pain service managed her pain with a
Bupivacaine/Dilaudid Epidural with good control. On POD1 she
responded to a IV fluid challenge for low urine output. Chest
film showed small basilar effusion/atelectasis for which
pulmonary toilet was continued The anterior chest tube airleak
persist. On POD2 she developed increased increased subcutaneous
emphysema, concern for airway dehiscence and anastomotic leak.
She was transferred to the SICU for bronchoscopy revealed no
evidence of the dehiscence or any anastomotic leak with saline
instilled. The chest-tubes were placed to suction. She
transferred back to the floor in stable condition on 100% O2 via
nasal cannula. On POD3 She spiked a fever to 101.2 was
pancultured and started on IV antibiotics. The epidural was
removed and converted to PO pain medication with good control.
On POD4 the basilar chest tube was removed. She was gently
diuresed. Her Crepitus slowly improved. POD5 the chest tube was
placed to water-seal a chest x-ray showed a stable left apical
pneumothorax and left lower lobe atelectasis. She was followed
by physical therapy. She was followed by serial chest films,
pulmonary toilet continued, tolerated a regular diet and her
pain was well controlled with PO Dilaudid. On POD 7 the
pneumovac was replaced with a pneumostat. A post CXR showed no
increase in PTX/effusion. The patient continued to ambulate
well. In the afternoon, she c/o chest pain when ambulating. An
EKG was done which was normal. In addition one set of cardiac
enzymes was normal was well. On POD 8 the patient will be
discharged to rehab and will have VNA for her pneumostat upon
completion of her rehab. Her Pneumostat is functioning well and
there is no apparent leak. Output is minimal (70 cc/day). CXR
shows no PTX.
Medications on Admission:
Singulair 10mg daily, astelin 137mcg IH daily celebrex 200mg
daily
Symbicort 160/4.5 IH [**Hospital1 **] nexium 40mg daily albuterol IH prn
triamterene/HCTZ 37.5/25mg daily, diovan 80mg daily
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 8641**], NH
Discharge Diagnosis:
Left upper lobe carcinoid tumor
Asthma
Morbid Obesity
OSA
Hypertension
OA of knee
GERD
Crohns
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops drainage
-Chest tube site remove dressing on Sunday cover with a bandaid
Should site drain cover with a clean dressing and change as
needed to keep clean and dry.
-You may shower on Sunday. No tub bathing or swimming for 6
weeks
-No driving while taking narcotics. Take stool softners with
narcotics
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2348**] [**2165-1-9**]:00am in
the [**Hospital Ward Name 121**] Building [**Hospital1 **] I Chest Disease Center [**Location (un) **].
Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology
Department for a Chest X-Ray 45 minutes before your appointment.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18412**] [**Telephone/Fax (1) 59340**]. You are
starting Metoprolol 25 mg twice a day for post-operative Atrial
fibrillation (now in sinus). Your PCP can decide whether or not
she wants to continue you on the metoprolol. In addition, your
BP in the hospital has been well controlled without your home BP
medications. Dr. [**Last Name (STitle) 18412**] can decide which medications you should
continue if any.
Completed by:[**2164-1-6**]
|
[
"530.81",
"715.96",
"278.01",
"401.9",
"209.21",
"V15.82",
"998.81",
"584.9",
"512.1",
"E878.6",
"518.0",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.74",
"32.49",
"40.3",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8329, 8407
|
5034, 7264
|
356, 585
|
8545, 8554
|
1860, 5011
|
9097, 10016
|
1643, 1661
|
7507, 8306
|
8428, 8524
|
7290, 7484
|
8578, 9074
|
1676, 1841
|
283, 318
|
613, 1287
|
1309, 1553
|
1569, 1627
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,181
| 129,084
|
44188
|
Discharge summary
|
report
|
Admission Date: [**2190-3-23**] Discharge Date: [**2190-3-26**]
Date of Birth: [**2136-1-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Left thyroid nodule
Major Surgical or Invasive Procedure:
Left thyroidectomy
History of Present Illness:
54M with history of left thyroid nodule admitted for scheduled
elective left thyroidectomy
Past Medical History:
History of thyroid nodule
Depression
Bipolar
PSH:
s/p ACL repair ([**2173**])
s/p tonsillectomy ([**2154**])
Social History:
patient denies alcohol and illicits, no tobacco.
Family History:
non-contrib
Physical Exam:
General Appearance: NAD
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Incision CD&I
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No S3,
No S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : , Crackles : R base)
Abdominal: Soft, Non-tender
Extremities: Right: Absent, Left: Absent
Skin: Warm, No(t) Rash:
Pertinent Results:
[**2190-3-24**] 03:47AM BLOOD WBC-8.4 RBC-4.06* Hgb-12.6* Hct-36.8*
MCV-91 MCH-31.1 MCHC-34.3 RDW-13.6 Plt Ct-197
[**2190-3-24**] 03:47AM BLOOD Glucose-122* UreaN-12 Creat-0.8 Na-138
K-3.9 Cl-108 HCO3-25 AnGap-9
[**2190-3-24**] 03:47AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.3
[**2190-3-24**] 03:47AM BLOOD TSH-1.8
[**2190-3-24**] 03:47AM BLOOD Lithium-0.8
.
CXR
As compared to the previous radiograph, the endotracheal tube
and the
nasogastric tube have been removed. Otherwise, the radiographic
appearance is unchanged. Moderate cardiomegaly with bibasilar
atelectasis, no evidence of pleural effusion, no newly appeared
parenchymal opacities suggestive of pneumonia.
Brief Hospital Course:
54M with significant psychiatric history including bipolar
disorder and severe depression and also history of left thyroid
nodule admitted for scheduled elective left thyroidectomy. The
pt underwent the procedure with no complications (for full
details, please see the dictated operative note).
However, immediately following the procedure in recovery,
patient became acutely agitated and combative, thrashing about,
pulling at lines requiring security to intervene and put the
patient in four-point restraints. An emergent psychiatry consult
was obtained who acknowledged that low dose haldol was safe to
administer given the fact that the pt takes a MAOI at baseline.
Patient intitially
received Versed 2mg IM, then Ativan 2mg IM and Haldol 5mg IV
with limited response. Given concerns for airway protection and
surgical site compromise, the pt was re-intubate and sedated and
admitted to the ICU on a propofol drip.
On the next morning, HD2, the pt was extubated with haldol given
in supplement. He was much less agitated, but remained quite
lethargic and thus stayed in the ICU for an additional day.
His ICU course was uncomplicated. He was extubated on [**3-24**], and
remained delirious for one more day, well-controlled on prn
haldol and zyprexa. By the day of discharge he was alert and
oriented and clinically stable.
Medications on Admission:
Nardil 30mg [**Hospital1 **]
Lithium 600mg [**Hospital1 **]
Discharge Medications:
1. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
2. Phenelzine 15 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Left thyroid nodule
Post-op psychosis
.
Secondary:
bipolar
Discharge Condition:
Stable
Tolerating regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please contact us or seek medical attention immediately for any
chest pain, shortness of breath, increased redness, swelling,
bleeding or purulent discharge from your incision, temperature
of 101.5 or greater, or any other concerning signs or symptoms.
.
Instructions after thyroid surgery:
*Avoid driving while taking pain medication.
*Continue taking stool softeners with pain medication to prevent
constipation.
*You may feel tingling around your lips, arms & legs. Take TUMS
(2 tabs four times for a few days until tingling goes away).
emergency room if unable to reach MD.
*You may return to work once you feel comfortable.
*Avoid physical/strenuous activity until you feel comfortable.
*You may shower. Avoid swimming or bath for 5-7 days.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) 60346**] as scheduled. Please
call to make/verify your appointment: ([**Telephone/Fax (1) 72024**]
2. Please also follow-up with your primary psychiatrist as soon
as possible.
|
[
"293.0",
"V58.69",
"296.80",
"241.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"06.2"
] |
icd9pcs
|
[
[
[]
]
] |
3591, 3597
|
1964, 3302
|
335, 356
|
3709, 3785
|
1276, 1941
|
4580, 4811
|
692, 705
|
3414, 3568
|
3618, 3688
|
3329, 3391
|
3809, 4557
|
720, 1257
|
276, 297
|
384, 476
|
498, 609
|
625, 676
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,098
| 148,776
|
49071
|
Discharge summary
|
report
|
Admission Date: [**2170-10-2**] Discharge Date: [**2170-10-8**]
Date of Birth: [**2110-1-10**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Hydrocodone
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
60 yo female S/P lumbar fusion [**4-21**]. Patient with continued
back pain and development of junctional kyphosis.
Major Surgical or Invasive Procedure:
s/p revision posterior thoracolumbar fusion with instrumentation
and iliac crest bone graft ([**2170-10-2**]).
History of Present Illness:
60 yo female s/p lumbar fusion [**4-21**]. Patient developed
junctional kyphosis and disc degeneration above previous fusion
construct. Patient developed significant low back pain
recalcitrant to nonoperative modalities of management. Patient
opted to pursue surgical intervention for revision of lumbar
fusion with extension above thoracolumbar junction.
Past Medical History:
gastric bypass
bilateral hip replacements
Social History:
Denies
Family History:
N/C
Physical Exam:
[**2170-10-6**]:
AO x 3, NAD
Afebrile, VSS
incsion clean, dry, intact.
BLE: FROM
[**4-20**] quadriceps/ADF/APF/[**Last Name (un) 938**]/FHL/EVERSION
L2-S1 sensation intact
distal pulses intact
Pertinent Results:
[**2170-10-6**] 08:50AM BLOOD WBC-5.6 RBC-3.18* Hgb-9.6* Hct-27.8*
MCV-88 MCH-30.3 MCHC-34.6 RDW-14.7 Plt Ct-86*
[**2170-10-5**] 12:40PM BLOOD WBC-6.6 RBC-3.15* Hgb-9.5* Hct-27.5*
MCV-87 MCH-30.3 MCHC-34.7 RDW-14.8 Plt Ct-68*
[**2170-10-4**] 08:14AM BLOOD WBC-5.4 RBC-2.99* Hgb-9.1* Hct-25.8*
MCV-86 MCH-30.3 MCHC-35.1* RDW-15.6* Plt Ct-71*
[**2170-10-3**] 06:46AM BLOOD WBC-5.8 RBC-3.17* Hgb-9.5* Hct-27.3*
MCV-86 MCH-30.1 MCHC-35.0 RDW-16.0* Plt Ct-77*
[**2170-10-2**] 08:08PM BLOOD WBC-4.6 RBC-2.79* Hgb-8.7* Hct-24.2*
MCV-87 MCH-31.2 MCHC-35.9* RDW-15.5 Plt Ct-90*
[**2170-10-6**] 08:50AM BLOOD Plt Ct-86*
[**2170-10-5**] 12:40PM BLOOD Plt Ct-68*
[**2170-10-5**] 12:40PM BLOOD PT-12.1 PTT-26.7 INR(PT)-1.0
[**2170-10-2**] 08:08PM BLOOD Plt Ct-90*
[**2170-10-2**] 08:08PM BLOOD PT-12.8 PTT-29.4 INR(PT)-1.1
[**2170-10-2**] 04:55PM BLOOD PT-13.6* PTT-30.5 INR(PT)-1.2*
[**2170-10-5**] 06:40AM BLOOD Glucose-124* UreaN-10 Creat-1.0 Na-137
K-4.1 Cl-104 HCO3-28 AnGap-9
[**2170-10-4**] 08:14AM BLOOD Glucose-130* UreaN-11 Creat-1.0 Na-143
K-3.9 Cl-109* HCO3-31 AnGap-7*
[**2170-10-3**] 06:46AM BLOOD Glucose-163* UreaN-14 Creat-1.1 Na-141
K-4.7 Cl-109* HCO3-26 AnGap-11
[**2170-10-3**] 01:32AM BLOOD Glucose-177* UreaN-16 Creat-1.1 Na-142
K-4.5 Cl-112* HCO3-24 AnGap-11
Brief Hospital Course:
Patient underwent revision lumbar fusion and extension to
thoracolumbar junction on [**2170-10-2**]. Patient tolerated procedure
well, but sustained significant blood loss. She was monitored
in SICU overnight without complications. Patient did receive
transfusion of PRBC's for low hematocrit. Patient was
transferred to orthopaedic floor. She was able to resume
regular diet with return of bowel function. She was able to
manage pain with oral meds. Incision was noted to be clean,
dry, and intact; wound drain was removed. Heme/Oncology c/s
was obtained because of intraoperative bleeding and concern for
possible occult coagulopathy. Heme/onc to complete workup on
outpatient basis. Patient demonstrated slow progress with PT
and was deemed suitable for extend rehab stay. After evaluation
by orthopaedic spine team on [**10-6**], patient was judged ready for
transfer to rehab bed.
Medications on Admission:
paroxetine
fluticasone
gabapentin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
5. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) 1000mcg/mL
Injection DAILY (Daily) for 7 days: Started [**10-7**].
11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) 1,000
mcg/mL Injection once a week for 4 weeks: Please begin after
daily dosing has completed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare center
Discharge Diagnosis:
Junctional kyphosis s/p lumbar fusion.
Discharge Condition:
Good.
Discharge Instructions:
Keep incision clean, dry. [**Month (only) 116**] shower with wound covered.
Use brace when OOB.
Take pain medication as directed when needed.
Resume home medications.
Physical Therapy:
Ambulate as tolerated. Patient to wear TLSO brace when OOB.
Treatments Frequency:
All sutures are soluble. No need for removal.
Keep incision clean, dry.
[**Month (only) 116**] leave wound open to air when dry.
Followup Instructions:
F/U Dr. [**Last Name (STitle) 363**] per previously scheduled appt. ([**Telephone/Fax (1) 11061**].
Completed by:[**2170-10-8**]
|
[
"722.51",
"737.12",
"285.1",
"287.5",
"V45.86",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"99.05",
"99.04",
"81.38"
] |
icd9pcs
|
[
[
[]
]
] |
4647, 4707
|
2527, 3426
|
393, 506
|
4790, 4798
|
1234, 2504
|
5245, 5377
|
1000, 1005
|
3512, 4624
|
4728, 4769
|
3452, 3487
|
4822, 4990
|
1020, 1215
|
5008, 5069
|
5091, 5222
|
237, 355
|
534, 894
|
916, 959
|
975, 984
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,343
| 150,744
|
16121
|
Discharge summary
|
report
|
Admission Date: [**2116-7-13**] Discharge Date: [**2116-8-13**]
Date of Birth: [**2039-9-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
worsening SOB
Major Surgical or Invasive Procedure:
CABG x2 (SVG->OM1/PDA)/MVr (#28 CE annuloplasty)-[**2116-7-20**]
History of Present Illness:
Cantonese speaking female(difficult to attain hx via phone
interpreter). 76 y/o female with atrial fibrillation on
[**Year (4 digits) **], CHF, severe mitral regurg, CAD scheduled for CABG MVR
[**7-20**], presenting with worsening sob and wheezing since
saturday.
.
Recent admission for shortness of breath [**Date range (1) 23342**] thought
related to HF exacerbation. On that admission rule out and
cardiac cath demonstrating moderate to severe mitral
regurgitation and two vessel CAD. Patient had pre-op evaluation
for CABG/MVR recently with Dr. [**Last Name (STitle) **] [**2116-7-8**]. On that PE, mild
rales bilaterally.
.
Saturday onset of SOB, w/o palpitations, chest pain, pleuritic
chest pain, nausea, vomiting, or fever. Reported cough with
whitish sputum, w/o rhinorrhea, sick contacts. Wheezing x two
days as well. + 2 pillow orthopnea. SOB at rest and with
ambulation. No weight gain, LE edema. Difficult to assess
functional capacity but worsening SOB, DOE over past months.
Patient and daughter(contact[**Name (NI) **] by phone state sx similar but
less severe then previous admission for HF exacerbation). As per
daughter one week prior received [**Name (NI) 31069**] from epi provider in
[**Name9 (PRE) **] after complaint of cough.
.
In ED vs 98.6, 94, 127/79, 20, 96%RA. Placed on 2L. Diffuse
wheezing on exam, irregular rhythm. EKG unchanged. BNP 1100. CE
-, CXR with no infiltrate and no visible edema. Given Combivent
neb, lasix 20 mg IV, potassium, ASA 325. Pt was admitted for
further evaluation and management.
Past Medical History:
Severe mitral regurgitation 3+ from [**2116-5-20**] cardiac cath.
CAD
Systolic and iastolic CHF
Atrial fibrillation
Hypertension
s/p cholecystectomy
s/p ERCP for CBD stone removal
Social History:
Never smoked, no alcohol use, no illicit drug use. She lives at
home alone. During the day she spends time with family, at night
she is by herself. She is very active at baseline. No issues
with ADLs or IADLs.
Family History:
Mother- colon CA
Brother- liver CA
[**Name (NI) 12238**] COPD
Physical Exam:
VS - 98, 139/81, 74, 20, 95%RA
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect
appropriate. Audible wheeze with speaking
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 15 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
irregularly irregurly. III/VI systolic murmur. Audible wheeze
with examination
Chest: No chest wall deformities, scoliosis or kyphosis. Rales
bases. Audible expiratory wheeze. No egophany, fremitus
Abd: Soft, NTND. surgical scar on abdomen. 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.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 46089**] (Complete) Done
[**2116-7-20**] at 10:20:27 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2039-9-14**]
Age (years): 76 F Hgt (in): 62
BP (mm Hg): 120/55 Wgt (lb): 140
HR (bpm): 82 BSA (m2): 1.64 m2
Indication: Intraop CABG MVR. Evaluate Valves, Ventricular
Function, Aortic Contours
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2116-7-20**] at 10:20 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: aw 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.7 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.15 >= 0.29
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: *4.2 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.0 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 6 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 3 mm Hg
Aortic Valve - LVOT pk vel: 0.71 m/sec
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *2.0 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 0.8 m/sec
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - Pressure Half Time: 72 ms
Mitral Valve - MVA (P [**2-12**] T): 3.1 cm2
Mitral Valve - E Wave: 0.8 m/sec
Findings
LEFT ATRIUM: Marked LA enlargement. Mild spontaneous echo
contrast in the LAA. Cannot exclude LAA thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
global LV hypokinesis. Mildly depressed LVEF. [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Moderately
dilated ascending aorta. Normal aortic arch diameter. Complex
(>4mm) atheroma in the aortic arch. Mildly dilated descending
aorta. Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Increased
transaortic velocity related to increased stroke volume due to
AR. Mild to moderate ([**2-12**]+) AR. Eccentric AR jet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. [**Name13 (STitle) 15110**]
to co-existing AR, the pressure half-time estimate of mitral
valve area may be an OVERestimation of true area. Moderate to
severe (3+) MR. Uninterpretable LV inflow pattern due to MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre Bypass: The left atrium is markedly dilated. Mild
spontaneous echo contrast is present in the left atrial
appendage. A left atrial appendage thrombus cannot be excluded.
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. There is mild global left
ventricular hypokinesis (LVEF = 45-50 %). Overall left
ventricular systolic function is mildly depressed [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 ascending
aorta is moderately dilated. There are complex (>4mm) atheroma
in the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. There is
no valvular aortic stenosis. The increased transaortic velocity
is likely related to increased stroke volume due to aortic
regurgitation. Mild to moderate ([**2-12**]+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric. The mitral
valve leaflets are mildly thickened. Due to co-existing aortic
regurgitation, the pressure half-time estimate of mitral valve
area may be an OVERestimation of true mitral valve area.
Moderate to severe (3+) mitral regurgitation is seen. There is
no pericardial effusion.
Post Bypass: Perserved biventricular function, LVEF 50%. There
is a #28 full annuloplasty ring in the mitral postion. MR is now
trace to 1+ Peak gradient [**6-16**], mean 3 mm Hg. AI remains [**2-12**]+.
Aortic contours intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
Brief Hospital Course:
Ms. [**Known lastname 2578**] is a 76 yr old female with CAD, A-fib scheduled for
CABG/MVR presenting with worsening SOB. Some complaints of chest
discomfort this morning.
Likely acute on chronic systolic heart failure with cardiac
wheeze in setting of reported dietary indiscretion especially
improved markedly after diuresis.
Her [**Known lastname **] was held given previously planned CABG/MVR and she
was started on a heparin drip for a-fib. She was transferred to
cardiac surgery.
She was taken to the operating room on [**2116-7-20**] where she
underwent a CABG x 2 and mitral valve repair. She was
transferred to the ICU in stable condition. She was given 48
hours of iv vancomycin as she was in the hospital > 24 hours
preoperatively. She remained intubated overnight secondary to
low svo2. She was transfused with packed red blood cells and was
extubated on post op day 1. She was started on an amiodarone gtt
for rapid atrial fibrillation. She was also restarted on
[**Date Range **]. She was transferred to the floor late on POD #2. She
was again transfused for a HCT 20. Chest tubes and pacing wires
removed. Beta blockade was titrated and diuresis was initiated.
The physical therapy service was [**Date Range 4221**] for assistance with
her postoperative strength and mobility. Ms. [**Known lastname 2578**] became
distended with mildly elevated LFT's consistent with
pancreatitis. A GI Consult was obtained and she was made NPO. A
CT Scan showed multiple stones within the extrahepatic bile
ducts as well as marked intra- and extra-hepatic biliary
dilatation. On [**2116-7-28**], Ms. [**Known lastname 2578**] became tacypneic. She was
returned to the ICU and reintubated for respiratory distress and
aggitation. ERCP was recommended for suspected cholangitis which
was performed [**2116-7-29**] in which a few biliary stones were
extracted and a biliary stent was placed. A repeat ERCP was
planned in 2 months for stent removal and further stone
extraction. Ciprofloxacin and flagyl were started. She was
successfully extubated on [**2116-7-30**]. Her abdominal discomfort
greatly improved however her NG tube was left in placed for
abdominal distention. Aggressive diuresis was initiated with
zaroxyln and diuril. A bowel regimen was also started to promote
GI motility. Her diet was advanced slowly beginning with
liquids. On [**2116-8-2**], she was transferred back to the step down
unit for further recovery. Her LFT's continued to trend towards
normal. A large right pleural effusion was noted on chest x-ray.
Her family originally refused drianage however she later
developed respiratory distress and cardiac arrest requiring
resuscitation and intubation. She was thus returned to the
intensive care unit for further care. A right chest tube was
placed which drained 2 liters. An echo showed no pericardial
effusion and mild aortic, mitral and tricuspid insufficiency.
She was again extubated successfully on [**2116-8-5**]. The wound care
nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for assistance with her lower extremity
wound. A wick wasplaced in the dehissed portion and a dry wrap
was applied. A PICC Line was placed for antibiotic coverage of
her surgical wounds. Ms. [**Known lastname 2578**] failed to void and her foley
catheter was replaced. She was transferred back to the step down
unit on [**2116-8-7**].
Ms. [**Known lastname 2578**] continued to make steady progress and was discharged to
home on [**8-13**]. She will follow-up with Dr. [**Last Name (STitle) **], the GI service,
her cardiologist and her primary care physician. [**Name10 (NameIs) 197**]
[**Name11 (NameIs) 702**] with resume with Dr. [**Last Name (STitle) 724**] as an outpatient for a goal
INR of 2.0-2.5.
Medications on Admission:
From last dc, pt does not know active list
-Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day)
-Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
-Nitroglycerin 0.3 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) Tablet,
Sublingual Sublingual PRN
-Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
-Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
-Toprol XL 100 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: Two (2)
Tablet Sustained Release 24 hr PO once a day.
-Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO ONCE (Once): take
as directed by your primary care physician.
[**Name Initial (NameIs) 46090**] 40 mg daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet [**Name Initial (NameIs) **]: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule [**Name Initial (NameIs) **]: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet [**Name Initial (NameIs) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Name Initial (NameIs) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet [**Name Initial (NameIs) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
INR to be drawn on Tuesday with results sent to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 724**] at
([**Telephone/Fax (1) 46091**]. Goal INR 2-2.5 for atrial fibrillation. Spoke
to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 724**] on [**2116-7-24**].
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
8. Warfarin 1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily) as
needed for afib: Please take 2 mg (2 pills) daily until
otherwise directed by the office of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 724**].
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet [**Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Diltiazem HCl 90 mg Tablet [**Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet [**Name (STitle) **]: 1.5 Tablets PO Q 8H
(Every 8 Hours).
Disp:*135 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
[**Name (STitle) **]: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
CAD s/p CABG, MR s/p MVR
Afib, HTN, s/p Chole, s/p ERCP for stone removal
acute on Chronic Systolic and diastolic heart failure
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower daily, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon OR at least 4 weeks.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 724**] 2 weeks [**Telephone/Fax (1) 46092**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1147**] 2 weeks [**0-0-**]
Dr. [**Last Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 42393**] for repeat ERCP, stent removal and stone extraction
in 2 months.
INR to be drawn on Saturday with results sent to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 724**]
at ([**Telephone/Fax (1) 46093**]. Goal INR 2-2.5 for atrial fibrillation.
Spoke to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 724**] on [**2116-7-24**].
Completed by:[**2116-8-13**]
|
[
"424.0",
"788.20",
"427.5",
"414.01",
"511.9",
"401.9",
"285.9",
"577.0",
"574.51",
"428.0",
"428.43",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"34.04",
"96.04",
"99.60",
"51.87",
"96.6",
"88.72",
"51.88",
"38.93",
"39.61",
"35.12",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15825, 15882
|
9138, 12875
|
335, 402
|
16054, 16062
|
3403, 9115
|
16401, 17069
|
2418, 2481
|
13794, 15802
|
15903, 16033
|
12901, 13771
|
16086, 16378
|
2496, 3384
|
282, 297
|
430, 1969
|
1991, 2172
|
2188, 2402
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,193
| 160,816
|
16106+56732
|
Discharge summary
|
report+addendum
|
Unit No: [**Numeric Identifier 46052**]
Admission Date: [**2131-7-13**]
Discharge Date: [**2131-8-30**]
Date of Birth: [**2067-9-19**]
Sex: F
Service: VSU
CHIEF COMPLAINT: Ruptured aortic abdominal aneurysm.
HISTORY OF PRESENT ILLNESS: The patient was shopping with
her husband. She had a syncopal episode. She was hypotensive.
The patient was transferred to a local emergency room and
then to our institution for surgical repair.
ALLERGIES: No known drug allergies.
MEDICATIONS: Toprol, Zocor and an over the counter
nonsteroidal for chronic back pain.
PAST MEDICAL HISTORY: Illnesses include
1. Hypertension.
2. Chronic back pain.
3. Hyperlipidemia on Zocor.
PAST SURGICAL HISTORY: Unknown.
PHYSICAL EXAMINATION: In the emergency room vital signs:
98.5, 115, 20, blood pressure 70/40. General appearance: An
anxious female in no acute distress. Head, eyes, ears, nose
and throat examination is unremarkable. Lungs are clear to
auscultation. Heart is regular rate and rhythm and
tachycardic. Abdominal examination is distended. Extremity
examination was without mottling. Pulse examination with
Dopplerable dorsalis pedis pulses.
HOSPITAL COURSE: The patient was initially seen in the
emergency room. Ultrasound of the abdomen was obtained and
found a ruptured abdominal aortic aneurysm. The patient was
taken to emergent surgery. She underwent an open repair with
a tube graft and a jump graft from the tube graft to the left
femoral artery. The patient was then transferred intubated to
the surgical Intensive Care Unit for continued care. The
patient required initially fluid boluses multiple for low
urinary output with good response. The following early A.M.
the patient was noted to have mesenteric ischemia and she
returned to the operating room for exploratory laparotomy and
ileocecotomy. The patient was placed on triple antibiotics
and Vancomycin, levofloxacin and Flagyl. On postoperative day
her platelet count was noted to be low and a hit panel was
sent which was negative for initially the heparin was
discontinued and restarted once the result was known. Patient
required transfusion for blood loss anemia. She had elevated
liver function tests secondary to her peripheral propofol and
this was discontinued. She also had triglyceridemia secondary
to her propofol and this was converted to another [**Doctor Last Name 360**].
Total parenteral nutrition was begun. Patient was returned to
the operating room on [**2131-7-16**] because of pancreatitis.
She underwent an exploratory laparotomy of the greater an
lesser sac with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] tube placement and ileostomy and
mucous fistula. Patient returned to the Surgical Intensive
Care Unit for continued care. The patient had an episode on
[**7-18**] of atrial fibrillation which responded to Lopressor.
Patient was rate controlled. The Swan was discontinued on
[**7-18**] and a central line was placed. Tube feeds were
started on [**7-19**].
Patient developed a temperature of 101.4 on [**7-20**]. Cultures
were sent. She returned to the operating room for open
abdominal exploration, wash out, VAC dressing placement and
discontinuation of the left pleural tube. On [**7-21**] the [**Location (un) 109**]
was discontinued. Patient had a transfusion reaction. On
[**7-25**] the fever work was continued. The blood cultures
grew gram positive cocci and yeast. The urine cultures grew
pseudomonas and yeast. Infectious disease was consulted for
recommendations as to appropriate antibiotics and therapy.
Cardiology was consulted for her recurrent atrial
fibrillation. The patient converted on her own. Her central
line was changed. Because of persistent fevers a CT of the
abdomen was obtained which did show fluid collections in the
lesser sac and a head CT was obtained which showed a basilar
cerebral artery aneurysm. On [**7-26**] the patient was
returned to operating room for exploratory laparotomy and
wash out with debridement of the pancreatic head and body.
Postoperatively she became hypotensive and required pressor
support. Pressors were weaned the next postoperative day and
she returned on [**7-29**] to the operating room for
exploratory laparotomy with wash out and a second pancreatic
debridement, VAC dressing placement. Her central line was
changed on [**7-29**] and she returned again that day for an
exploratory laparotomy for mid colic artery bleeding. On
[**7-31**] she went back to surgery again for exploratory
laparotomy and wash out with debridement of the pancreas and
VAC dressing placement.
On [**8-2**] the patient had a tracheostomy placed. On [**8-4**] and [**8-6**] she had wash out of the abdomen at bedside.
On [**8-7**] the VAC dressing was changed. On [**8-9**] the
patient underwent a split thickness skin graft to the lower
[**1-25**] of her abdominal wall without complication. Her central
line was changed at that time. The patient had been on Zosyn
and Flagyl since infectious disease consult and Zosyn was at
this time changed to Gentamicin. Patient VAC dressing was
changed again on [**8-14**] and a repeat CT scan was obtained
and a tracheostomy mask trial was begun. The patient's H2
blocker was discontinued because of persistent fevers. The
patient was required to go back on CPAP and on [**8-17**] was
weaned to a tracheostomy collar. On [**8-19**] the
tracheostomy was changed to a fenestrated tracheostomy. On
[**8-20**] ambulation with an abdominal binder was begun. The
patient required multiple fluid boluses for lower urinary
output and she was put back on bed rest.
She also complained of left eye vision loss. She was seen by
ophthalmology. Recommendations were to begin prednisone and
obtain a temporal artery biopsy for ischemic optic neuritis.
Neurology was also consulted at the same time. Multiple head
CTs were obtained. A speech and swallow evaluation was
obtained on [**8-21**] which was negative for aspiration and
the patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 46053**] Trache valve placed. Rheumatology
was consulted on [**8-23**] to add inputs to concern whether
the patient had an ischemic optic neuritis or whether she had
a giant cell arteritis. Their recommendations were to obtain
ultrasound of the carotids which showed less than 40%
stenosis bilaterally in the internal carotid arteries and to
do a temporal biopsy and if this was negative to take the
patient off her prednisone. On [**8-23**] the patient
underwent a left temporal artery biopsy. The results of this
were negative for giant cell arteritis. Neurology felt that
the patient's symptoms were related to her basilar cerebral
artery aneurysm and neurointerventional radiology was
requested to see the patient for consideration of coilization
of the artery. At this time the patient deferred treatment.
Steroids were discontinued. Recommendations were that the
patient after she recovers from her current hospitalization
course should follow up with neurointerventional radiology
for reconsideration of embolization of her cerebral artery
aneurysm.
The patient continued to run low grade fevers and cultures
did not show a source of infection. In fact, infectious
disease was reconsulted on [**7-27**] and they felt that this
was related to colonization and they would not recommend
restarting antibiotics. The patient continued to work with
physical therapy and occupational therapy while she was
hospitalized. She began bed to chair ambulation the day prior
to discharge to rehabilitation. The patient was discharged in
stable condition. Abdominal wound dressings were dry sterile
dressing with some tubes to suction. These are to remain on
suction and the dressing gets changed daily. The patient has
tracheostomy in place and routine tracheostomy care should be
provided. Downsizing of the tracheostomy can be done at the
rehabilitation.
DISCHARGE MEDICATIONS: Artificial tears 1 drop o.u. p.r.n.
Nystatin cream to affected areas b.i.d.
Miconazole nitrate powder to affected areas p.r.n.
Acetaminophen 325 mg tablets 2 q 4 to 6 hours p.r.n. as
needed.
Lorazepam 1 mg q 4 to 6 hours p.r.n.
Oxycodone/acetaminophen 5/325 per 5 cc, 5 to 10 cc q 4 to
hours p.r.n .
Vitamin A 10,000 unit capsule, 2 capsules daily.
Vitamin E 800 units daily.
Lopressor 50 mg tablets 1.5 tablets t.i.d., a total dose of
75 mg t.i.d.
Ferrous sulfate 325 mg q.d.
Amiodarone 200 mg daily.
Loparidamide 2 mg q.i.d. as needed for ileostomy drainage
greater than 1,000 cc.
Folic acid 1 mg daily.
NPH insulin 100 units, 20 units at breakfast and 10 units at
bedtime with a regular Humulin sliding scale before meals.
FOLLOW UP: Patient should follow up with transplant service,
Dr. [**First Name (STitle) **]. She should call for an appointment in one to two
weeks. She should also follow up with Dr. [**Last Name (STitle) **] in one
to two weeks and should call for an appointment, [**Telephone/Fax (1) 46054**]. She should follow up with Dr. [**Last Name (STitle) 46055**],
neurointerventional radiology, for consideration of treatment
of her various aneurysms. She can call [**Telephone/Fax (1) 15664**] which is
at our institution, [**Hospital1 69**] and
his other office is at the [**Hospital6 1708**], [**Telephone/Fax (1) 46056**].
DISCHARGE DIAGNOSES:
1. Ruptured abdominal aortic aneurysm.
2. Mesenteric ischemia postoperatively.
3. Postoperative respiratory failure requiring tracheostomy.
4. Postoperative blood loss anemia, transfused.
5. Postoperative hypertriglyceridemia consistent with
pancreatitis.
6. Postoperative intermittent atrial fibrillation converted
to normal sinus.
7. Postoperative transfusion reaction.
8. [**Doctor Last Name **] aneurysm by CT scan.
9. Postoperative left ischemic arthritis.
10. Status post left temporal artery biopsy which was
negative for giant cell arthritis.
11. Postoperative fungemia.
12. Postoperative thrombocytopenia, resolved.
13. HIT panel was negative.
14. Bilateral carotid disease less than 40% internal carotid
arteries via carotid ultrasound.
15. Postoperative pseudomonas wound infection.
16. Status post open repair of ruptured abdominal aortic
aneurysm with tube graft and a left jump graft from tube
graft left femoral artery on [**7-13**], exploratory
laparotomy with ileocecotomy of [**7-14**], and exploration
of the lesser sac with [**Doctor Last Name 406**] tube placement ileostomy
with a mucous fistula [**7-16**]. Open abdomen wash out with
VAC dressing and left chest tube removal on [**7-20**].
Exploratory laparotomy and abdominal wash out with
pancreas debridement on [**7-26**] and [**7-29**].
Exploratory laparotomy for middle colic artery bleeding
and VAC dressing on [**7-29**]. Tracheostomy on [**8-2**].
Abdominal wash out at the bedside on [**8-4**] and [**8-6**]. Split thickness skin graft to the lower [**1-25**] abdominal
wall on [**8-9**]. Tracheostomy change to fenestrated
tracheostomy
on [**8-19**] and left temporal artery biopsy on [**8-23**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2131-8-29**] 17:36:33
T: [**2131-8-29**] 19:18:13
Job#: [**Job Number 46057**]
Name: [**Known lastname **],[**Known firstname 1647**] A Unit No: [**Numeric Identifier 8477**]
Admission Date: [**2131-7-13**] Discharge Date: [**2131-9-4**]
Date of Birth: [**2067-9-19**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 726**]
Addendum:
[**Date range (1) 8478**] Trach changes to Portex #6cuffed and Pessiemuere vale
placed. patient tolerating this vewry well. Diet advance to
house diet and boost tid.
Wound vac placed and last changed [**2131-9-1**] due for change [**9-4**].
VAC suction @ 125mm pressure.
Patient transfered to rehab in stable condition.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**]
Completed by:[**2131-9-3**]
|
[
"682.2",
"486",
"117.9",
"998.59",
"427.31",
"041.7",
"577.0",
"584.9",
"369.60",
"437.3",
"287.5",
"999.8",
"553.21",
"518.5",
"557.0",
"599.0",
"428.0",
"567.2",
"285.1",
"441.3",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"39.25",
"38.21",
"53.61",
"99.69",
"46.11",
"31.1",
"31.74",
"46.01",
"45.72",
"86.69",
"52.22",
"54.4",
"96.6",
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
11970, 12197
|
9253, 11947
|
7881, 8608
|
1172, 7857
|
704, 714
|
8620, 9232
|
737, 1154
|
179, 216
|
245, 568
|
591, 680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,831
| 117,035
|
484
|
Discharge summary
|
report
|
Admission Date: [**2171-9-26**] Discharge Date: [**2171-10-1**]
Date of Birth: [**2095-11-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
sdfsda
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known lastname 4048**] is a 75 y.o. female with pertinent history of MDS x 2
years, chronic anemia requiring blood transfusions (last
transfusion 1 wk prior to admission), and recent admission for
melanotic stools w/ neg GI workup. Pt was recently discharged
[**9-16**] from [**Hospital1 **] following admission for GIB, and subsequent
stabilization w/o intervention. Following discharge reports that
she was feeling tired and weak, with decreased appetite. +for
black, tarry stools (states she has had this intermittently x
6-8 weeks). Denies BRBPR. No abdominal pain. Went to Heme/onc
clnic on day of admission and was found to have a HCT of 10.
Sent to ED where she was af, hr 120, bp 122/56, received 2U PRBC
(with appropriate Hct rise [**9-8**]), and 2L NS. She had been on
Cipro for treatment of asymptomatic UTI x 1day which was changed
on hospital day 2 to Cefepime since she was considered to be
functionally neutropenic with an ANC of 320 and declining. She
was seen in the unit by GI who performed a push enteroscopy on
[**9-27**] despite recent negative EGD and found no source of bleeding
to mid jejunum. She continued to have melenic stools but vitals
remained stable. Despite having no previous cardiac history, she
also developed a mild troponin leak that peaked at 1.04 and CK's
of 160's with 17MB. She was never symptomatic and was treated
medically with aspirin and B-blocker. In total she was
transfused another 4 units PRBC's with appropriate increase in
Hct from 17.4-29.3, which has been stable for the last 12 hours
Past Medical History:
1) MDS-evaluated [**1-22**] for anemia leukopenia and fatigue seen by
DR. [**First Name (STitle) **] with bone bx=nondiagnostic. Cont to be followed and
started on procrit for anemia. In [**5-25**] repeat biopsy revealed
similar patttern to previous but for unclear reason was
diagnosed with MDS. Pt had moderate response to procrit. in [**2-24**]
pt developed more profound anemia and at that point developed
guaiac positive stools and has required occasional transfusion.
2) Melena/guaiac positive stools, s/p workup positive only for
ileal diverticulosis. [**6-18**] Colonoscopy- Diverticulosis of the
entire colon
Otherwise normal Colonoscopy to cecum
[**6-18**] EGD- Normal EGD to second part of the duodenum
[**6-28**] SBFT Ileodiverticulosis without evidence of diverticulitis.
No source of bleeding identified within the small bowel.
[**7-18**] Colonoscopy- Polyps in the proximal ascending colon,
mid-ascending colon and transverse colon (polypectomy)
Diverticulosis of the sigmoid colon
Otherwise normal Colonoscopy to cecum
Capsule Enteroscopy
1. Erythema and pethiciae in the duodenum
2. Small non bleeding ileal diverticulum
3. No site of GI bleding
3) Osteoarthritis
4) diphtheria in [**2115**] treated with penicillin
5) repeatedly positive PPD due to work-related TB exposures and
negative CXR (per pt's report)
6) a CVA in [**2159**] that led to right-sided hemiparesis (minimal
residual) and increased distractibility
7) a fall in [**2168-11-2**] that caused a right wrist fracture
8) hypothyroidism
9) history of cystitis
10) cataracts
11) HTN
12) hypercholesterolemia
13) back pain
14) hip fx, s/p surgery [**9-25**]
Social History:
Pt lives alone in senior living facility. She has someone who
helps her with her grocery shopping, laundry, and her son [**Name (NI) 4049**]
helps her out also when needed. Used to work as a PN. Her Niece
is her proxy, as she lives the closest - pt. has two sons, but
they are further away. She lives alone in a 1 bedroom at a
senior living facility. She smoked [**11-23**] PPD x 60 years, and used
to drink 4-5 drinks/night, but her last drink was months ago, as
she "lost her taste for it." She denies any IVDU.
Family History:
non-contributory: She had 7 brothers and sisters. 1 brother
died of colon CA, and one sister also died of colon CA. Her
mother died in her late 60s from
CAD and obesity. Her father had a cerebral hemorrhage.
Physical Exam:
t 98.7, hr 86, bp 120/48, r18 100% 2L NC
PERRLA. Pale sclera.
Diffuse white lesions of tongue.
7cm JVP. No cervical/sm/sc LA
Regular s1,s2. no m/r/g
LCA b/l
+bs. soft. nt. nd. Liver margin palpable at lower costochondral
border.
No le edema.
2+ dp pulses b/l. Pale palms.
Pertinent Results:
CBC:
[**2171-9-26**] 09:36PM WBC-1.7* RBC-2.04*# HGB-5.9*# HCT-17.4*#
MCV-85 MCH-28.8 MCHC-33.9 RDW-16.9*
[**2171-9-26**] 05:20PM PLT SMR-LOW PLT COUNT-100* LPLT-2+
[**2171-9-26**] 05:20PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
Chemistries:
[**2171-9-26**] 11:00AM GLUCOSE-114* UREA N-54* CREAT-1.6* SODIUM-138
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-20* ANION GAP-14
[**2171-9-26**] 11:00AM LD(LDH)-242 CK(CPK)-62 TOT BILI-0.5
[**2171-9-26**] 11:00AM CK-MB-NotDone cTropnT-0.21*
Coags:
[**2171-9-26**] 11:00AM PT-13.8* PTT-25.0 INR(PT)-1.2
UA:
[**2171-9-26**] 07:10PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2171-9-26**] 07:10PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2171-9-26**] 07:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
CXR: No acute cardiopulmonary process
ECG: 100 bpm, nl axis, nl intervals, sinus, STd in II,F,V3-V6,
new compared to ecg of [**9-16**]
Brief Hospital Course:
1. [**Name (NI) 4056**] Pt has undergone extensive endoscopic workup which has
all been negative, although she continued to have melenic stools
now with no BM x 5d. Difficult to assess what proportion of
anemia is due to GIB versus progressoin of her MDS. History of
four known RBC antigens to match versus. She received "weakly
incompatible" blood, although hemolysis labs neg. Four units
cross typed and matched in blood bank waiting but Hct remained
stable >72 hours but no BM so couldn't assess for melena. She
was discontinued aminocaproic acid and GI recommended tagged RBC
scan if pt rebleeds.
2. Elevated troponin- Pt small troponin leak with ST depressions
on ECG consistent with demand ischemia in the setting of anemia.
ECG changes now resolved and planned to transfuse as above and
medically manage with B-Blocker but hold on ASA due to bleeding
risk.
3. UTI- although asymptomatic and afebrile, pt is neutropenic
and was being treated more aggressively as neutropenic fever
with Cefepime 2g IV q8h day discontinued [**9-30**] since UA clear. No
need for further antibiotic treatment was advised.
4. MDS-Pt cont declining ANC with otherwise stable cell lines.
Decline coincides with starting Cefepime and metoprolol although
leukopenia is no a major SE of these meds. Plan was to start pt
on thalidomide after discharge today and will need weekly
procrit and CBC checks by VNA.
5. Hypothyroidism-cont on outpatient dose levothyroxine
6. Oral thrush-appears to have resolved after using Nystatin S
and S.
7. LBP-likely due to MDS. Well controlled on percocet elixir
although pt not requiring greater than every 24 hours while in
hospital.
Medications on Admission:
1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
4. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) as needed.
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Ciprofloxacin 500mg po qday
Discharge Medications:
1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 2-5 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*300 ML(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. 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:*0*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Aminocaproic Acid 500 mg Tablet Sig: Four (4) Tablet PO Q6H
(every 6 hours).
Disp:*480 Tablet(s)* Refills:*2*
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
10. Procrit 40,000 unit/mL Solution Sig: One (1) 40,000u dose
Injection once a week.
Disp:*12 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Anemia
Urinary tract infection
Discharge Condition:
Hematocrit and Vitals stable
Discharge Instructions:
If you experience any fever, chills, nausea, vomiting, bloody or
black stool, or increasing diziness you should call your doctor
and if he/she is not available you should go to the emergency
room. You will also start on your Thalidomide therapy today
after leaving the hospital which you should take as prescribed
by Dr. [**Last Name (STitle) **].
Followup Instructions:
Please schedule an appointment with Dr. [**Last Name (STitle) 1266**] or Dr. [**Last Name (STitle) **]
in the next 1-2 weeks for post hospitalization follow-up.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2171-11-26**] 2:00
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,031
| 152,173
|
39756
|
Discharge summary
|
report
|
Admission Date: [**2175-10-4**] Discharge Date: [**2175-10-6**]
Date of Birth: [**2095-10-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2248**]
Chief Complaint:
Elective Cardiac Catheterization
Major Surgical or Invasive Procedure:
Cardiac Catheterization with deployment of 3 drug eluting stents
History of Present Illness:
79 yo female with hx Sjogren's Syndrome, HTN, HLD with
complaints of new onset exertional anginal symptoms with
diaphoresis and lightheadedness, found to have abnormal sress
test, admitted for cardiac catheterization.
.
The patient reports she has been experiencing progressively
worsening dizziness, nausea, and diaphoresis on exertion over
the past year. About 2-3 months ago, she began experiencing
worsening symptoms of lightheadedness, nausea, diaphoresis, and
weakness with climbing stairs and when she cooked or did
housework for about an hour. She became more sedentary to avoid
the symptoms, though she is normally very active. Due to these
symptoms, the patient underwent a persantine MIBI at at [**Hospital 3856**] on [**2175-9-26**], which showed a moderate sized septal infarct in
addition to anteroseptal and apical ischemia with an LVEF of
68%. She was referred to [**Hospital1 18**] for cardiac catheterization.
.
Of note, in the setting of her lightheadedness symptoms, her
amlodipine dose was recently decreased by half to 2.5mg daily
with no impact in her symptoms. She denies presyncope or
syncope.
.
In the cath lab, the patient was found to have 1 vessel disease
with 90% stenosis of the LAD and had three DES placed to the
LAD. She complained of significant back pain between her
scapula, and also had nausea and emesis. During the
intervention, the LAD was dissected. ~425cc of contrast was
used during the procedure. She was admitted to the CCU for
further monitoring.
.
Of note, the patient has had unchanged chronic back pain for
years, which she describes as pain between her scapula which
occurs when she is under significant emotional stress or when
she is fatigued.
.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: No prior CABG, PCI, Pacing/ICD
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Sjogren's syndrome
Anxiety
Moderate Arthritis
Tonsillectomy
Chronic Back pain
Social History:
Tobacco: Denies.
Alcohol: Denies.
Drugs: Denies.
Originally from [**Country 2784**]. Married. Owns her own business
manufacturing military boot laces loops.
Family History:
Mother died of MI at 65yo, two maternal aunts died of MIs in
60's.
Physical Exam:
On Admission:
VS: T=95.8 BP=133/63 HR=68 RR=13 O2 sat=99%RA
GENERAL: WDWN in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of [**8-28**] cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB anteriorly and laterally, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. R groin site with small amount of blood
around angioseal closure site.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: 2+ DP 2+ PT 2+
.
On Discharge:
VS: Tm/Tc: 98.2/98.2, BP: 112/57 (112-141/52-75), HR: 73
(64-74), RR: 18 (16-18) O2 sat: 95%RA
GENERAL: WDWN in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of [**8-28**] cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB anteriorly and laterally, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. dressing C/D/I
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ radial 2+ DP 2+ PT 2+
Left: Carotid 2+ radial 2+ DP 2+ PT 2+
Unchanged from prior
Pertinent Results:
[**2175-10-4**] 09:30PM BLOOD WBC-5.6 RBC-3.95* Hgb-12.2 Hct-34.7*
MCV-88 MCH-30.8 MCHC-35.1* RDW-13.7 Plt Ct-197
[**2175-10-5**] 04:30AM BLOOD WBC-6.4 RBC-3.97* Hgb-12.1 Hct-34.8*
MCV-88 MCH-30.5 MCHC-34.8 RDW-13.6 Plt Ct-199
[**2175-10-6**] 05:35AM BLOOD WBC-5.9 RBC-3.90* Hgb-11.9* Hct-35.7*
MCV-91 MCH-30.6 MCHC-33.5 RDW-13.6 Plt Ct-206
[**2175-10-4**] 09:30PM BLOOD PT-13.7* PTT-30.6 INR(PT)-1.2*
[**2175-10-4**] 09:30PM BLOOD Plt Ct-197
[**2175-10-5**] 04:30AM BLOOD PT-13.0 PTT-23.6 INR(PT)-1.1
[**2175-10-5**] 04:30AM BLOOD Plt Ct-199
[**2175-10-4**] 09:30PM BLOOD Glucose-154* UreaN-12 Creat-0.7 Na-138
K-4.2 Cl-103 HCO3-28 AnGap-11
[**2175-10-5**] 04:30AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-140
K-3.3 Cl-104 HCO3-27 AnGap-12
[**2175-10-6**] 05:35AM BLOOD Glucose-97 UreaN-12 Creat-0.7 Na-137
K-4.0 Cl-102 HCO3-28 AnGap-11
[**2175-10-4**] 09:30PM BLOOD CK(CPK)-53
[**2175-10-5**] 04:30AM BLOOD CK(CPK)-151
[**2175-10-5**] 01:00PM BLOOD CK(CPK)-169
[**2175-10-4**] 09:30PM BLOOD CK-MB-4 cTropnT-0.03*
[**2175-10-5**] 04:30AM BLOOD CK-MB-19* MB Indx-12.6* cTropnT-0.18*
[**2175-10-5**] 01:00PM BLOOD CK-MB-19* MB Indx-11.2* cTropnT-0.21*
[**2175-10-4**] 09:30PM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2
[**2175-10-5**] 04:30AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 Cholest-147
[**2175-10-6**] 05:35AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
[**2175-10-5**] 04:30AM BLOOD Triglyc-70 HDL-72 CHOL/HD-2.0 LDLcalc-61
LDLmeas-61
.
Echocardiogram ([**2175-10-5**]):
Conclusions
Left Ventricle - Ejection Fraction: 45% to 50%
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with mild hypokinesis of
the mid to distal anterior septum and anterior wall. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) 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. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
IMPRESSION: Mild focal LV systolic dysfunction consistent with
LAD ischemia/infarction. No pathologic valvular abnormality
seen.
.
Cardiac Catheterization report was pending at the time of
discharge.
Brief Hospital Course:
79 yo female with hx Sjogren's Syndrome, HTN, HLD presenting
with exertional angina and abnormal stress test, admitted
following a complicated cardiac catheterization.
.
# CAD: The patient denies frank chest pain, and describes her
anginal equivalent as diaphoresis, nausea, lightheadedness, and
weakness presenting as atypical chest pain. Persantine MIBI on
[**2175-9-26**] at [**Hospital3 1280**] showed moderate sized septal infarct and
anteroseptal and apical ischemia. Cardiac catheterization
revealed 1 vessel disease with 90% stenosis of the LAD,
complicated by dissection of the LAD during intervention.
Patient is now s/p 3 DES to the LAD and denies symptoms
including chest pain, dyspnea, diaphoresis, lightheadedness,
nausea. She was monitored in the CCU post procedurally and did
well. She had no episodes of chest pain and her EKGs remained
unchanged. Her enzymes were trended with a slight bump
associated with the dissection. She had an echo that showed a
depressed EF to 45-50% and evidence of septal wall infarct. She
was loaded with plavix and placed on [**Hospital1 **] dosing for one week to
be followed by daily dosing. Her aspirin 325mg was continued.
We initiated metoprolol and discontinued her amlodipine. She
was continued on her statin 40mg. We did not start an ACEI out
of concern for her kidney function with a high contrast load.
She will need to be started on a small dose of ACEI as an
outpatient so long as her kidney function remains normal.
.
# LAD Dissection: Patient with LAD dissection during
catheterization, s/p 3 DES for the dissection. She had no events
on telemetry during her stay. Her EKGs were unchanged with a
sinus rhythm and LBBB with elevated j points, but no changes
after catheterization. Cardiac enzymes were trended and had a
slight expected increase in troponins. Repeat EKGs were
unchanged from prior.
.
# Renal Function: Patient with baseline normal renal function.
She recieved ~425cc of contrast during the catheterization.
Given the amount of contrast and the patient's age, she was at
increased risk for contrast induced nephropathy. We gave 2L of
normal saline as well as 2 doses of mucomyst and 6hours of
sodium bicarb for renal protection. Her creatinine was at 0.7
on discharge. We will have her get labs drawn Monday to make
sure her renal function is stable.
.
# Hypertension: Normotensive while in the CCU. We discontinued
her home amlodipine and initiated metoprolol 12.5mg [**Hospital1 **] with
transition to metoprolol xl 25mg daily on discharge.
.
# Migraines: She has a history of migraines, and while in house
she was given IV compazine which helped. She takes PR migraine
medications at home and we gave her a dose before she left.
.
# Chronic Back Pain: Stable. We gave Tylenol prn and one dose
of flexeril 5mg which worked.
.
# Sjogren's: Stable, we continued Hydroxychloroquine 200 mg per
her home regimen.
Medications on Admission:
- Amlodipine 2.5mg daily
- Simvastatin 40mg daily
- Aspirin 325mg daily
- Hydroxychloroquine Sulfate 200mg daily
- Prevacid 15mg daily
- Ambien 2.5-5mg qhs prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours.
Disp:*60 Tablet(s)* Refills:*2*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 6 days: Please take your evening dose tonight ([**10-6**])
and take 1 pill two times a day until [**10-11**].
Disp:*12 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day:
Please take one pill by mouth daily starting [**2175-10-12**].
Disp:*30 Tablet(s)* Refills:*11*
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Outpatient Lab Work
Please draw Chem 7 on Monday [**2175-10-9**] and fax results to Dr.
[**First Name (STitle) **] [**Name (STitle) **] Fax: [**Telephone/Fax (1) 84233**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Coronary Artery Disease
Migraines
.
Secondary Diagnoses:
Hypertension
Hyperlipidemia
Decreased left ventricular systolic function
Sjogren's syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 18**] for a cardiac catheterization to fix
a blockage in one of the arteries in your heart. During the
procedure, 3 stents were placed to open the obstruction in the
artery to help improve blood flow. The procedure was
complicated because your artery has a lot of twists and turns,
and because of that, the wire formed a flap in the wall of the
artery. The flap was fixed with one of the stents that were
placed. You were monitored in the cardiac intensive care unit
to closely watch for signs of chest pain. You did well
overnight and were transitioned to the floor, and you were in
good condition at the time of your discharge.
.
Also during the procedure, because of the difficulty, a lot of
contrast dye was used. Contrast can cause injury to the
kidneys. We gave you IVF and medications to protect your
kidneys after the procedure your kidney function was excellent.
.
We made the following changes to your medications:
We STOPPED your amlodipine 2.5 mg daily
We STOPPED your lansoprazole (Prevacid) 15mg daily
We ADDED metoprolol XL 25 mg by mouth daily
We ADDED clopidogrel (Plavix) 75 mg by mouth twice a day until
[**2175-10-11**]. Then take clopidogrel (Plavix) 75 mg by mouth once a
day ongoing (starting [**2175-10-12**])
We STARTED Ranitidine 150 mg by mouth 2 times a day
.
You will need to start an ACE inhibitor at the time of your next
primary care doctors [**Name5 (PTitle) 648**].
.
Please have your labs drawn next Monday to check your kidney
function. The results will be faxed to your primary care
physicians office.
.
Please drink plenty of fluids at home.
.
It has been a pleasure taking part in your care.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 7331**]
Phone: [**0-0-**]
[**Year (4 digits) **]: Friday [**2175-10-13**] 10:00am
We are working on a follow up [**Year (4 digits) 648**] in Cardiology with Dr.
[**First Name (STitle) **] [**Name (STitle) 66097**] within 1 month. The office will contact you at
home with an [**Name (STitle) 648**]. If you have not heard or have any
questions please call [**Telephone/Fax (1) 2258**]
.
Fax: [**Telephone/Fax (1) 84233**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2264**]
Completed by:[**2175-10-6**]
|
[
"411.1",
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"414.12",
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icd9cm
|
[
[
[]
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[
"36.07",
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icd9pcs
|
[
[
[]
]
] |
11684, 11690
|
7435, 10343
|
349, 416
|
11902, 11902
|
4929, 7412
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11917, 12029
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2706, 2758
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2950, 3109
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,410
| 197,017
|
24142
|
Discharge summary
|
report
|
Admission Date: [**2168-3-31**] Discharge Date: [**2168-4-7**]
Date of Birth: [**2119-7-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Suicidal Ideation and ETOH intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48 yoM w/ a h/o depression and anxiety presents to the ER with
suicidal ideation. The patient recently had a death of his
sibling (sister, 2 months ago) and subsequently has suffered an
emotional decompensation. He has also had both visual (something
out of the corner of his eye, either a light or a mouse / rat)
and auditory hallucinations (woman crying and someone telling
him to kill himself x few weeks). He has been more depressed
lately and has started drinking. Given his depression and
suicidal ideation he called 911 as he was feeling like his
suicidal ideation was worsening, he had planned to shoot himself
but did not have a gun. He has had SI in the past, no prior
plans or attempts. He has been depressed since the age of 10,
with anxiety as well but no manic periods, and a history of
hallucinations in the past as well. He has a previous history of
ETOH abuse but been sober with AA since [**2153**]. He drinks about 2
pints of vodka per day. Has not stopped in the past 2 months but
prior has had DTs and seizures. His last drink was the day prior
to visit but not sure the timing.
.
The patient also states he has a history of "stomach cancer"
based on a blood test and complains of intermittent blood in his
stool and vomitus. Last blood in his BM and hematemesis was [**2-24**]
days ago, no BMs since then. He states the blood is pink. He
also has a history over the past few weeks of black stool.
.
The patient complains of darkening of his urine but no hematuria
or dysuria, no frequency / urgency.
.
He notes diffuse / upper abdominal pain, which has been ongoing
for a few days.
.
He feels thirsty, has had frequent falls including a fall with
loss of consciousness. He has no Fevers but occasional chills,
has had a 50 pound weight loss over the past few months.
.
The patient was initially noted to be tachycardic in the ER
(ranging from 116 to 130, this improved to 90 after IVF). The
patient was not ever hypotensive. He was noted to have a gap
acidosis of unclear cause (possibly ETOH). His ETOH level was
430 at 4 a.m. Psychiatry was also consulted in the ER. He was
given thiamine, folate and a multivitamin. Serum tox negative, U
tox not yet sent.
.
Past Medical History:
Depression (seems like he has reported history of psychotic
features but no mania) - since the age of 10, on celexa which he
states is not working
Anxiety
ETOH abuse, sober since [**2153**] then relapsed 2 months prior to
admission, with 2 pints of vodka per day. H/o DTs and seizures.
in AA prior to relapse.
Hypothyroid
COPD
Social History:
SOCIAL HISTORY: lives in [**Location **] alone. ETOH abuse as
above. Has sister who died 2 months ago, but has support from
other sister who lives in the [**Hospital3 **]. He has been smoking
for 39 years, roughly 1 pack per day. He has used cocaine
remotely, no IVDU ever.
Family History:
FAMILY HISTORY: father w/ MI at age 62, sister with bipolar.
Physical Exam:
PHYSICAL EXAM:
Vitals - BP: 132/92 HR: 110 RR: 11 02 sat: 95% on 2L
GENERAL: NAD, AOX3
HEENT: MM dry, JVP 8cm, EOMI, sclera anicteric, conjunctiva pink
CARDIAC: tachycardic but regular, no m/r/g
LUNG: CTAB
ABDOMEN: soft, mildly distended, tender to RUQ and epigastrium,
no rebound, BS+, +shifting dullness and fluid wave, liver edge
felt 2cm below R costal margin and is tender, no splenomegaly.
Minimal yellow stool in rectal vault, guaic negative, no rectal
masses.
EXT: WWP, DP and PT 2+ bilaterally, no edema
NEURO: AOx3, resting tremor, no nystagmus
Pertinent Results:
==================
ADMISSION LABS
==================
[**2168-3-31**] 04:42AM BLOOD WBC-6.2 RBC-4.67 Hgb-14.4# Hct-43.3
MCV-93 MCH-30.8 MCHC-33.2 RDW-21.9* Plt Ct-83*#
[**2168-3-31**] 04:42AM BLOOD Neuts-71.6* Lymphs-19.5 Monos-7.6 Eos-0.3
Baso-1.1
[**2168-3-31**] 09:45AM BLOOD PT-12.2 PTT-26.8 INR(PT)-1.0
[**2168-3-31**] 09:45AM BLOOD Fibrino-201
[**2168-3-31**] 04:42AM BLOOD Glucose-61* UreaN-13 Creat-0.8 Na-138
K-3.7 Cl-91* HCO3-15* AnGap-36*
[**2168-3-31**] 07:50AM BLOOD ALT-133* AST-240* AlkPhos-100 TotBili-0.5
[**2168-3-31**] 02:45PM BLOOD Calcium-7.1* Phos-2.8 Mg-1.4*
[**2168-3-31**] 09:56AM BLOOD Type-ART pO2-105 pCO2-38 pH-7.38
calTCO2-23 Base XS--1
[**2168-3-31**] 09:56AM BLOOD Lactate-3.1*
===============
RADIOLOGY
==============
ABDOMINAL ULTRASOUND:
FINDINGS: The liver is mildly echogenic, suggesting fatty
infiltration. No
focal liver lesion is identified. There is no biliary
dilatation, and the
common duct measures 0.2 cm. The portal vein is patent with
hepatopetal flow. The gallbladder is partially filled with
sludge, but no gallstones are identified. The pancreas is
obscured from view by overlying bowel. The
spleen is unremarkable and measures 7.0 cm. There is no
hydronephrosis. The right kidney measures 10.0 cm, and the left
kidney measures 10.8 cm. The aorta is of normal caliber
throughout. There is no ascites identified in the abdomen.
IMPRESSION:
1. Mildly echogenic liver, which may indicate probable fatty
infiltration.
This can be associated with more significant liver disease such
as
cirrhosis/fibrosis. No focal liver lesion identified.
2. Sludge within the gallbladder, but no stones identified.
3. No splenomegaly and no ascites identified.
CHEST X-RAY:
FINDINGS: AP single view of the chest has been obtained with
patient in
sitting upright position. Comparison is made with the next
preceding PA and lateral chest examination of [**2167-12-19**]. The
heart size remains normal. No typical configurational
abnormality is identified. Thoracic aorta is stable. No local
contour abnormalities. The pulmonary vasculature is not
congested. There exists a local thickening of the pleural space
on the right base extending in posterior direction and
containing several local calcifications.
Coinciding with this is an old deformity in the mid right
clavicle, all
suggestive of old trauma, but stable in comparison with previous
examinations, including a chest CT examination of [**2167-1-4**].
Thus, no evidence of new acute parenchymal infiltrates or CHF in
this 48-year-old male patient with signs of hypoxia and cough.
Brief Hospital Course:
Mr. [**Known lastname **] is a 48 year old male with a history of ETOH abuse
and depression / anxiety presents with ETOH intoxication and
suicidal ideation.
.
# Suicidal Ideation: The patient has a longstanding history of
depression, no attempts but thoughts of suicidal ideation.
Patient was evaluated by psychiatry and felt not to be a [**Doctor Last Name 13205**]
to himself. Patient was restarted on home SSRI and at time of
discharge psychiatry felt that he needed further inpatient
treatment for his depression.
.
# ETOH withdrawal: On admission, showing signs of ETOH
withdrawal with tremor and tachycardia, no evidence of DTs.
Patient was treated at first with IV valiaum until withdrawal
improved, then transitioned to PO Valium per CIWA > 10. Patient
required 150mg of total valium during MICU stay, and was
transferred to the floor. Patient remained stable without any
need for valium as dictated by his CIWA scale, which was
discontinued on [**4-4**] per psychiatry.
.
# AG acidosis: Likely due to ethanol. Gap improved with
hydration and with time, resolved at time of transfer to the
floor.
.
# Abdominal Pain: given history of ETOH use, ddx included ETOH
hepatitis (especially given liver tenderness), no jaundice on
exam. In addition could be pancreatitis. Also, given a history
of hematemesis, melena, and BRPRB could be gastric malignancy,
vs. ulcer, vs. gastritis/duodenitis. RUQ ultrasound with mildly
echogenic liver, however without biliary obstruction. Patients
symptoms at time of discharge were improved with no complaints
of abdominal pain.
.
# GI Bleed: Subjective complaints of GI bleed. The patient has
been adverse to EGD in the past. Possibilities include ulcer,
malignancy, etc as above. Hct stable during admission and
patient's guiac was negative on admission and throughout
hospitalization. Defer further workup to outpatient provider.
.
# Thrombocytopenia: normal WBC and HCT. Baseline plts relatively
normal but in-patient platlets nadired at 47. The etiology was
felt to be from acute alcohol damage, however, persistent liver
disease, ITP, myelosuppresion from ETOH (less likely given no
anemia or leukopenia), DIC were all considered. Abdominal
ultrasound on [**3-31**] showed mildly echogenic liver, which may
indicate probable fatty infiltration. No focal liver lesion was
identified although they couldn't rule out cirrhosis.
Fortunately, platlets trended up with cessation of alcohol and
were 314 on the day of discharge.
.
# Hypothyroidism: Patient has known hypothyroidism and was being
maintained on 25 mcg synthyroid daily. His TFTs were checked as
part of his depression work. They revealed persistent
hypothyroidism. As such, synthyroid was increased to 50 mcg
daily on [**4-3**]. These will need to be rechecked in 4 weeks.
.
# Subjective sense of gait instability. Patient felt unsteady
on his feet which was a change from his baseline. He had a head
CT on admission that was negative for acute change. PT was
consulted and they gave him a cane which significantly improved
sense of gait instability. PT did not feel there was any need
for continued PT at a psychiatric facility. He previously used
meclizine for vertigo, which was restarted as an inpatient to
further improve his sense of gait instability. He felt
comfortable ambulating independently at the time of discharge.
.
# FEN: Patient tolerated a regular diet
.
# PPX: PPI, pneumoboots, bowel regimen. Patient did not receive
sc heparin given his history compatible with GI bleed.
.
Mr. [**Known lastname **] was medically cleared for discharge to a psychiatric
facility on [**4-4**], however, he was unable to obtain a psychiatric
bed until [**4-7**], at which time he was transferred to [**Hospital 48616**] for further psychiatric treatment.
Medications on Admission:
Celexa 60mg daily
Levothyroxine 25mcg daily
iron supplementation
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 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 BID (2 times a day).
4. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for vertigo.
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation twice a day as needed for shortness of
breath or wheezing.
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze,
sob.
10. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze, sob.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 44097**]
Discharge Diagnosis:
Primary:
Alcohol intoxication complicated by alcohol withdrawl
Alcoholic ketoacidosis
Alcoholic hepatitis
Depression with suicidal ideation
Hypothyroidism
Meniere's disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Dear Mr.[**Known lastname **],
You were admitted to [**Hospital1 69**] with
alcohol intoxication, depression and suicidal ideations. You
went into alcohol withdrawl. You were admitted to Medical
Intensive Care Unit for close monitoring. You were evaluated by
both Medical and Psychiatric teams. You will be discharged to
inpatient Psychiatric unit for further management of your
depression.
The following changes were made to your medications:
INCREASE Levothyroxine from 25 mcg a day to 50 mcg a day
START Folic acid
START Thiamine
START Meclizine
Please follow up with your primary care doctor within one week
of discharge.
Followup Instructions:
Will need inpatient psychiatric treatment
Will need primary care doctor follow up within one week of
discharge from the inpatient psychiatric unit. You will need
follow up TSH in one month.
|
[
"276.2",
"496",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11380, 11428
|
6486, 10259
|
354, 361
|
11645, 11645
|
3886, 6463
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12478, 12670
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,236
| 171,579
|
4673
|
Discharge summary
|
report
|
Admission Date: [**2136-2-14**] Discharge Date: [**2136-2-21**]
Date of Birth: [**2054-10-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Fever, hyperkalemia, altered mental staus
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 81 year-old male with a history of CML who presents
with unresponsiveness from [**First Name3 (LF) 3242**] floor. Patient was seen in
clinic today with report of body aches and rigors for the last
several days. Patient was afebrile at the time with out a
leukocytosis. Potassium found to be 6, Cr 2.5 (baseline 2.0).
ANC 5420. Cultures were sent, UA was negative. VS upon
discharge from clinic: T 98.4, HR 80, RR 20, BP 135/69, O2 sat
100% on RA.
Patient had word finding difficulties and went to STAT CT where
he became acutely agitated. He received ativan 0.5mg and became
unresponsive, though VS continued to be stable, 98% on RA. CT
showed no acute bleed. Prior to transfer, patient spiked to
102.5, repeat WBC 11.7.
ROS: Unable to give as patient is unresponsive.
Past Medical History:
CML - On desatinib, dose reduced
CAD s/p CABG [**2114**] (LBBB on previous EKG)
Chronic Diasolic heart failure. (EF 50%)
HTN
Hypercholesterolemia
CRI - Cr baseline 2.0
Anemia of Chronic Disease
TIA [**11/2135**]
Social History:
Occupation: Retired criminal defense attorney. Lives with
daughter. ~ 13 pack-year smoking hx, quit ~ 30 yrs ago. Rare
EtOH, ADL's - independant at baseline.
Family History:
NC
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2136-2-14**] 02:20PM UREA N-54* CREAT-2.5* SODIUM-132*
POTASSIUM-6.0* CHLORIDE-102 TOTAL CO2-21* ANION GAP-15
[**2136-2-14**] 02:20PM ALT(SGPT)-22 AST(SGOT)-27 LD(LDH)-247
CK(CPK)-145 ALK PHOS-78 TOT BILI-0.3
[**2136-2-14**] 02:20PM CK-MB-3 cTropnT-0.02*
[**2136-2-14**] 02:20PM CALCIUM-9.1 PHOSPHATE-4.4 MAGNESIUM-2.6
[**2136-2-14**] 02:20PM WBC-7.3 RBC-3.57* HGB-9.7* HCT-30.3* MCV-85
MCH-27.1 MCHC-32.0 RDW-15.5
[**2136-2-14**] 02:20PM NEUTS-74.5* LYMPHS-16.2* MONOS-7.0 EOS-2.0
BASOS-0.3
[**2136-2-14**] 02:20PM PLT COUNT-182
[**2136-2-14**] 02:20PM GRAN CT-5420
[**2136-2-14**] 04:55PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2136-2-14**] 04:55PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
ECG: AV paced
Imaging:
CXR: R heart border obscured, L hemidiaphragm obscured
CT HEAD W/O CONTRAST Study Date of [**2136-2-14**] 7:44 PM:
IMPRESSION: No acute intracranial hemorrhage or major vascular
territorial infarct. If there is concern for acute ischemia, MRI
with DWI is more sensitive.
Brief Hospital Course:
81 year-old male with a history of CML who presented to clinic
with rigors, hyperkalemia, metabolic acidosis and acute on
chronic renal failure. Admitted for workup and became acutely
agitated in CT. Received iv ativan x1 and became unresponsive.
He was treated with insulin, D50, and kayexylate. He was also
treated for his pneumonia. His altered mental status cleared. We
felt his hyperkalemia may have been due to acute renal failure,
allthough despite fluid challenge to the point of oxygen
requirement, his creatinine had been slow to improve.
He had an abnomrmal blood gas, which was consistent with a
respiratory alkalosis and a metabolic acidosis. In addition to a
urinary anion gap that was posative @ 40, we flt this consistent
with an RTA, possible type 4 RTA, which also could have
contributed to his hyperkalemia. The etiolody of the RTA remains
unclear, but he is currently being treated with bicarbonate
supplements as we feel this will decrease his work of breathing.
Pt. was discharged with bicarbonate supplements and had
outpatient renal follow up.
Altered Mental Status: Concern for infectious process given
fever to 102.5, received cefepime in ED. Cultures send,
received cefepime in clinic. UA negative. Fever curve
gradually decreased during stay and WBC was at 6.5 on discharge.
# Hyperkalemia: Unclear cause, not an issue during floor stay.
# Non Anion Gap Metabolic Acidosis: diarrhea, type 1, 2, 4 RTA,
approached as stated above, sent home with renal follow up.
# CLL: On desatinib, followed here by Dr. [**Last Name (STitle) 410**]. Was held
during his stayin the the [**Hospital Unit Name 153**] and was restarted once back on
the oncology floor. Was discharged with follow up with Dr.
[**Last Name (STitle) 410**] 2 days post discharge.
# CAD s/p CABG [**2114**] (LBBB on previous EKG): No active issues.
# Chronic Diasolic heart failure. (EF 50%): No active issues.
Cont. home valsartan.
# Code: Full code
# Comm: daughter [**Name (NI) 19753**] [**Name (NI) 9483**], cell: [**Telephone/Fax (1) 19754**], his daughter
[**Name (NI) **] [**Name (NI) 19755**] cell is: [**Telephone/Fax (1) 19756**].
Medications on Admission:
Dasatinib 50 mg Tablet qod
Levothyroxine 12.5 mcg qd
Toprol XL 25 mg [**Hospital1 **]
Aspirin 81 mg Tablet qd
Cyanocobalamin
Discharge Medications:
1. Dasatanib Sig: One (1) EVERY 3 DAYS (Every 3 Days).
2. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
Altered Mental Status
Hyperkalemia
Pneumonia
Secondary:
Chronic Myelogenous Leukemia
Discharge Condition:
Stable, conversant, ambulating, eating, drinking, and voiding
without complaints.
Discharge Instructions:
You were admitted for fevers, high values of your serum
potassium, and altered mental status along with evidence of a
pneumonia on a chest x-ray. You were transferred to the
intensive care unit, and then were transferred back to the floor
where you began to recuperate. You received your regularly
scheduled dasatanib injections, and have been scheduled to
receive them in clinic once you leave. In addition, given that
some of the values in your blood were concerning for kidney
disease, we have scheduled you for follow up with a kidney
specialist. Please attend all appointments that have been
scheduled for you. Your next dose of dasatanib is tomorrow.
You have been started on one new medication:
START Sodium Bicarbonate 1300mg two times a day
If you experience any fevers, chills, nausea, vomiting,
diarrhea, constipation, chest pain, loss of consciousness, or
unstoppable bleeding please contact your primary care
provider/primary oncologist immediately.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2136-2-23**] 3:00
2. Provider: [**Name10 (NameIs) 3242**] CHAIR 2 Date/Time:[**2136-3-1**] 9:30
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2136-2-23**] 11:30
Completed by:[**2136-2-22**]
|
[
"272.4",
"584.9",
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"276.7",
"518.81",
"585.9",
"V45.81",
"403.90",
"276.1",
"428.0",
"276.2",
"205.10",
"428.32",
"348.30",
"414.00",
"276.3",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6341, 6392
|
3487, 4568
|
357, 364
|
6531, 6615
|
2372, 3464
|
7633, 8061
|
1611, 1616
|
5815, 6318
|
6413, 6510
|
5666, 5792
|
6639, 7610
|
1631, 2353
|
276, 319
|
392, 1182
|
4584, 5640
|
1204, 1418
|
1434, 1595
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,368
| 107,228
|
40853
|
Discharge summary
|
report
|
Admission Date: [**2173-7-20**] Discharge Date: [**2173-8-1**]
Date of Birth: [**2102-6-11**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
OSH transfer who had enlarged 10 mm CBD
present with bloody ascites and likely hepatic artery
pseudoaneurysm with extravasation
Major Surgical or Invasive Procedure:
[**2173-7-20**]: IR coil embolization
History of Present Illness:
71F transferred from OSH for workup of an enlarged 10 mm CBD
present with bloody ascites and likely hepatic artery
pseudoaneurysm with + extravasation. Pt state that she was in
her usual state of health aside from new onset migraines when
yesterday am she
noted the acute onset of severe abdominal pain. The pain
initially began in the lower and middle abdomen with radiation
to
the back [**11-1**]. Currently pain is localized to RUQ, w/ [**2172-3-26**]
pain.
Nausea accompanied the strongest pain, without emesis. She
describes otherwise normal bowel habits, no fevers, chills,
melena, hematochezia or BRBPR. She was initially evaluated at
[**Hospital 1562**] hospital where RUQ US showed 10 mm CBD with trace free
fluid in the abdomen. HCT was 39 but patient was hypotensive to
the 79/55 and given 3 L of fluid. Ct head was performed because
of new migraines. She was given Unasyn and transferred to [**Hospital1 18**]
where she has remained normo to hypertensive 150s but
persistently tachycardic in sinus. She is currently on her
hypotensive 5th liter of fluid, HCT 31.
Past Medical History:
PMH: Hypothyroid, Recurrent UTIs, Insomnia, Hx of EtOH abuse
PSH: Vagotomy, pyloroplasty and hiatal hernia repair elective
([**2122**], elective )Breast lumpectomy for atypical hyperplasia,
Right shoulder
Social History:
32 years sober from AA, No IVDA, former smoker quit in [**2142**]
Family History:
Brother recently at [**Hospital1 18**] for perforated viscus, AZD, Lung ca
in father
Physical Exam:
98.2 120 142/91 20 97% 4L Nasal Cannula
Gen: NAD, A&Ox3, tan female without pallor.
CVS: Tachycardic , no m/r/g/
Pulm: Clear anteriorly
Abd: tender in RUQ and epigastrium with fullness but no discrete
masses, no pulsations noted. Midline well healed scar.
Rectal: No hemorrhoids, guaiac neg
Ext: WWP
Pertinent Results:
Initial labs:
[**2173-7-20**] 02:15AM BLOOD Glucose-159* UreaN-11 Creat-0.7 Na-136
K-4.2 Cl-103 HCO3-18* AnGap-19
[**2173-7-21**] 01:47AM BLOOD Glucose-131* UreaN-16 Creat-0.5 Na-134
K-4.0 Cl-101 HCO3-24 AnGap-13
[**2173-7-20**] 02:15AM BLOOD PT-11.9 PTT-22.7 INR(PT)-1.0
[**2173-7-20**] 02:15AM BLOOD Plt Ct-184
[**2173-7-20**] 02:15AM BLOOD WBC-11.9* RBC-3.22* Hgb-10.4* Hct-31.1*
MCV-97 MCH-32.4* MCHC-33.6 RDW-12.8 Plt Ct-184
[**2173-7-20**] 02:15AM BLOOD ALT-185* AST-163* LD(LDH)-547* AlkPhos-81
TotBili-0.3
[**Hospital **] hospital course labs:
[**2173-7-31**] 06:20AM BLOOD Glucose-87 UreaN-5* Creat-0.4 Na-133
K-4.0 Cl-97 HCO3-28 AnGap-12
[**2173-7-23**] 01:19AM BLOOD WBC-17.1* RBC-3.60* Hgb-11.1* Hct-31.7*
MCV-88 MCH-30.8 MCHC-35.0 RDW-15.2 Plt Ct-177
[**2173-7-31**] 06:20AM BLOOD WBC-10.7 RBC-3.49* Hgb-10.9* Hct-31.3*
MCV-90 MCH-31.1 MCHC-34.7 RDW-14.4 Plt Ct-412
[**2173-7-21**] 02:29PM BLOOD ALT-3494* AST-3962* CK(CPK)-266*
AlkPhos-313* TotBili-1.2
[**2173-7-24**] 11:12PM BLOOD ALT-820* AST-140* AlkPhos-315*
TotBili-2.0*
[**2173-7-31**] 06:20AM BLOOD ALT-140* AST-48* AlkPhos-220* TotBili-1.5
[**2173-7-21**] 01:07PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
Studies:
[**7-20**] RUQ U/S
IMPRESSION:
1. Moderate ascites, with echogenicity which may represent
blood. Correlation with hematocrit values is recommended, and CT
can be considered for further evaluation.
2. The CBD is not dilated and the gallbladder appears normal. No
biliary stone is seen.
[**7-20**] CT Abd pelvis:
IMPRESSION:
1. Large left hepatic arterial pseudoaneurysm, resulting in
compression of
the left portal vein, with active extravasation at the left
inferior aspect. The left hepatic lobe is hypoperfused.
2. Moderate intrapelvic and intra-abdominal hemorrhagic ascites.
3. Diffusely dilated pancreatic duct warrants further evaluation
with MRCP or ERCP following treatment of acute issues.
[**7-27**] CT Abd Pelvis:
IMPRESSION:
1. Increased distribution of ground-glass opacities, now diffuse
in nature. Differential includes pulmonary hemorrhage,
infection or possibly fluid overload. However, given lack of air
bronchograms, pyogenic pneumonia is less likely though a viral
pneumonia is still a consideration. Fluid overload, is less
likely given interval resolution of pleural effusions. Thus the
most likely diagnoses include pulmonary hemorrhage or viral
pneumonia.
2. Distention with increased gallbladder wall edema and
irregularity of the luminal surface of the gallbladder wall is
concerning for potential gangrenous cholecystitis. Recommend
further evaluation with an ultrasound to further assess for any
intraluminal membranes or other evidence of gangrenous
cholecystitis. Given patient's lack of feeding status and
hepatic hypoperfusion, clinical and lab values or HIDA scan
would be of little utility in further diagnosis.
3. Stable hypoperfusion of the entire left hepatic lobe and the
hepatic dome.
4. Bilateral hepatic artery aneurysm coiling without evidence of
residual
flow noted within the aneurysm or in the left hepatic artery.
5. Improved abdominal and pelvic ascites
Brief Hospital Course:
ICU:
[**2173-7-26**] trigerred [**7-26**] @ 17:50 for RR 27
[**2173-7-24**] cont lasix gtt, added acetazolamide
[**2173-7-23**] off dilt, BP improved, a-line d/c'd, duplex - patent
hepatic arteries
[**2173-7-22**] episodes of SBP 200s, responds to dilt, TTE: WNL, CTA -
coils working
[**2173-7-21**] off labetolol gtt, HCT 24->27 s/p 1u pRBC, +1add'l
pRBC, rheum c/s, west 1 c/s
ICU COURSE:
[**7-20**]: She was admitted to the ICU and sent urgently to IR for
coil embolization: 3 aneurysms seen on arteriogram, 2 visible
during IR. Per report "multiple aneurysms,
coiled dominant L HA bilobed aneurysm to stasis, coils & gelfoam
to branch of RHA, 3rd aneurysm not visible end of procedure'. On
return to ICU she was mildly hypertensive (SBP 160) and was
started on a labetolol gtt and hydralazine. She was transfused
2u prbc prior to embolization with increasing hematocrit after
the procedure.
[**7-21**]: Showing signs of stability, further work-up was performed
for question of auto-immune vasculitis. A hepatobiliary surgery
and rheumatology consult were obtained. A renal U/S done was
normal. She showed signs of fluid overload this day,
desaturating to the low 80's with a CXR consistent with
pulmonary edema. She responded well to diuresis with lasix but
required 2 more units PRBC to keep her hct above 28. The
labetolol drip was DC'd in exchange for prn hydralazine. Her
liver enzymes peaked, as expected, this day. They were monitored
daily or twice daily, to ensure they peaked and receded as we
expected.
[**7-22**]: Aggressive diuresis was continued. ECHO showed normal
ventricular function while CTA chest showed no PE but continued
volume overload. CT of the liver showed resolution of the
aneurysms, functioning coils and patent hepatic vein with the
expected hypoperfused left liver segments.
[**7-23**]: Liver duplex showed sucessful embolization of L hepatic
artery and patent R hepatic arterial system. Being >48 hours out
from embolization, subcutaneous heparin was started. Diuresis
continued with good effect (-1650mL/24hr). Liver enzymes
continued to return towards normalcy. Her bilirubin peaked at
2.2 on post-procedure day 4 and then also began to normalize. At
beginning of diuresis 2 days prior, she was positive 8L. Our
target diuresis was 1.0-1.5L/day. Over the following 2 days this
was achieved. She continued to spike fevers nightly while all
cultures and work-up remained negative. We were aware of her
issue with chronic UTI, but urine studies were not consistent
with this being the source. The most likely explanation is an
inflammatory cascade driven by the areas of infarcted liver.
Consistent with this theory, her fevers reduced as LFTs and
bilirubin returned to [**Location 213**].
While in the ICU, she was seen by rheumatology consult, who
recommended vasculitis labs, all of which were negative (ANCA,
anti-Sm, [**Doctor First Name **] & dsDNA). Rheum recommended no steroids at this
time. At the time of transfer to the floor, she was tolerating
regular diet, fevers had resolved, her hematocrit was stable,
ambulating independently.
Floor:
Mrs. [**Known lastname 65014**] was transferred to the floor in stable condition and
she continued to improve clinically. Her bilirubin continued to
remain elevated while her LFTs trended downwards and there was
concern for gallbladder pathology. a RUQ U/S performed on [**7-28**]
showed a heterogenous gallbladder that was concerning for
necrosis. She was evaluated for a perc chole on [**7-29**] but repeat
U/S did not show necrosis. She tolerated a regular diet and was
up and out of bed, with minimal pain. She was set to be
discharged home on [**2173-8-1**].
Medications on Admission:
levothyroxine 112 mcg, nitrofurantoin 50 mg, Vitamin C 1000
mg, Calcium 600 with Vitamin D3 600 mg", Fish Oil, MVI, folic
acid 400 mcg, Vitamin B Complex, Stool Softener 100 mg,
melatonin 300 mcg, magnesium 250 mg, Lunesta Qhs
Discharge Medications:
1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA [**Hospital3 **]
Discharge Diagnosis:
Left hepatic artery aneurysm with active extravasation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You had
a work-up done at an outside hospital which showed bloody fluid
in your abdomen and hepatic artery pseudoaneurysms and you were
transferred to [**Hospital1 18**]. You were initially admitted to the ICU for
resuscitation and management and underwent IR embolization of
your hepatic artery aneurysms. You were transferred to the floor
on [**2173-7-25**] and continued to improve daily. There was concern for
your gallbladder being infected, since your liver function
studies were elevated, but an ultrasound performed did not show
evidence of that. You were tolerating a regular diet,
ambulating, and pain was well controlled.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. You may take
tramadol or ibuprofen for pain control. Please follow-up with
your PCP.
Followup Instructions:
Please follow-up with the acute care service in 1 month with Dr.
[**Last Name (STitle) **] or Dr. [**Last Name (STitle) 853**] with a CT A/P w/ IV contrast in the arterial
phase performed before your appointment. You can schedule this
appointment and the imaging study by calling the [**Hospital 2536**] clinic:
#[**Telephone/Fax (1) 600**].
|
[
"788.5",
"573.4",
"784.0",
"244.9",
"458.9",
"285.1",
"568.81",
"514",
"780.62",
"789.59",
"V12.71",
"276.69",
"459.2",
"442.84",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
9632, 9700
|
5482, 9138
|
429, 469
|
9799, 9799
|
2334, 5459
|
10859, 11204
|
1911, 1998
|
9417, 9609
|
9721, 9778
|
9164, 9394
|
9950, 10836
|
2013, 2315
|
262, 391
|
497, 1582
|
9814, 9926
|
1604, 1812
|
1828, 1895
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,611
| 183,217
|
16397
|
Discharge summary
|
report
|
Admission Date: [**2106-1-4**] Discharge Date: [**2106-1-19**]
Date of Birth: Sex: M
Service:
BRIEF NOTE: The patient had a complicated hospital course
from [**2106-1-3**]. The patient was accepted to the Medicine
Service on [**1-17**] after hospitalization since [**2106-1-4**]. The patient was originally transferred to [**Hospital1 1444**] with right lower extremity
edema and pain found to be secondary to compartment syndrome.
This had begun on _______ status post a heavy drinking binge
with questionable deep venous thrombosis or trauma leading to
increasing tissue destruction over the next weeks which was
progressive and resulting in fasciotomy. Fasciotomy led to
worsening of the patient's coagulopathy with decrease in
platelets and red blood cell counts and increase of INR, PT,
PTT, SBP, d-DIMER, although normal factor 8. Probable DIC
combined with ARS from rhabdomyolysis led to uremia and
increased platelet dysfunction which led to chronic bleeding
from fasciotomies. Of note, the patient's initial acute
renal failure was most likely secondary to a tension/prerenal
state and then worsened with prolonged myoglobinemia. In the
setting of chronic bleeding, the patient required
transfusions and progressive DIC and encephalopathy and it
was decided to take the patient for above-the-knee
amputation. The patient was then sent to the MICU for
aggressive hemodynamic therapy. The patient received five
units of packed red blood cells, six units of fresh frozen
plasma, cryo, platelets, ursodiol, midodrine, octreotide.
The patient has been followed throughout the hospital course
by Vascular Surgery, Renal, Liver and Hematology.
PAST MEDICAL HISTORY: Notable for alcohol cirrhosis status
post upper GI bleed, sphincterectomy secondary to motor
vehicle accident and peripheral vein thrombosis.
HOSPITAL COURSE: The patient is a 47-year-old Portugese man
with cirrhosis, compartment syndrome, status post right
above-the-knee amputation.
1. Mental status: The patient is very somnolent after
admission to Medicine Service and was nonverbal. The patient
had somewhat elevated sodium to 148 and was given free water
boluses to decrease sodium. The patient's oxycodone was also
decreased while the intravenous morphine was kept on for pain
control. The patient was also continued on lactulose for
possible hepatic encephalopathy.
2. His CT was considered as no improvement. For the right
above-the-knee amputation compartment syndrome, the patient
was followed by Vascular Surgery. The stump was kept
elevated. The patient did not receive antibiotics, however,
the patient underwent serial blood cultures.
3. For the end-stage liver disease the Hepatology Service
the patient was receiving Aldactone for diaphoresis, Pentasa,
__________ and ursodiol. The patient had ascites but never
received a therapeutic tap. Daily weights and I's and O's
were followed.
4. Renal: The patient's BUN and creatinine were followed.
The patient's _____________ was discontinued from the
octreotide and midodrine after transfer from the floor for
the final time. The patient continued to diurese with
Aldactone and free water boluses were given for the elevated
sodium.
5. Hematology: The patient was not given any more fresh
frozen plasma after the MICU stay. The hematocrit, platelet
count and coags were followed. The patient was continued on
epoetin.
6. For his cardiovascular system, the patient had TR per
echocardiogram in [**2106-1-12**]. No vegetation. His blood
pressure remained normal and the patient was continued on
nadolol.
7. Nutrition: Tube feeds were given and changed to
Ultracal. Also the Tums were discontinued.
On the early morning of [**2106-1-19**], a code was called
at midnight after the patient was found unresponsive without
respirations or pulse having vomited his tube feeds. The
patient had a complex medical history including end-stage
liver disease. This was complicated with compartment
syndrome, hypernatremia and renal failure. The patient was
seen at approximately 11:00 p.m. on the night when he died.
The patient at that time had been tachypneic and poorly
responsive. On initial examination the patient was
pulseless, no respiration. On monitor, the patient was
asystolic. The patient had a triple lumen catheter in the
right internal jugular. The patient was intubated by
Anesthesia with good breath sounds bilaterally. The patient
was given 1 mg of epinephrine times two, 1 mg of atropine.
Attempts at transcutaneous pacing were ineffective. After
approximately 15 minutes of attempts at reversal, pupils were
found to be fixed and dilated. The team was unable to obtain
other arterial blood. The code was called at 12:10 a.m.
This patient was not responded to medical treatment. The
attending, Dr. [**First Name (STitle) **], was notified. The family was also
notified. The family declined postmortem examination. The
death certificate was completed.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 10034**]
MEDQUIST36
D: [**2106-6-3**] 16:24
T: [**2106-6-3**] 17:42
JOB#: [**Job Number 46647**]
|
[
"958.8",
"E888.9",
"286.6",
"287.5",
"453.8",
"285.1",
"998.59",
"571.2",
"303.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"83.14",
"38.93",
"96.59",
"84.17"
] |
icd9pcs
|
[
[
[]
]
] |
1867, 1998
|
2014, 5240
|
1706, 1849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,655
| 164,353
|
8054
|
Discharge summary
|
report
|
Admission Date: [**2160-12-13**] Discharge Date: [**2160-12-20**]
Date of Birth: [**2096-3-24**] Sex:
Service:
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This is a patient with known
abdominal aortic aneurysm with an increase in size. Patient
now is admitted for elective repair.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 325 mg daily. This was
stopped 5 days prior to [**12-15**]. Insulin Lantus 56 units
at bedtime with a Humalog sliding scale, Lipitor 20 mg daily,
lisinopril 5 mg daily, Zyprexa 10 mg daily, Lamictal 25 mg
q.i.d., Desipramine, oxycodone daily, Toprol XL 25 mg daily.
PAST MEDICAL HISTORY: Known cardiomyopathy with diastolic
dysfunction by echocardiogram, history of dysrhythmia
symptomatic with syncope, AVNRT status post ablation in [**2154**],
history of hypertension, history of negative stress test on
[**2159-1-16**]. Echocardiogram showed EF of greater than 60% with
mildly thickened aortic valve and mitral valve and impaired
relaxation in inflow pattern, normal systolic function,
arthritis of the back and cervical spondylolysis with
foraminal stenosis on C2, type 2 diabetes with peripheral
neuropathy with a history of falls, type 2 diabetes with
nephropathy and chronic renal insufficiency, baseline
creatinine 2.9, history of hepatitis B remote, remote drug
history of IV drug use and cocaine. Has not used drugs since
[**2138**].
SOCIAL HISTORY: Patient is a current smoker with 1 pack per
day since [**2160-7-18**], previously went to 2 packs for 30
years; had discontinued this smoking pattern in [**2149**]. Denies
alcohol or current drug use.
PHYSICAL EXAM: Blood pressure is 157/90, pulse rate 94,
respirations 16. General appearance is alert white male in no
acute distress, but somewhat vague historian. Heart is a
regular rate and rhythm without carotid bruits. Lungs are
clear to auscultation. Abdomen is protuberant, soft,
nontender with palpable femoral pulses bilaterally.
Extremities are unremarkable. Pedal pulses are 1+ palpable
bilaterally.
HOSPITAL COURSE: Patient was admitted to the preoperative
holding area. On [**2160-12-11**], he underwent abdominal
aortic repair with tube graft, tolerated the procedure well.
Had palpable pedal pulses. He was transferred to the PACU in
stable condition. He continued to have persistent acidosis
with a normal lactate and normal hematocrit.
Patient remained intubated and was transferred to the SICU
for respiratory ventilation support. Epidural was placed
intraoperatively for analgesic control. Pain was moderately
controlled with epidural. Adjustments are made. Psychiatry
was requested to see the patient because of his agitation
postoperatively. They felt his picture was consistent with
acute delirium with multiple contributing factors including
recent anesthesia and sedation, with elevated creatinine and
a predisposed psychiatric history.
Patient was continued on antipsychotics. Narcotics were
minimalized. Anticholinergic agents were avoided. Urine and
urine C and S was sent which were negative. Attempts were
made to reorient patient and maintain a consistent
environment. Patient was extubated on postoperative day 1. He
had improvement in his mental status exam. His antipsychotics
were reinstituted, and Haldol was utilized on a p.r.n. basis.
Patient remained in the SICU. On postoperative day 4, the
epidural was discontinued. Patient was transferred to the
regular nursing floor for continued postoperative care.
Patient continued to be followed by psychiatric service, and
his antipsychotic medications were adjusted accordingly. Was
continued on the olanzapine 2.5 mg t.i.d. He has noted some
left arm swelling on postoperative day 6. An ultrasound was
done which was negative for DVT.
Patient was transferred to the VICU on [**12-17**] and then
transferred to the regular nursing floor on [**2160-12-18**].
Patient will be evaluated by physical therapy and discharge
plan is to discharge to rehab. His mental status is slowly
improving. He is tolerating his POs. Patient will be
discharged when medically stable and bed available.
DISCHARGE MEDICATIONS: Atorvastatin 20 mg daily, aspirin 325
mg daily, nicotine patch 21 mg per 24 hours, olanzapine 2.5
mg t.i.d., oxycodone/acetaminophen 5/325 tablets [**11-18**] q.4-6
hours p.r.n. for pain, metoprolol 100 mg b.i.d., Colace 100
mg daily, senna tablets 8.6 mg tablets 1 b.i.d. as needed,
pentamidine 20 mg daily. His insulin is glargine 55 units at
bedtime, Humalog sliding scale before meals and at bedtime.
DISCHARGE DIAGNOSES: Abdominal aortic aneurysm of increasing
size, history of cardiomyopathy with diastolic dysfunction,
history of cardiac arrhythmias, atrioventricular node reentry
tachycardia status post ablation, history of arthritis,
cervical spondylolysis with foraminal stenosis, history of
type 2 diabetes with neuropathy, renal insufficiency with a
baseline creatinine of 2.9, history of falls, history of
hepatitis C, history of remote intravenous drug use and
cocaine; last episode was in [**2138**], current tobacco use 1 pack
per day since [**2160-9-17**], prior to that was 1-2 packs per
day x30 years which was discontinued in [**2149**], history of
bipolar disorder, depression, postoperative delirium
resolved.
POSTOPERATIVE INSTRUCTIONS: The patient may shower, but no
tub baths. No driving until seen in followup. He may ambulate
essential distances until seen in followup. Dr.[**Name (NI) 1392**]
office should be called if he develops fever greater than
101.5, whether incision wound has become red, or swollen, or
drain.
MAJOR SURGICAL PROCEDURE: Abdominal aorta repair with tube
graft on [**2160-12-11**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2160-12-18**] 10:32:15
T: [**2160-12-18**] 11:03:56
Job#: [**Job Number 28788**]
|
[
"293.0",
"458.29",
"403.90",
"250.60",
"305.1",
"441.4",
"296.7",
"250.40",
"357.2",
"425.4",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
4595, 5981
|
4167, 4573
|
397, 672
|
2101, 4143
|
1687, 2083
|
148, 176
|
205, 370
|
695, 1452
|
1469, 1671
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,631
| 159,670
|
34381
|
Discharge summary
|
report
|
Admission Date: [**2180-10-2**] Discharge Date: [**2180-10-21**]
Date of Birth: [**2101-6-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
shoulder pain
Major Surgical or Invasive Procedure:
cardiac catheterization [**2180-10-5**]
[**2180-10-6**] AVR ( 21mm St. [**Male First Name (un) 923**] porcine)/ cabg x3 (LIMA to LAD, SVG
to OM, SVG to RCA)
History of Present Illness:
79M w/ CAD, AS, DM, HTN, hyperlipidemia p/w acute onset
bilateral shoulder pain occuring at rest, radiating down the
arms, associated w/ SOB and mild diaphoresis. Notably, the
patient has had subacute crescendo angina over the course of
weeks to months refractory to SL nitro, prompting use of a nitro
patch at night. He sleeps sitting upright in a chair due to
orthopnea. He notes intermittent LE swelling. He has had a week
h/o URI symptoms, dry cough, and occasional chills. The
patient's wife notes that he had LOC and a fall 1 month ago. He
has not had fever, abdominal pain, or N/V/D. He has not had sick
contacts or recent travel.
He presented to [**Hospital1 **]-[**Location (un) 620**] where BP 144/75 HR 79 RR 20 O2sat 95%
RA. EKG showed diffuse 2-[**Street Address(2) 79078**] depressions. He
was given plavix 600 mg, heparin gtt, and nitro gtt prior to
transfer to [**Hospital1 18**]. In our ED, T 98.8 HR 71 BP 118/56 RR 22 O2sat
99% RA. EKG showed resolution of STD in II,III,F (c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 620**]
EKG), <1 mm STE in V1-V2, and persistent >1 mm STD in V4-V5. He
was started on nitro gtt for persistent CP and heparin gtt,
which was d/c'd when noted to be guaiac positive. He was
transferred to the floor for further evaluation. He is currently
pain-free off nitro. Ruled in for NSTEMI.
Past Medical History:
CAD
dCHF (EF 55-60% [**2179-4-23**] TTE)
AS ([**Location (un) 109**] 1.0 cm2 [**2179-4-23**] TTE)
DMII
HTN
hyperlipidemia
prostate CA s/p prostatectomy
Social History:
Lives with wife in [**Name (NI) **], MA. Retired salesman. Former 3
pack/day smoker, quit >30 years ago. Currently smokes a pipe.
Drinks 2-4 ETOH 2-3x/week.
Family History:
Mother had CVA. Father had bladder CA. No known h/o premature
CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM
5'8" 190#
V/S - T 97.5 HR 68 BP 122/64 RR 18 O2sat 99% 2L.
GEN: Elderly obese male lying flat in bed, NAD
HEENT: NC/AT, sclera anicteric, PERRL, EOMI, OP clear with dry
MM
Neck: Supple, JVP difficult to assess due to habitus
CV: RRR nl S1S2 III/VI SEM @ LUSB no r/g
PULM: L basilar crackles no wheeze/rhonchi
ABD: soft obese NTND normoactive BS
Ext: warm, dry w/ 1+ PT/DP pulses, 1+ symmetrical pitting LE
edema
Pertinent Results:
[**2180-10-2**] @ 0856 - SR @ 70 bpm, LAD, <1 mm STE R, <1 mm STD
II,F,V3, <2 mm STD V4-V5; QTc 453 ms
[**10-6**] Echo: Pre-CPB: The left atrium and right atrium are normal
in cavity size. No mass/thrombus is seen in the left atrium or
left atrial appendage. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. No left
ventricular aneurysm is seen. There is moderate regional left
ventricular systolic dysfunction with LVEF approximately 30-35%.
. No masses or thrombi are seen in the left ventricle. The
remaining left ventricular segments contract normally. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
stenosis. ([**Location (un) 109**]~ 0.8-0.9 cm2) Trace aortic regurgitation is seen.
The aortic regurgitation jet is eccentric. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is no pericardial effusion. POSTBYPASS: The pt is
receiving an infusion of milrinone at 0.15 uck/kg/min and
norepinephrine at 0.08 ucg/kg/min. There is preserved RV
systolic. LV systolic function is mildly improved in the setting
of inotropes (Walls that contact[**Name (NI) **] well prebypass are more
hyperdynamic/walls that were hypokinetic remain hypokinetic)
There is a well seated bioprosthesis in the aortic position.
There is a perivalvular AI jet originating in the area outside
and between the left and right coronary cusps of the prosthesis.
The AI is moderate (2+) in quantity. The remaining study is
unchanged from prebypass.
[**10-2**] Cath: 1. Selective coronary angiography of this right
dominant system
demonstrated 3-vessel disease. The LMCA is short and heavily
calcified. The LAD is totally occluded proximally. There is
collateral flow from left to left and right to left. The LCX is
non-dominant with a discrete 90% OM2 lesion. The RCA is a
dominant vessel with an 80% lesion at the origin and is heavily
calcified. There are robust right to left collaterals. 2.
Resting hemodynamics revealed a systolic arterial blood pressure
of 133/62 mmHg.
[**2180-10-19**] 02:16AM BLOOD WBC-14.5* RBC-3.55* Hgb-11.0* Hct-33.2*
MCV-94 MCH-30.9 MCHC-32.9 RDW-16.0* Plt Ct-334
[**2180-10-9**] 02:10AM BLOOD PT-13.5* PTT-32.1 INR(PT)-1.2*
[**2180-10-20**] 11:50AM BLOOD Glucose-183* UreaN-27* Creat-1.0 Na-141
K-3.7 Cl-105
[**Known lastname **],[**Known firstname **] [**Age over 90 79079**] M 79 [**2101-6-9**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2180-10-19**] 7:12
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2180-10-19**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79080**]
Reason: evaluate effusions
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate effusions
Final Report
SINGLE VIEW OF THE CHEST [**2180-10-19**]
HISTORY: 79-year-old man, status post CABG; evaluate effusions.
FINDINGS: Single bedside AP examination labeled "supine at 7:25
a.m." is
compared with upright studies obtained the preceding day. The
patient is
status post recent CABG with midline surgical staples in situ
and intact
sternal cerclage wires. Allowing for the positioning, the
overall appearance
is not much changed. There is persistent LV enlargement without
vascular
congestion and only small bilateral pleural effusions. There is
right more
than left basilar subsegmental atelectasis, with no other
airspace process.
Atherosclerotic calcification of the thoracic aorta is
redemonstrated.
IMPRESSION: Status post recent CABG without CHF or significant
effusion.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: FRI [**2180-10-20**] 2:12 PM
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] presented to an OSH with a
NSTEMI. He was medically managed and transferred to [**Hospital1 18**] for
further care. On [**10-5**] he underwent a cardiac cath which revealed
three vessel coronary artery disease and aortic stenosis. On
[**10-6**] he was brought to the operating room where he underwent a
coronary artery bypass graft and aortic valve replacement.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Remained on Levophed, milrinone, and
vasopressin drips which were slowly weaned over a few days.
Within 25 hours he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day four chest
tubes were removed. Bedside swallowing eval. performed on
post-op day five as he had some dysphagia with emesis along with
altered mental status. He slowly developed worsening pulmonary
edema despite aggressively pulmonary toilet. He required a right
thoracentesis for an effusion on post-op day twelve. He also had
thoracentesis on the left and his respiratory status improved.
He was intermittently on BIPAP at night and no longer requires
this. His mental status and respiratory status improved and he
was discharged to rehab in stable condition on POD#15.
Medications on Admission:
ASA 325 mg daily, plavix 75 mg daily, atenolol 25 mg daily,
isosorbide 30 mg qAM, norvasc 1.25 mg qPM, lasix 60 mg daily,
metformin 500 [**Hospital1 **], lipitor 80 mg daily, klor-con 20 mEq [**Hospital1 **],
nitro patch 0.4 mg/hr, oscal 600+ BIDa, MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO PRN (as needed)
as needed for K<4.0.
11. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
14. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous once a day.
15. Insulin Lispro 100 unit/mL Solution Sig: various
Subcutaneous four times a day: ss.
16. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
17. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic valve replacement
CAD s/p Coronary artery bypass graft x 3
PMH: Hypercholesterolemia, ETOH abuse, h/o prostate CA, s/p
prostatectomy, NIDDM, HTN
Discharge Condition:
Good
Discharge Instructions:
No lifting more than 10 pounds for 10 weeks
Shower daily,no baths or swimming
No creams, lotions or powders to incisions
No driving for 4 weeks and off narcotics
Take all prescribed medications as directed
Report any wound drainage/redness or fever greater than 101 to
our office.
Followup Instructions:
Followup with Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks
see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79081**] in [**3-12**] weeks
Completed by:[**2180-10-21**]
|
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"285.9",
"440.0",
"414.01",
"250.00",
"276.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"38.93",
"37.22",
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icd9pcs
|
[
[
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9989, 10061
|
6782, 8113
|
335, 494
|
10276, 10282
|
2777, 5701
|
10612, 10922
|
2237, 2305
|
8416, 9966
|
5741, 5771
|
10082, 10255
|
8139, 8393
|
10306, 10589
|
2320, 2758
|
282, 297
|
5803, 6759
|
522, 1872
|
1894, 2047
|
2063, 2221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,982
| 196,874
|
20145
|
Discharge summary
|
report
|
Admission Date: [**2202-3-2**] Discharge Date: [**2202-4-17**]
Date of Birth: [**2139-6-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
GPC bacteremia in the setting of septic right hip (s/p THA).
Major Surgical or Invasive Procedure:
1. Irrigation and debridement of right total hip replacement
with removal of cerclage wires from the femoral shaft ([**2202-3-3**]).
2. Irrigation and debridement of left foot osteomyelitis x2 ([**3-3**]
and [**2202-3-4**]).
3. Irrigation and debridement of the right hip with removal of
the polyethylene on the acetabular side and the femoral head
from the femoral side with replacement components ([**2202-3-8**]).
4. Partial vertebrectomy of C5 and C6, Fusions C5-C6, Anterior
spacer times C5-C6, Structural allograft ([**2202-3-18**]).
5. Total laminectomy of C5-6, Fusion C5-C6, Autograft ([**2202-3-18**]).
6. Arteriogram and embolization of branch of middle colic artery
([**2202-3-9**]).
History of Present Illness:
Mr. [**Known lastname 50873**] is a 62 year-old man with a history of THR and septic
hip who presnts on transfer from an OSH with a septic hip.
Initially presented to an OSH on [**3-1**] with hip pain severe
enough to make him unable to ambulate. A CT abdomen showed focal
fluid collection along the superficial posterolateral aspect of
the right hip. His WBC was 20 with ESR of 125. Blood cultures
grew out GPC in pairs/chains/cluters and he underwent
fluoroscopic guided aspiration of the THR on [**3-2**]. The aspirate
showed GPCs. Also noted to have elevated troponins (0.113,
0.541, 0.91) and was started on Lovenox 60mg SC BID.
Upon arrival to [**Hospital1 18**], he was swifty taken to the OR.
Past Medical History:
PAST MEDICAL HISTORY
1. s/p THR x5 on right due to septic joint
2. Atrial fibrillation
3. COPD
4. Hyperlipidemia
5. History of NSCLC s/p lobectomy
6. GERD
7. Hypertension
8. Chronic lymphedema of the left leg
9. Interstitial lung disease
10. Pulmonary hypertension
11. ETOH abuse
Social History:
Drinks 6-8 shots per day. Denies smoking. Works as a
locksmith.
Family History:
Noncontributory
Physical Exam:
Vitals - T 98.4, BP 107/75, HR 105, O2Sat 95% on room air
GEN: AOx3, NAD, appears somewhat confused and slow in cognition
HEENT: COP, poor dentition, MMM
Neck: supple, non tender
Lung: CTA andteriorly
Heart: Tachycardic, no m/r/g
Abdomen: Diffusely tender, most prominent in RUQ
Extremities: Bilateral LE edeama R>L with ankle erythema and
tenderness L>R
Right hip: Tender decreased range of motion [**1-2**] pain.
Pertinent Results:
[**2202-3-3**]
WBC-17.5*# Hgb-10.1* Hct-30.6* MCV-97 RDW-15.4 Plt Ct-286
Neuts-93.0* Bands-0 Lymphs-5.3* Monos-1.4* Eos-0.2 Baso-0.1
PT-13.1 PTT-37.7* INR(PT)-1.1
Glucose-120* UreaN-23* Creat-1.2 Na-139 K-3.4 Cl-102 HCO3-26
AnGap-14
Calcium-8.1* Phos-1.8* Mg-1.9
ALT-30 AST-49* LD(LDH)-347* CK(CPK)-61 AlkPhos-351* TotBili-0.6
Lipase-128* Albumin-2.6*
Cortsol-39.5*
ABG pO2-326* pCO2-43 pH-7.40 calTCO2-28 Lactate-1.3
OR tissue cultures: group B strep and MRSA
AP PELVIS AND AP AND LATERAL VIEWS OF THE RIGHT HIP.
The patient is status post right THR, with cemented femoral
stem. There is acetabular protrusio. No periprosthetic lucency
to suggest loosening is identified. The extreme distal tip of
this long femoral stem component is not included on these films.
Skin staples are present. Residue of oral contrast is present in
bowel.
RIGHT KNEE, TWO VIEWS.
No true lateral view is identified, and there is overlying
trauma board artifact. There is evidence of osteopenia and
probable degenerative change, not well assessed on this exam.
There is some subchondral lucencies -- the appearance is not
typical for osteomyelitis and is more likely to represent
osteopenia.
RIGHT LOWER LEG, TWO VIEWS.
No suspicious focal lytic or sclerotic lesion to confirm the
presence of osteomyelitis is identified. Scattered phleboliths
noted.
CXR [**2202-3-3**]: there is again diffuse prominence of interstitial
markings. The findings are again consistent with pulmonary
edema, though some chronic pulmonary disease cannot be excluded.
Endotracheal tube is now in place with its tip approximately 5.5
cm above the carina. Right IJ catheter extends to lower portion
of the SVC.
Brief Hospital Course:
ASSESSMENT/PLAN: 62 year-old man with a history of prior THR and
septic hip; again presenting with septic joint and bacteremia.
#. Septic joint / bacteremia: The patient presented to an
outside hospital as above with pain, elevated WBC/ESR, GPC
bacteremia and GPC on aspirate from hip. Cultures grew both
MRSA and Group B strep. On arrival to [**Hospital1 18**], the patient was
taken to the OR for wash-out on [**3-2**] with subsequent irrigation
and debridement of the right hip with removal of the
polyethylene on the acetabular side and the femoral head from
the femoral side with replacement components on [**3-8**]. Post op he
became febrile to 102 with new levophed requirement, which
subsequently improved without change in antibiotics. The patient
was placed on a course of high dose ceftriaxone, vancomycin, and
rifampin.
# L foot osteomyelitis / lower extremity ulcers. Plain films
were without clear evidence of osteomyelitis but he was debrided
and cultured by podiatry. Cultures grew out the same MRSA and
GBS as above. Lower extremity ulcers monitored and adressed by
plastics. An MRI if the lower extremities did not show other
areas of osteomyelitis. Prior to discharge the podiatry service
felt as if the surgical wound was well-healed and signed-off.
# Epidural abscess of cervical spine: During his course the
patient developed swelling of his left arm followed by weakness
of proximal muscles. He was evaluated for DVT, brachial plexus
injury, bony injury. Finally, a cervical spine MRI showed
evidence of phlegmon, discitits, osteo at C5-6. He went to the
OR on [**3-18**] for anterior and posterior approach to washout as
above. OR cultures were negative but as above he will continue
an 8 week course of antibiotics starting from his OR date of
[**3-18**]. The patient will conclude his antibiotic course on
[**2202-5-14**].
# LGIB: The patient developed an episode of large bright red
blood per rectum on [**3-9**]; had tagged RBC study showing bleed
within 6 minutes. He went to angio with IR; had coiling to the
mid-colic artery with successful hemostasis. GI and general
surgery also involved but did not require further intervention.
Later in the hospitalization the patient had a fall in his
hematocrit from a stable 21 to 17. He had one guaiac positive
stool and was given 2 units of PRBCs. The patient's hematocrit
was subsequently stable at 24-26. Further stools were guaiac
negative. The GI service was further contact[**Name (NI) **] but felt that
endoscopy was not indicated.
# Left lung collapse: The patient had a bronch on [**3-6**] for white
out of his entire L lung. A large mucous plug was removed,
however still with some obstruction of lingula. The bronch
showed some generalized narrowing without focal lesion -
possibly related to past lung resection. Bronchial washings
were without growth on culture. He had subsequent CXRs
demonstrating improved expansion of his left lung. With further
mobilization, incentive spirometry, ans chest physical therapy,
the patient continued to saturate in the low to mid 90s without
the need for oxygen.
# Dysphagia: Following cervical spine surgery, the patient had
evidence of dysphagia on bedside and video swallow. Initially an
NG tube was placed. A PEG tube was subsequently placed given the
prolonged nature of the patient's dysphagia. At the time of
discharge the patient continues to have PO trials with tube
feeds as the principal source of nutrition.
#. Acute renal failure: Mild creatinine elevation on admission
that resolved quickly following admission with some hydration.
#. Atrial fibrillation: Following stabilization post-GI bleed,
the patient's beta-blocker was titrated up until his rate was
controlled.
Medications on Admission:
1. Atenolol 50mg daily
2. Lasix 40mg daily
3. Advair 250/50 [**Hospital1 **]
4. Coumadin (stopped 2 weeks prior to admission)
5. Prednisone 2mg daily
6. Percocet PRN
7. Proair 2 puffs Q6H PRN
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
2. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
3. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Nortriptyline 25 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO HS (at
bedtime).
6. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day) as needed for constipation.
7. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q4H (every 4
hours) as needed.
8. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO TID (3
times a day).
9. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
10. Cyclobenzaprine 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times
a day) as needed for muscle pain.
11. Fentanyl 50 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
12. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours): Please continue through
[**2202-5-14**].
13. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback [**Year (4 digits) **]:
One (1) Intravenous Q24H (every 24 hours): Please continue
through [**2202-5-14**].
14. Rifampin 150 mg Capsule [**Year (4 digits) **]: Four [**Age over 90 1230**]y (450) mg PO
q12 hours: Please continue PO/PG through [**2202-5-14**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 86**]
Discharge Diagnosis:
Septic hip/prosthesis
Epidural abscess
Osteomyelitis of foot
Lower GI bleed
Dysphagia
Left lung collapse
Atrial fibrillation
Discharge Condition:
Stable. The patient is afebrile and his vital signs are stable.
Discharge Instructions:
You were admitted with infection in your hip. In addition, you
were found to have evidence of infection in both your left foot
and neck. You have had several surgical procedures for
treatment of this, and you will also be on antibiotics for a
total of 8 weeks.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed.
Please call your doctor or return to the emergency room if you
experience:
--fever or chills
--weakness or numbness anywhere
in your body
--stomach pain
--nausea or vomiting
--chest pain
--shortness of breath
--cough
--blood in your stool
--black, tarry stool
--any other symptom that concerns you
Followup Instructions:
You should follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 54160**] [**Name (STitle) **], within 2 weeks of discharge. His phone number
is [**Telephone/Fax (1) 44354**].
You should follow-up with your infectious disease physician:
[**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone: [**Telephone/Fax (1) 457**] Date/Time:
[**2202-5-3**] 10:30
You should follow-up with your general surgeon, Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **].
He placed the G-tube in your stomach. It is important to follow
up with him within the next 2 weeks to have your abdominal
staples removed. His phone number is [**Telephone/Fax (1) 10693**].
You should follow-up with your orthopedist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**], for
continued surveillance of your hip. You should see him with 2
weeks of discharge. His phone number is [**Telephone/Fax (1) 7807**].
You should follow-up with your spinal surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**],
within 2 weeks of discharge. His phone number is [**Telephone/Fax (1) 3573**].
You should follow-up with the podiatry service at [**Hospital1 18**]. You can
make an appointment at [**Telephone/Fax (1) 543**].
|
[
"303.90",
"584.9",
"428.0",
"V10.11",
"682.7",
"518.81",
"324.1",
"424.2",
"238.71",
"457.1",
"790.7",
"996.66",
"424.0",
"V43.64",
"428.22",
"518.0",
"787.20",
"730.27",
"496",
"041.11",
"V09.0",
"578.9",
"486",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.02",
"88.47",
"43.19",
"00.73",
"99.07",
"33.22",
"96.6",
"81.03",
"86.04",
"77.89",
"39.79",
"96.05",
"38.93",
"99.04",
"80.15",
"78.65",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
10132, 10198
|
4391, 8116
|
374, 1072
|
10367, 10433
|
2677, 4368
|
11165, 12519
|
2208, 2225
|
8359, 10109
|
10219, 10346
|
8142, 8336
|
10457, 11142
|
2240, 2658
|
274, 336
|
1100, 1805
|
1827, 2109
|
2125, 2192
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,999
| 181,276
|
6008
|
Discharge summary
|
report
|
Admission Date: [**2133-7-11**] Discharge Date: [**2133-7-15**]
Date of Birth: [**2062-8-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube
History of Present Illness:
CC: Abdominal pain
HPI: Asked to see this 70 M who was transferred from [**Hospital1 **] [**Location (un) 620**]
after presenting with acute onset of abdominal pain starting at
3
pm this afternoon. Pain came on suddenly and located in
epigastrium and RUQ. + chills. He denies fevers, nausea,
vomiting, shortness of breath, or chest pain. He also denies
constipation, diarrhea, or any urinary symptoms. Pain unrelated
to eating.
Past Medical History:
# Coronary artery disease
-- s/p multiple PCI, last in [**Hospital1 18**] records from [**2124**]
-- s/p MI in [**2130**] with stent placement
# Dilated Cardiomyopathy -- LVEF of 20-25%
-- s/p PPM/ICD placement
# Hypertension
# Hyperlipidemia
# Hypothyroidism
# Depression
# ICH -- while on Coumadin
# Benign Prostatic Hypertrophy
# Bilateral Hydroceles
# Colonic polyps
# Hand osteomyelitis history
# Babesiosis history
# SCC -- left 4th finger and penis
# Appendectomy
# Gout
Social History:
He lives with his wife and has 3 sons.
# [**Name2 (NI) 1139**]: Smoked 1 PPD for several years in his 20s but none
since.
# Alcohol: Drinks [**2-1**] glasses of wine on social occasions or
when eating at restaurants, none at home.
# Drugs: None
Family History:
# Father -- died from throat cancer at age 63, heavy smoker and
alcohol consumption
# Mother -- congenital [**Last Name **] problem (unsure what), but lived
into her 90s
# Brother -- renal cancer, treated
# Sister -- healthy
# Children -- all healthy
Physical Exam:
PHYSICAL EXAMINATION upon admission
Temp: 98.1 HR: 87 BP: 118/72 Resp: 22 O(2)Sat: 93
Constitutional: Comfortable
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Tender right upper quadrant epigastric area,
good bowel sounds, no palpable masses
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Pertinent Results:
[**2133-7-15**] 04:40AM BLOOD WBC-7.8 RBC-3.81* Hgb-10.8* Hct-32.6*
MCV-86 MCH-28.2 MCHC-33.0 RDW-14.2 Plt Ct-159
[**2133-7-14**] 04:40AM BLOOD WBC-7.4 RBC-3.67* Hgb-10.3* Hct-31.1*
MCV-85 MCH-28.0 MCHC-33.0 RDW-14.4 Plt Ct-136*
[**2133-7-11**] 10:40AM BLOOD WBC-12.4* RBC-4.27* Hgb-12.0* Hct-36.6*
MCV-86 MCH-28.1 MCHC-32.7 RDW-14.6 Plt Ct-173
[**2133-7-11**] 04:30AM BLOOD WBC-11.2*# RBC-3.97* Hgb-11.5* Hct-34.0*
MCV-86 MCH-28.9 MCHC-33.7 RDW-14.5 Plt Ct-167
[**2133-7-11**] 04:30AM BLOOD Neuts-85* Bands-1 Lymphs-4* Monos-8 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2133-7-15**] 04:40AM BLOOD Plt Ct-159
[**2133-7-14**] 04:40AM BLOOD Plt Ct-136*
[**2133-7-12**] 04:06AM BLOOD PT-14.6* PTT-30.6 INR(PT)-1.3*
[**2133-7-12**] 04:06AM BLOOD PT-14.6* PTT-30.6 INR(PT)-1.3*
[**2133-7-15**] 04:40AM BLOOD Glucose-106* UreaN-11 Creat-0.8 Na-140
K-3.9 Cl-106 HCO3-24 AnGap-14
[**2133-7-14**] 04:40AM BLOOD Glucose-128* UreaN-13 Creat-0.8 Na-144
K-4.0 Cl-110* HCO3-24 AnGap-14
[**2133-7-13**] 01:59AM BLOOD Glucose-112* UreaN-13 Creat-0.8 Na-144
K-4.1 Cl-111* HCO3-23 AnGap-14
[**2133-7-14**] 04:40AM BLOOD ALT-120* AST-63* AlkPhos-55 TotBili-1.3
[**2133-7-13**] 01:59AM BLOOD ALT-183* AST-139* AlkPhos-66 Amylase-23
TotBili-1.6*
[**2133-7-12**] 12:21AM BLOOD ALT-256* AST-258* LD(LDH)-224 AlkPhos-64
Amylase-25 TotBili-3.3*
[**2133-7-13**] 01:59AM BLOOD Lipase-14
[**2133-7-12**] 04:06AM BLOOD Lipase-19
[**2133-7-12**] 01:01PM BLOOD CK-MB-4 cTropnT-0.02*
[**2133-7-11**] 09:15PM BLOOD CK-MB-3 cTropnT-0.03*
[**2133-7-11**] 10:40AM BLOOD CK-MB-3 cTropnT-0.02*
[**2133-7-15**] 04:40AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.8
[**2133-7-11**] 04:47AM BLOOD Lactate-1.8
[**2133-7-11**]: EKG:
Sinus rhythm with atrial sensed and ventricular paced rhythm and
short
A-V interval. There is occasional fusion. Compared to the
previous tracing
of [**2133-7-11**] no diagnostic interim change.
TRACING #1
[**2133-7-11**]: liver/gallbladder ultrasound:
IMPRESSION: Prominent gallbladder, with mild gallbladder wall
thickening and a small mobile stone. Additionally, there is
common bile duct dilatation and mild intrahepatic biliary ductal
dilatation. The patient is experiencing no pain. These findings
are suggestive, but not diagnostic of cholecystitis, or possibly
choledocholithiasis, though no obstructive CBD stone is seen. If
indicated, this could be better evaluated with HIDA scan or
MRCP.
[**2133-7-12**]: EKG:
Sinus rhythm. Left atrial abnormality. Atrial sensed and
ventricular paced rhythm. Occasional fusion. The rate has
slowed. Otherwise, no diagnostic interim change.
TRACING #2
[**2133-7-12**]: gallbladder scan:
IMPRESSION: Suboptimal study secondary to lack of patient
cooperation. There is probably normal hepatocellular function
with questionable faint visualization of the gallbladder. At 3.5
hours, there is no obvious tracer in the gallbladder, suggesting
at least a partial obstruction to bile flow through the cystic
duct.
Brief Hospital Course:
Admitted to the acute care service with abdominal pain. Upon
admission, he was made NPO, given intravenous fluids and
underwent radiographic imaging of his abdomen which showed a
prominent gallbladder, with mild gallbladder wall thickening and
a small mobile stone. To further confirm these findings, he
underwent a HIDA scan which showed a partial obstruction to bile
flow through the cystic duct. Intraveous antibiotics were
initiated. He initially was admitted to the surgical floor but
on HOD #2, he developed hypotension, ventricular ectopy, and
chest pain. Because of his extensive cardiac history he was
transferred to the intensive care unit for further monitoring.
He received additional intravenous fluids and his cardiac status
was monitored. His cardiac enzymes were cycled and were
indeterminant.
He was transferred again to the surgical floor on HOD #3. He was
strated on a clear liquid diet with progression to a regular
diet. He was reported to have episodes of deliurium notable at
bedtime, resolving during the day. His home medications were
resumed and his analgesics were reviewed. Psychiatry was
consulted regarding his delirium and insomnia. They made
recommendations for management of his care.
His vital signs are stable and he is afebrile. He is tolerating
a regular diet. His white blood cell count is normal. His liver
function tests are normalizing.
He is preparing for discharge home with VNA services to monitor
the drain output. He will follow-up with the acute care service
in 2 weeks. He has been instructed to follow-up with his
primary care provider [**Last Name (NamePattern4) **] 1 week.
Medications on Admission:
[**Last Name (un) 1724**]: ASA 81, plavix 75', effexor 225', ativan 0.5",
allopurinol300', coreg 12.5', digoxin 0.125', spironolactone
25',
flomax 0.4', finasteride 5', lisinopril 20', synthroid 125',
lipitor 80', tricor 145', colace 100', NTG prn, ambien 5 QHS
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
5. methyl salicylate-menthol Ointment Sig: One (1) Appl
Topical PRN (as needed) as needed for pain.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for loose stool.
14. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
15. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
16. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
17. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
18. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime for
7 days: as needed for insomnia.
Disp:*7 Tablet(s)* Refills:*0*
19. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You
underwent a ultrasound of the abdomen which showed gallbladder
thickening. You had a tube placed into your gallbladder. Your
abdominal pain and resovled and you are now preparing for
discharge home with the following instructions;
You will be discharged with the drain in place with the
following instructions:
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation
Please call your doctor or return to the emergency room if you
have 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.
* 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.
Activity:
No heavy lifting of items [**11-14**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises
Followup Instructions:
Please follow-up with the acute care service in 2 weeks. You
can schedule your appointment by calling # [**Telephone/Fax (1) 600**]. Please
record drain output and bring record on your visit.
Please follow-up with your primary care provider [**Last Name (NamePattern4) **] 1 week.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2133-7-23**]
|
[
"348.30",
"V12.72",
"311",
"574.00",
"272.4",
"425.4",
"780.52",
"414.01",
"412",
"244.9",
"401.9",
"V45.02",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.01"
] |
icd9pcs
|
[
[
[]
]
] |
9005, 9079
|
5295, 6934
|
317, 353
|
9137, 9137
|
2327, 5272
|
11373, 11795
|
1593, 1847
|
7247, 8982
|
9100, 9116
|
6960, 7224
|
9288, 11350
|
1862, 2308
|
263, 279
|
381, 812
|
9152, 9264
|
834, 1314
|
1330, 1577
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,210
| 126,330
|
43727
|
Discharge summary
|
report
|
Admission Date: [**2188-6-3**] Discharge Date: [**2188-6-20**]
Date of Birth: [**2137-12-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Elavil
Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
abdominal pain, n/v
Major Surgical or Invasive Procedure:
Intubation/Mechanical Ventilation
Right internal jugular central venous catheter
History of Present Illness:
50F s/p cholecystectomy, h/o depression, h/o pyelonephritis
presents with abdominal pain, nausea and vomiting that has
acutely worsened but has been present over last 6 weeks. She has
a h/o of frequent gallstones now s/p choly and nephrolithiasis
for which she often receives lithiotripsy. Patient reports
significant financial stress at home and since then has had
persistent GI complaints. Her abdominal pain is different from
her gallbladder or kidney pain. She describes the pain as
epigastric radiating to her umbilicus and left lower quadrant,
no pain radiating to her back. The pain has worsened and she is
unable to keep anything down and she finally decided to present
to the ED. She also reported diarrhea for one month but has not
had a bowel movement for 6 days. She denies any fevers or
chills. She has lost significant weight and has gone from size
10 pant to size 6 and her dentures no longer fit. She c/o
palpitations and tightness in her chest that often radiates to
her neck and arm. She believes it is related to her anxiety and
she has been having frequent panic attacks. She denies any
shortness of breath. She reports productive cough over last few
weeks of green sputum. On further ROS, pt reports severe
depression recently but denies SI or SA. She denies any EtOH
use. She also reports a longer history of occasional
word-finding difficulty but no weakness or memory deficits. She
denies dysuria or hematuria. She is post-menopausal but had e/o
vaginal bleeding last month. Had normal pap.
.
In the ED the patient was noted to have elevated lipase and CT
abdomen showed pancreatitis. She received dilaudid 3mg IV and
Morphine 12mg IV with minimal relief of her pain.
Past Medical History:
s/p cholecystectomy
h/o pyelonephritis
recurrent nephrolithiasis s/p multiple episodes lithiotripsy
depression
h/o thrombocytosis thought to be acute phase reaction
h/o pneumonia
fibromyalgia
Social History:
Used to work as nurse, stopped 15 years ago to take care of her
2 daughters. Lives with her husband and children. Reports
financial strain and recently lost house to foreclosure. She
smokes about one pack per day. She denies any drug use.
Family History:
nc
Physical Exam:
98.0 108/70 100 20 95%RA
GEN'L: ill appearing, appears in pain, no acute distress
HEENT: nc/at, conjunctivae pink, sclera anicteric, MM dry, OP
clear, edentulous with caries
NECK: supple, no [**Last Name (un) **]/submandib/supraclavic LN
CVS: tachy, regular, no m/r/g
PUL: crackles left lung base
[**Last Name (un) **]: distended, no bowel sounds, +guarding esp RUQ and
epigastrium, no masses clearly felt, no rebound or peritoneal
signs
EXT: dry skin, no c/c/e, 2+ radia, 2+ DP pulses bilaterally
NEURO: alert and oriented, sad affect
Pertinent Results:
Admission Labs:
--------------
[**2188-6-3**] WBC-19.1*# HGB-14.6 HCT-43.6 MCV-106*
[**2188-6-3**] GLUCOSE-101 UREA N-13 CREAT-0.7 SODIUM-139
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-21* ANION GAP-20
[**2188-6-3**] TRIGLYCER-118 HDL CHOL-18 CHOL/HDL-6.4 LDL(CALC)-74
[**2188-6-3**] ALT(SGPT)-9 AST(SGOT)-24 LD(LDH)-467* CK(CPK)-67 ALK
PHOS-113 TOT BILI-0.6 LIPASE-[**2085**]*
.
Discharge labs:
--------------
[**2188-6-20**] WBC-11.0 RBC-3.02* Hgb-10.0* Hct-30.2* MCV-100* Plt
Ct-450*
[**2188-6-20**] Glucose-99 UreaN-53* Creat-4.2* Na-142 K-3.7 Cl-102
HCO3-26
.
CTA abdomen:
There is new bibasilar atelectasis, without evidence of
effusion. There is a small amount of perihepatic fluid. There is
marked peripancreatic fluid, extending into the anterior
pararenal space bilaterally, with fat stranding without any
evidence of an organizing fluid collection or pseudocyst. There
is normal parenchymal pancreatic enhancement without evidence of
necrosis. The surrounding vessels are normal without evidence of
pseudoaneurysm. There is trace perisplenic fluid, the spleen is
normal. The right adrenal is normal. The left adrenal is
somewhat crowded due to fluid in the lesser sac. There has been
prior cholecystectomy. The kidneys enhance symmetrically and
excrete contrast normally without evidence of hydronephrosis.
There is no mesenteric or retroperitoneal adenopathy. There is
no free air. The visualized small and large bowel is normal.
CT PELVIS WITH IV CONTRAST: There is some free fluid in the
pelvis. The
rectum, bladder, and distal ureters are normal.
MUSCULOSKELETAL: There is minimal DJD.
IMPRESSION:
1. Acute pancreatitis. Marked peripancreatic fluid without
evidence of
organization into a focal collection. No pseudocyst, pancreatic
necrosis or pseudoaneurysm is detected.
2. There is bibasilar atelectasis.
.
MRI abdomen (w/o contrast):
The entire pancreas is swollen and edematous, of heterogeneous
but increased signal intensity on T2-weighted sequence. There is
no evidence of pancreatic ductal dilatation. There is increased
retroperitoneal fluid in addition to ascites. There is a
loculated area of fluid in the anterior pararenal space,
anterior to the head of the pancreas measuring a maximum of 2.8
cm in diameter. There is no evidence of biliary dilatation.
There is no evidence of choledocholithiasis. There is no focal
liver lesion.
Both kidneys are essentially normal. There is no evidence of
adrenal mass. There is subcutaneous edema. It is noted that
the images are degraded by artifacts, and subtle hepatic lesions
for example cannot be excluded.
IMPRESSION:
1. Acute pancreatitis.
2. No evidence of choledocholithiasis.
3. Retroperitoneal fluid and ascites. Loculated area of fluid
anterior to
the head of the pancreas measuring 2.8 cm in maximum diameter.
.
TTE [**2188-6-10**]:
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened. No masses or vegetations are seen on the
aortic valve, but cannot be fully excluded due to suboptimal
image quality. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. No masses or vegetations are seen
on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. Moderate [2+] tricuspid regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad. IMPRESSION: Suboptimal image quality. No
definite evidence of endocarditis. Minimal aortic stenosis. Mild
mitral regurgitation. Moderate tricuspid regurgitation.
Preserved biventricular systolic function
.
CT TORSO ON [**2188-6-9**]
FINDINGS: Right IJ central line terminates at the cavoatrial
junction. There is no pericardial effusion. Hyperdense
interventricular septum indicates underlying anemia. There is a
small left pleural effusion and a tiny right pleural effusion.
Associated atelectatic changes are noted in the surrounding
pulmonary parenchyma. There is a diffuse prominence to the
interlobular septa with peripheral nodular opacities seen
bilaterally which is likely indicative of fluid overload;
however, developing multifocal consolidations is a
consideration. There is underlying mild emphysematous change;
however, respiratory motion artifact limits thorough evaluation.
Trachea and main central airways are patent. There are numerous
mediastinal lymph nodes, the largest seen in prevascular
location measuring approximately 16 x 10 mm.
Large area of peripancreatic stranding and inflammatory change
is again seen around the pancreas without interval change,
allowing for lack of contrast administration. There is a small
fluid collection anterior to the pancreas, as seen on prior
study. There is no developing abscess evident. Complications
such as splenic vein thrombosis, pancreatic necrosis and/or
pseudoaneurysm formation are unable to be evaluated on
non-contrast study. No biliary dilatation. Small amount of
ascites. The remainder of the abdomen is unchanged when compared
to four days previously. There is a non-obstructing left renal
calculus. Atherosclerotic calcifications are present. Within the
pelvis there is increasing amount of free fluid as compared to
study of [**6-3**]. No dilated loops of bowel or peritoneal gas is
evident. There is a Foley catheter within a normally distended
bladder. Soft tissue anasarca is seen throughout. No mass or
lymphadenopathy.
IMPRESSION:
1. Essentially stable pancreatitis, within the limitations of a
non-contrast examination.
2. Prominent pulmonary interstitial markings and scattered
bilateral
peripheral opacities, small bilateral pleural effusions, left
greater than
right, and underlying anemia, all most suggestive of fluid
overload.
Developing pneumonia cannot be entirely excluded, and continued
clinical
surveillance will be necessary.
Brief Hospital Course:
The patient is a 50 year-old woman s/p cholecystectomy, with a
history of depression, fibromyalgia, and recurrent
nephrolithiasis who presents with acute pancreatitis. Her
hospital course was complicated by severe ATN due to contrast
nephropathy as well as respiratory failure, requiring a period
of mechanical ventilation.
# Pancreatitis: She was treated with dilaudid PCA, NPO, and
IVF resuscitation. She underwent three seperate CT
abd/pelvis--two of which were done with IV contrast. These were
done to evaluate for evolution of pancreatic abscesses,
psuedocysts, or other fluid collections. She did show a
possible area of fluid collection anterior to the head of the
pancreas. MRCP was also done. This showed no evidence of
cholelidolithiasis or dilated biliary ducts but did confirm a
loculated area of fluid anterior to the head of the pancreas
measuring 2.8 cm in maximum diameter.
The cause of her pancreatitis was never determined. She had no
evidence of gall stones on MRCP. Her history lacked evidence of
alcohol abuse. Two of her medications for depression,
escitalopram and buspirone, were both stopped on the remote
chance that they may have triggered the process, though these
rarely cause pancreatitis. Malignancy is still in the
differential, though there is no clear evidence of this.
However, the patient reportedly described some weight loss on
admission. She was seen by the GI consult team and they did
recommend pancreas protocol abdominal imaging in [**3-23**] weeks to
assess for a mass lesion. However, the timing of this study
will depend on her renal recovery.
Days prior to discharge, her diet was advanced as tolerated.
She advanced to regular diet, though she still experienced some
bouts of nausea and vomiting, for which she received Zofran ODT,
which she will be discharged with this as a PRN medication.
# Respiratory Failure: The patient was transferred to MICU in
setting of hypoxia while on the wards. Initial hypoxia and
respiratory distress thought to either be due PNA vs. ARDs from
pancreatitis. However, there was also likely components of
volume overload from her severe ATN as well as decreased
ventilatory drive due to opiate-related narcosis from high dose
MScontin given for her pancreatitis pain. She required
intubation for hypoxic/hypercarbic respiratory failure. Given
the multiple possible causes of her respiratory failure, she was
treated with antibiotics, diuretics, and with ARDS-like
ventilation protocol. Her anti-biotic coverage included broad
spectrum antibiotics (Aztreonam, Levofloxacin, and Vancomycin)
to cover for a possible HAP. She completed an 8 day course of
these antibiotics. She was diuresed with lasix. Opiates were
also held during this period. The patient was intubated for 3
days, and extubated without complication. She was transferred
to the wards, where she was weaned off of all supplemental
oxygen.
# Acute renal failure: In setting of receiving two IV contrast
studies in a span of 3 days the patient developed rapidly rising
creatinine. Her creatinine started at 0.6 and peaked at 7.2.
She was followed closely by the renal team, lead by attending
Dr. [**Last Name (STitle) 7473**]. It was thought that her renal failure was
primarily from acute tubular necrosis due to contrast
nephropathy. She never required hemodialysis. Her renal
function is slowly improving. It is expected that she should
eventually recover full renal function. If she does not, she
should follow-up with a nephrologist.
# Acute on chronic pain: Patient has history of fibromyalgia.
On admission, she also complained of pain due to her
pancreatitis. The pain service was initially consulted to help
manage her pain. A dilaudid PCA was used along with neurontin,
tizanidine, and a lidocaine patch. She was eventually
transitioned to MS Contin. This was discontinued after she
became confused and somewhat sedated. After extubation and with
improvement in her renal function, low-dose MS Contin was
restarted. She will be discharged on low dose MScontin. As her
renal function improves, this may be increased as necessary.
She continued using the lidocaine patch.
# Enterococcus UTI: Noted from urine culture on admission. Given
PCN allergy, pt was treated with 3 day course of IV vancomycin
with subsequent urine cultures with no growth.
# Depression/anxiety - Mrs. [**Doctor Last Name 93973**] has a history of
depression and anxiety disorder. Psych was consulted during the
hospital, and suggested decreasing benzo dosing and reducing
buproprion from 300mg to 150 mg. These medications were held
upon transfer to the ICU in the setting of acute renal failure
and altered mental status. Following extubation, the psychiatry
team visited patient and recommmended continuing to hold
escitalopram & buspirone, though they felt in near future she
would likely need to restart some anti-depressant. They
recommended close follow-up with her outpatient psychiatrist.
# Anemia: Noted to have 3 point Hct drop on day of transfer to
MICU. Initial smear did reveal rare schistocytes which was
thought to possibly be [**1-19**] low grade DIC; however, upon repeat
peripheral smear review, no schistocytes were visualized. The
patient was transfused 1 unit pRBC and subsequently had a
relatively stable Hct. No signs of GI bleed during hospital
course. Iron studies did show reduced B12 and Fe levels with
increased ferritin. Methylmalonic acid was nml. Her hct
stabilized. She was recommended to have this followed-up as an
outpatient.
CODE: Full.
CONTACT: [**Name (NI) 4906**] [**Name (NI) **] ([**Name2 (NI) 3788**]) [**Telephone/Fax (1) 93974**] (mobile);
[**Telephone/Fax (1) 93975**] (work); sister [**Name (NI) **] [**Telephone/Fax (1) 93976**]
Medications on Admission:
1.Bupropion [Wellbutrin SR]-150 mg Tablet Sustained Release-2
Tablet(s) by mouth twice a day- (POE Med Reconciliation)
2.Carisoprodol [Soma]-350 mg Tablet-1 Tablet(s) by mouth four
times a day- (POE Med Reconciliation)
3.Clonazepam [Klonopin]-0.5 mg Tablet-[**12-19**] Tablet(s) by mouth
twice a day- (POE Med Reconciliation)
4.Escitalopram [Lexapro]-10 mg Tablet-1 Tablet(s) by mouth
daily- (POE Med Reconciliation)
5.Eszopiclone [Lunesta]-1 mg Tablet-1 Tablet(s) by mouth at
bedtime- (POE Med Reconciliation)
6.Morphine [MS Contin]-100 mg Tablet Sustained Release-1
Tablet(s) by mouth twice a day- (POE Med Reconciliation)
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours) for 7 days.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
4. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO WITH MEALS () for 10 days: Take 1/2 hour prior
to eating.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
5. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 30 days: Adjust
PRN potassium levels.
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
6. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
with meals: Continue until phosphate level normalizes.
7. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY:
pancreatitis
acute tubular necrosis due to contrast nephropathy
respiratory failure
SECONDARY:
anxiety and depression
acute on chronic pain
Discharge Condition:
Good, ambulating, off oxygen.
Discharge Instructions:
You were admitted with acute pancreatitis--the cause of this was
not clearly determined. While hospitalized, you developed acute
kidney failure and respiratory failure. You required support
for your breathing with a mechanical ventilator for a few days.
Your lung and kidney injuries are improving. Your creatinine on
discharge is 4.2.
You will need a follow-up imaging study of your pancreas within
6 weeks of discharge or when your kidney fuction has recovered.
Please talk with you PCP about scheduling this.
If you develop any fevers, inability to tolerate food/drink,
shortness of breath, chest pain, abdominal pain or any other
concerning symptoms, please call your physician or proceed to
the emergency department.
Your escitalopram and buspirone were discontinued while you were
in the hospital. These medications can--on rare occasion--cause
pancreatitis, thus they were stopped.
Additionally, the following medications were discontinued or
changed because they are cleared by the kidney. They may be
restarted--as necessary--once your kidney function normalizes:
- Soma (Carisoprodol)-->discontinued
- MS Contin-->dose reduced
Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) **] on Wednesday [**2188-6-25**] at
5:15pm
Please see your psychiatrist Dr. [**Last Name (STitle) 93977**] at [**Hospital3 18648**] for follow-up as soon as possible.
[**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
|
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icd9cm
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[]
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[
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[
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309, 392
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17267, 17299
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3186, 3186
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2603, 2607
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420, 2114
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3202, 3570
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2136, 2329
|
2345, 2587
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,781
| 121,781
|
47314
|
Discharge summary
|
report
|
Admission Date: [**2186-12-29**] Discharge Date: [**2187-1-4**]
Date of Birth: [**2110-2-5**] Sex: F
Service: MEDICINE
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
CC: Cough, congestion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 76 y.o. independent female with Afib, HTN,
hypercholesterolemia, who presents from home with URI symptoms
[cough productive of clear sputum,congestion] x 5 days. She
denies chest pain, SOB, or F/C. Does feel fatigued after 10
steps but denies shortness of breath with this. Usually can walk
up to a mile. No sick contacts.
.
ED COURSE: Initial vitals T 98.7, BP 186/93, HR 75, RR 20, 91%
RA. She received nebs and Azithromycin. CXR unremarkable. She
was hypoxic, 91% on 2L. D-dimer 588, BNP 1565. She is on
coumadin for Afib, INR 3.3. Went for CTA which was negative for
PE or consoldiation but showed emphasematous changes. Admitted
for w/u of hypoxia.
Past Medical History:
PMHx:
1. Chronic atrial fibrillation
2. Hypertension
3. Hyperrcholesterolemia
4. Aortic regurgitation (mild AR echo [**10-11**])
Social History:
Social History: Lives alone in a two story home. She no longer
smokes but has a 30 pack year smoking hx. Rare wine at holidays.
.
Family History:
Family History: Her parents are both deceased - late 80s
(unknown causes). She is the oldest surviving sibling of 7
(deceased older brother and sister with 4 living younger
brothers).
Physical Exam:
Physical Exam:
T: 95.8 BP: 164/72 P: 105 RR: 24 O2 sat96% 3L:
Gen: difficult for her to speak full sentences, looks in mild
resp distress
HEENT:PERRL, EOMI, MMM
Neck: no JVD
CV: irreg, rate wnl no MRG, nl S1, S2
Resp: diffuse expiratory wheezes throughout
Abd: NABS, soft, NTND, no guarding/rigidity/rebound
Ext: no CCE, 2+/4 symmetric pedal pulses
Neuro: AAO x 3
Pertinent Results:
EKG: wavy baseline, appears to have some TWI in aVF. .
[**2186-12-29**] 05:15PM BLOOD WBC-5.9 RBC-5.17 Hgb-16.3* Hct-45.5
MCV-88 MCH-31.4 MCHC-35.7* RDW-13.5 Plt Ct-158
[**2187-1-4**] 07:15AM BLOOD PT-24.9* PTT-38.9* INR(PT)-2.4*
[**2187-1-4**] 07:15AM BLOOD Glucose-85 UreaN-29* Creat-1.0 Na-142
K-3.3 Cl-98 HCO3-37* AnGap-10
[**2186-12-31**] 11:17AM BLOOD Type-ART pO2-74* pCO2-58* pH-7.29*
calTCO2-29 Base XS-0 Intubat-NOT INTUBA
Chest CTA:
IMPRESSION:
1. No evidence of central or segmental pulmonary embolus.
Evaluation for subsegmental emboli is limited due to contrast
timing.
2. Changes of moderate centrilobular emphysema with upper lobe
predominance. No airspace consolidation or pulmonary nodules are
seen.
3. Bilateral adrenal adenomas.
4. Incomplete assessment of a partially imaged possible
pathologically enlarged porta hepatis lymph node. Clinical
correlation and comparison with outside imaging studies is
recommended. If no prior studies are available, follow up with
contrast enhanced abdominal CT should be performed.
.
Renal US:
FINDINGS: The right kidney measures 8.1 cm and the left kidney
measures 8.8 cm. There is no hydronephrosis and no stones or
solid masses are identified on either kidney. There is a simple
cyst on the right kidney which measures 1.3 x 1.2 x 1.1 cm.
Images of the bladder are unremarkable.
IMPRESSION: Simple 1.3 cm left renal cyst. Otherwise,
unremarkable renal
ultrasound.
Brief Hospital Course:
A/P: 76 y.o. female with Afib on coumdain, HTN, hyperlipidemia
who presents with URI symptoms and hypoxia. She subsequently
required an overnight overnight stay in the MICU on hospital day
#2 with worsening respiratory disress, and was found to have +
RSV. Patient improved with IV steroids but had an ambulatory
oxygen requirement upon d/c. She is discharged home with 2L
oxygen and pulmonary rehab.
.
# Hypoxia - Initially, CXR neg for pneumonia, CTA neg for PE or
consolidation, but does show evidence of emphysema. Upon
admission to regular floor patient with increased hypoxia
requiring 6 L of O2 and tachypnea with accessory muscle use.
Patient ABG was 7.29/58/74 on 3L NC. In MICU pt. received IV
methylprednisolone, ipratropium nebs & supplemental 6L O2 with
improvement of hypoxia. She was transfered back to regular
floor and her RSV antigen returned positive at that time. Her
wheezing improved on IV steroids and she is discharged on 2
weeks of steroid tapers, along with combivent nebs and advair.
Pt. also completed 5 day course of Azithromycin for COPD
exacerbation.
Diff dx also included CHF, ACS, or blossoming pna. No h/o COPD
but does have 40 pack year smoking hx and mild pulm htn by last
echo. The CT scan confirmed emphysema and wheezing necessitated
steroids. She would probably benefit from pulmonary PFTs as
outpatient once improved and pulmonary evaluation. CHF
considered given elevated BNP but pt dry on exam. Her recent
echo showed nl systolic and diastolic function, but she does
have mild cor pulmonale likely due to pulmonary hypertension.
Her lasix was held while in house as she was dehydrated. No MI
w/cardiac enzymes WNL.
.
# ARF - Baseline creatinine 1.1-1.2 & without signs of clinical
hypervolemia. Creatine was followed and returned to 0.8 by HD#3.
Pt. was continued on Moexipril after resolution of renal
failure, while continued to hold lasix as pt without signs of
volume overload with likely dehydration.
.
# Afib - Pt. anticoagulated w/ warfarin. Warfarin held on HD#3
as INR 3.9. INR normalized prior to discharge and pt. resumed
warfarin therapy as prior to admission. Pt. continued metoprolol
100mg [**Hospital1 **].
.
# Hypertension - Pt. remained hypertensive (SBP 130-150's)
throughout admission and was continued on metoprolol, moexipril.
Her amlodapine is restarted upon discharge.
.
# Hypercholesterolemia - continued Pravastatin
.
# Code Status: FULL
Medications on Admission:
Amlodipine 5mg daily
Lasix 20mg po daily
Metoprolol 100mg PO BID
Pravastatin 40mg daily
Moexipril 15mg po BID
Calcium 250 mg
Vit D
MV
Warfarin 2mg Monday/Thursday, 3mg all other days
.
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Monday &
Thursday.
4. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Sunday, Tuesday,
Wednesday, Friday, Saturday.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
7. Calcium Carbonate 250 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
8. Moexipril 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
10. Carbamide Peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 2 days.
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) inhaller
Inhalation every six (6) hours.
Disp:*1 inhaller* Refills:*5*
14. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: 4 x 10 mg from [**1-5**] to [**1-7**] 3 x 10 from [**1-8**] to [**1-10**], 2 x 10
from [**1-11**] to [**1-13**], then 5 mg tablets x 3 days after .
Disp:*27 Tablet(s)* Refills:*0*
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: after you finish the 10 mg prednisone taper.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary
RSV viral infection
Emphysema
Secondary
history tobacco abuse
atrial fibrillation
Hypertension
Hypercholesterolemia
Discharge Condition:
Good. assymptomatic. afebrile. Sats > 90% on 2 L O2
Discharge Instructions:
You were admitted for shortness of breath. You were found to
have viral respiratory infection which exacerbated your chronic
lung condition called emphysema.
We are discharging you on oxygen that you should wear with
exertion, you should be able to be weaned off oxygen in a few
weeks. Please continue to wear it until instructed otherwise by
your physician.
[**Name10 (NameIs) 357**] resume taking all medications as you were previously
taking with the following exceptions:
- Advair disk has been added to your medication regimen.
- you should also continue combivent daily
- Please do not take lasix until following up with your PCP
Please continue checking your coumadin level as prior
Please discuss your blood pressure control with your primary
care doctor.
.
Please call your physician or come to the emergency department
for worsening difficulty breathing or shortness of breath,
fever, chills.
Followup Instructions:
You have scheduled the following appointments:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2187-6-11**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 10464**]
Date/Time:[**2187-2-1**] 10:20
Please follow up with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) **],[**First Name3 (LF) **] G. [**Telephone/Fax (1) 3329**] on [**1-12**] @ 11:30 am.
Completed by:[**2187-1-5**]
|
[
"799.02",
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"272.0",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7546, 7604
|
3347, 5766
|
292, 299
|
7773, 7827
|
1891, 3324
|
8780, 9362
|
1321, 1491
|
6001, 7523
|
7625, 7752
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5792, 5978
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7851, 8757
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1521, 1872
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231, 254
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327, 988
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1010, 1140
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1172, 1289
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,198
| 165,547
|
4710
|
Discharge summary
|
report
|
Admission Date: [**2119-2-15**] Discharge Date: [**2119-2-20**]
Date of Birth: [**2050-1-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
Fever, chills, epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69F s/p ccy c/b bile leak and stent placement returns with
fevers, chills and rigors. Pt states fevers to 103 with anorexia
and rigors. pt denies diarrhea, jaundice, CP, or SOB.
Past Medical History:
HTN
cholecystitis s/p open ccy [**2119-2-1**]
hypercholesterolemia
Back pains
Social History:
primarily russian speaking but does understand and speak some
English.
Family History:
no history of small bowel or colon cancer.
Physical Exam:
AAO X3
Pale, toxic appearing
Tachy, RR
Decreased lung sounds at bases o/w CTA
Soft, NT/ND, no guarding, no rebound, no ascites, no drainage
from JP site
Trace bipedal edema
Pertinent Results:
[**2119-2-14**] 08:40PM BLOOD WBC-17.3*# RBC-3.85* Hgb-11.6* Hct-34.9*
MCV-91 MCH-30.2 MCHC-33.3 RDW-13.7 Plt Ct-379
[**2119-2-15**] 05:45AM BLOOD WBC-19.2* RBC-3.56* Hgb-10.6* Hct-31.9*
MCV-90 MCH-29.9 MCHC-33.3 RDW-13.8 Plt Ct-341
[**2119-2-15**] 05:18PM BLOOD WBC-9.9 RBC-3.40* Hgb-10.4* Hct-30.4*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.7 Plt Ct-324
[**2119-2-20**] 05:15AM BLOOD WBC-5.9 RBC-3.45* Hgb-10.3* Hct-30.7*
MCV-89 MCH-29.8 MCHC-33.6 RDW-13.9 Plt Ct-317
[**2119-2-14**] 08:40PM BLOOD Neuts-91.4* Lymphs-3.5* Monos-4.8 Eos-0.2
Baso-0
[**2119-2-15**] 05:45AM BLOOD Neuts-89.9* Lymphs-6.3* Monos-3.5 Eos-0.2
Baso-0.1
[**2119-2-14**] 08:40PM BLOOD PT-13.4 PTT-21.8* INR(PT)-1.1
[**2119-2-15**] 05:18PM BLOOD PT-13.9* PTT-24.3 INR(PT)-1.2
[**2119-2-14**] 08:40PM BLOOD Glucose-123* UreaN-12 Creat-0.8 Na-138
K-3.7 Cl-100 HCO3-26 AnGap-16
[**2119-2-15**] 05:45AM BLOOD Glucose-107* UreaN-9 Creat-0.7 Na-140
K-4.0 Cl-103 HCO3-30* AnGap-11
[**2119-2-20**] 05:15AM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-142 K-4.1
Cl-104 HCO3-32* AnGap-10
[**2119-2-14**] 08:40PM BLOOD ALT-23 AST-17 AlkPhos-109 Amylase-45
TotBili-0.6
[**2119-2-15**] 05:18PM BLOOD ALT-295* AST-540* LD(LDH)-617*
AlkPhos-575* TotBili-1.3
[**2119-2-16**] 02:52AM BLOOD ALT-233* AST-219* LD(LDH)-196
AlkPhos-537* Amylase-48 TotBili-0.7
[**2119-2-20**] 05:15AM BLOOD ALT-53* AST-20 AlkPhos-236* Amylase-40
TotBili-0.3
[**2119-2-14**] 8:40 pm BLOOD CULTURE
**FINAL REPORT [**2119-2-20**]**
AEROBIC BOTTLE (Final [**2119-2-20**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2119-2-20**]): NO GROWTH.
CHEST (PA & LAT) [**2119-2-14**] 9:20 PM
IMPRESSION: Minimal linear opacity at the left base without
obscuration of the diaphragm, likely represents vascular
crowding. Otherwise stable radiographic appearance of the chest.
Brief Hospital Course:
69F admitted on [**2-15**] after being seen in the office on [**2-14**] for
ICU care, IV abx and an ERCP. Pt start on IV Levo/Flagyl, Cx
drawn and GI consulted. LFTs drawn and found to be elevated. An
ERCP performed on HD 1 with removal of stent, sphincterotomy and
without evidence of bile leak, pus or abnormal biliary tree. Pt
continued to spike fevers and ampicillin added on HD 2. Pt began
to improve and was transferred to the floor on HD 2. Clear
liquids started on the evening of HD 2 and pt tol well. Pt
continued to improve and diet advanced over the next few days to
a regular diet by HD 4. Repeat LFT's improving and pt with
decreased fever spikes. On HD 6, pt switched to PO Levo/Flagyl.
Pt afebrile for 24 hrs on PO abx. Pt tolerating regular diet,
with improving LFT's and decreased pain. Pt d/c'd home on HD 7
in stable condition.
Discharge Medications:
1. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis
HTN
hypercholesterolemia
back pain
Discharge Condition:
stable
Discharge Instructions:
Continue to take antibiotics as directed.
[**Name8 (MD) **] MD if develop fever or chills, severe pain, yellow skin or
eyes.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 10533**] for an
appointment.
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2119-2-20**]
|
[
"401.9",
"724.5",
"576.1",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.55",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
4262, 4268
|
2833, 3681
|
345, 352
|
4359, 4367
|
1016, 2810
|
4540, 4770
|
764, 808
|
3704, 4239
|
4289, 4338
|
4391, 4517
|
823, 997
|
275, 307
|
380, 559
|
581, 660
|
676, 748
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,214
| 191,488
|
32076
|
Discharge summary
|
report
|
Admission Date: [**2184-9-11**] Discharge Date: [**2184-9-16**]
Date of Birth: [**2136-10-28**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Transfer from OSH for respiratory distress, concern for ARDS.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 year-old woman with past medical history of tobacco abuse,
hemochromatosis transferred from OSH with respiratory distress.
The patient had abdominoplasty and liposuction of waist and neck
at [**Hospital3 **] on the [**2184-9-7**] (1L removed). Procedure was
reportedly uncomplicated but pt was slow to awake from sedation.
She was successfully extubated later that day and admitted to
[**Hospital3 **] for observation. The patient was cleared for
discharge [**2184-9-8**] but the patient opted to stay for improved
pain control. Her oxygen saturations unexpectedly dropped the
next day the 80s on room air and she required admission to MICU.
Chest x-ray and CTA showed bilateral pneumonitis and RLL
pneumonia but was negative for pulmonary embolus or evidence of
CHF. The patient was treated with solumedrol, bronchodilators,
and zosyn. The patient was then transferred to [**Hospital1 18**] and
admitted to the [**Hospital Unit Name 153**].
.
The patient states the SOB developed gradually during her
hospitalization. The patient complains of cough productive of
small amounts of white sputum. Denies fevers, chills, chest
pain, calf pain. Home in [**Doctor Last Name 6641**] with exposure to ticks but does
not recall tick bite. The patient states she had a stress test
within the year that was negative for reversible ischemia. The
patient may have had pulmonary function testing within the year
but is unaware of the results.
.
ROS: As above. Otherwise negative for abdominal pain, nausea,
vomiting, melena, BRBPR, dysuria, hematuria.
Past Medical History:
Hemochromatosis; phlebotomy at least twice annually
Hyperlipidemia
GERD
Depression
Tobacco abuse; quit one week ago, 34 pack yr history
Status post tubal ligation
Social History:
Lives with husband at home. 1-1.5 pack-year smoking history x
34 years but quit one week prior. Rare alcohol use, 3 drinks
per month.
Family History:
Mother had CABG thought due to rheumatic heart disease, "lung
disease due to smoking," DVT. Father with hemochromatosis,
gout.
Physical Exam:
VS: T: 98.8 BP: 137/29 HR: 97 RR: 25 Sat: 96% on NRB FiO2 1
(although mask does not form seal secondary to bandaging)
Gen: Comfortable appearing woman in mild respiratory distress
but speaking comfortably
HEENT: NC/AT, sclera anicteric, conjunctiva pink, PERRL, OP
clear
Neck: Supple, no LAD, no JVD
CV: RRR, no m/r/g
Resp: Good air flow, crackles bilateral bases, scattered
expiratory wheezes throughout, increased expiratory phase
Abdomen: Bandaging in place, NT, ND, +BS
Ext: No c/c/e. DP pulses/radial 2+ bilaterally
Neuro: A + O x3, CN II-XII grossly intact
Skin: No rashes, lesions.
Pertinent Results:
OSH chest x-ray [**2184-9-11**]: Diffuse bilateral airspace disease.
No cardiac enlargement to suggest CHF. Severe bilateral
pneumonitis versus ARDS
.
OSH CTA [**2184-9-9**]: Severe bilateral alveolar lung disease.
Significant consolidation RLL with air bronchograms. Moderate
consolidation LLL with air bronchograms. No pleural effusions.
.
ECG: NSR.
[**2184-9-11**] CXR IMPRESSION: Bilateral interstitial alveolar
opacities.
.
[**2184-9-11**] 03:29PM BLOOD WBC-17.4* RBC-3.64* Hgb-11.6* Hct-33.7*
MCV-93 MCH-32.0 MCHC-34.5 RDW-14.1 Plt Ct-393
[**2184-9-11**] 03:29PM BLOOD Neuts-86.5* Bands-0 Lymphs-7.8* Monos-5.0
Eos-0.7 Baso-0.1
[**2184-9-11**] 03:29PM BLOOD PT-12.8 PTT-24.3 INR(PT)-1.1
[**2184-9-11**] 03:29PM BLOOD Glucose-123* UreaN-15 Creat-0.7 Na-139
K-4.9 Cl-103 HCO3-28 AnGap-13
[**2184-9-11**] 03:29PM BLOOD ALT-158* AST-156* LD(LDH)-413* AlkPhos-94
TotBili-0.9
[**2184-9-11**] 03:29PM BLOOD Albumin-3.6 Calcium-9.6 Phos-3.0 Mg-2.6
[**2184-9-11**] 03:56PM BLOOD Type-ART pO2-74* pCO2-44 pH-7.45
calTCO2-32* Base XS-5
[**2184-9-11**] 03:56PM BLOOD Lactate-1.5
Brief Hospital Course:
47 year-old woman with past medical history of tobacco abuse,
hemochromatosis transferred from OSH with acute respiratory
distress, hypoxia s/p post-abdominoplasty and liposuction.
.
1) Hypoxia/respiratory distress: exact etiology unclear. CXR
notable for bilateral interstitial alveolar opacities.
Differential included pneumonia (aspiration, less likely
community acquired), ARDS (?secondary to infection, fat
embolus). Outside hospital had already ruled out PE. Though
she does not have known COPD, she is a smoker so COPD could also
have played a component but unlikely to be the precipitant for
these findings.
She was treated for presumed pneumonia and covered with
levofloxacin/flagyl, treated with nebs. She improved overnight
[**9-11**] and was able to wean off high flow oxygen. CXR much
improved [**9-12**], likely due to diuresis of negative 1 liter. She
had no signs or symptoms for infection/sepsis from other source.
No history of blood transfusion. Given her clinical
improvement, steroids (started at OSH) were discontinued.
She was transferred to the floor without event and gradually
weaned off oxygen successfully. She is now able to maintain her
sats on RA though she does get mildly dyspneic with ambulation.
She will complete a 10 day course of antibiotics as outpatient.
2) s/p liposuction, abdominoplasty and chin tuck
Her incisions appeared clean and healing well. Two abdominal JP
drains still remain, draining very minimal serosanguinous fluid.
She will f/u tomorrow with her plastic surgeon and anticipate
that the drains can be removed.
3) Mild transaminitis: her LFTs were notable for mild AST/ALT
elevation in the 100s. Unlikely due to sepsis as her levels
did not change with resolution of her acute respiratory distress
and clinicaly recovery. Unclear if she has had LFT
abnormalities in the past. She does have a hx of
hemochromatosis but she believes her labs have been normal
previously. She had no physical exam findings to suggest
chronic liver disease. She was instructed to f/u with her PCP
regarding this at her next appointment.
4) Depression: continue zoloft
5) Hemochromatosis: Patient is phlebotomized twice yearly and
will follow-up with her PCP
A copy of this discharge summary will be sent to her PCP [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and her Plastic surgeon Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 2520**]
Medications on Admission:
Medications at home:
Gemfibrozil 600 mg [**Hospital1 **]
Zoloft 150 mg QD
.
Medications on transfer:
Zosyn 3.75 mg Q6H started [**2184-9-9**]
Solumedrol 20 mg Q6H (40 mg Q8H 10 [**2184-9-10**])
Albuterol PRN
Flovent
Singulair
Protonix
Zoloft
Gemfibrozil
Toradol PRN
Valium PRN
Dilaudid PRN
MOM PRN
[**Name (NI) **]
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Please resume your prior home dose of 150 mg daily.
2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Hypoxia
2) Pneumonia, aspiration vs. community acquired
s/p abdominoplasty, liposuction
Discharge Condition:
stable
Discharge Instructions:
Please call your PCP or return to hospital for any worsening
symptoms of shortness of breath, fever, chills, abdominal pain.
You had some mild elevation of your liver enzymes this
admission. Please have your PCP recheck this at your next
visit.
Followup Instructions:
Please keep your f/u appointment with Dr. [**Last Name (STitle) 2520**] tomorrow, as you
are planning.
Please f/u with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 67886**] within
the next 2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2184-9-16**]
|
[
"486",
"E932.0",
"997.3",
"530.81",
"275.0",
"E878.8",
"272.4",
"790.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7409, 7415
|
4136, 6609
|
332, 338
|
7551, 7560
|
3030, 4113
|
7855, 8261
|
2277, 2406
|
6974, 7386
|
7436, 7530
|
6635, 6635
|
7584, 7832
|
6656, 6711
|
2421, 3011
|
230, 294
|
366, 1922
|
6736, 6951
|
1944, 2108
|
2124, 2261
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,593
| 169,495
|
51095
|
Discharge summary
|
report
|
Admission Date: [**2111-8-14**] Discharge Date: [**2111-8-17**]
Date of Birth: [**2057-12-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Respiratory distress during HD
fevers
shooting pains
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 11182**] is a 53 yo woman with HIV (? not taking HAART, WBC
of 1.3 with 17% bands, last CD4 of 274 [**7-9**] from [**Hospital1 2177**]), CHF,
mitral regurgitation, AVNRT, HTN, HepC, Asthma/COPD (on 4L home
O2, still smoking), [**Hospital1 **] [**Hospital1 106114**] pneumonitis, ESRD
on HD, who was transferred on day of admission from dialysis
with chills, malaise and mild SOB near the end of her HD
session. Two days before admission, toward the end of her
dialysis session, the patient felt like the inside of her body
was on fire. The pain was not localized, was described as [**11-11**]
burning, and lasted about five minutes. Thereafter, she felt
cold and had chills, and described being lightheaded and that
her blood pressure dropped. She noted a ringing in her ears when
her blood pressure dropped. She was then transferred to the
[**Hospital1 18**] ED. Patient reports USOH prior to HD. She denied recent
increase in her chronic dry cough. Denied dysuria. Denied
headache, neck stiffness. In terms of her SOB, she did not feel
it is far from her baseline, and it was worse when she was
receiving HD.
.
In the ED, the patient had blood cultures drawn and was admitted
to the MICU for respiratory distress. Her vital signs in the ED
were 101.2, 111, 120-130 systolic, 96% on 2L (up to 15L NRB due
to poor pleth). On exam, they reported increased WOB, SOB,
difficulty completing sentences.
.
She received methylprednisolone 125 IV, 3 Combivent nebs,
aspirin 325, vancomycin 1 gram, ceftazadime 1 gram,
acetaminophen and 1 L NS. She was also given enoxaparin 60
subcutaneously.
.
She denied any recent weight loss, diarrhea, vomiting, or change
in appetite. On transfer to CC7, she felt much better and had
no complaints, except for a number of itchy skin spots
distributed throughout her body. This had been evaluated prior
to this admission. Her WBC was 7.8 with 13% bands.
Past Medical History:
Past Medical History:
HIV (CD4 Ct in [**1-7**] was 217)
ESRD on HD
HTN
AVNRT diagnosed at [**Hospital1 2177**]
Recent vaginal bleed s/p conization
HCV
ESRD on hemodialysis
Asthma/COPD (on 4L O2 at home)
Cardiomyopathy w/ echo on [**8-6**] EF>55%, mild MR
[**Month/Year (2) 106113**] [**Month/Year (2) 106114**] pneumonitis followed by Dr. [**Last Name (STitle) **] [**Name (STitle) **]
at [**Hospital1 2177**] ([**Telephone/Fax (1) 7799**] #6564
PSurgH:
C-section
R knee surgery
Ovarian cysts removed
Social History:
Lives with her 17 year old son; has been medically handicapped
for many years. She has 4 children; one son is incarcerated. 45
pack years tobacco history, reports having quit for last 1 week.
She admits cocaine and "speedy pill" use. She states being clean
for 2.5 years, and that she never tried IV drugs because she's
"scared to death" of needles. She is in recovery from
alcoholism, and has been dry for 4 years. No travel recently
except on a "retreat" to [**Location (un) 7658**], CT two months prior to
admission. She said that she went on long walks outside, with
questionable mosquito exposure. She used bug spray at the time.
Pt currently lives in [**Location 669**], contemplating moving out. She has
not been sexually active for 3 years. In the 70s, she was a
nurses' aide for 3 years in upstate NY, and has lived in [**Location 86**]
for 20 years. Her last job was with the department of the IRS,
and she worked there for 4 years. She is currently unemployed.
Family History:
Her mother had a stroke and her aunt and mother had DM. Her
Daughter only has one kidney and has a "thyroid problem." Family
history is also significant for glaucoma.
Physical Exam:
VS: 98.9, 105, 124/79, 24, 100% on 4LNC
General: Able to sppeak in complete sentences. Not using
accessory muscles. Nontoxic appearing.
HEENT: NCAT, anicteric, no conjunctival pallor or injection,
EOMI, MM dry
Neck: supple, JVP not elevated
Chest: Crackles at the right base
Cardiac: RR nS1, loud S@, ? S4, no appreciable murmurs, rubs or
gallops
ABD: soft, NT, ND, normoactive bowel sounds
Ext: LUE fistula with good thrill, no LE edema
Skin: warm, dry
Pertinent Results:
[**2111-8-14**]
WBC-1.3*# RBC-5.18# Hgb-13.1# Hct-43.6# MCV-84 MCH-25.4*
MCHC-30.2* RDW-20.5* Plt Ct-169
Neuts-66 Bands-17* Lymphs-14* Monos-0 Eos-1 Baso-0 Atyps-0
Metas-2*
Myelos-0
D-Dimer-717*
Glucose-90 UreaN-29* Creat-5.5*# Na-139 K-3.0* Cl-91* HCO3-35*
AnGap-16
ALT-19 AST-42* LD(LDH)-272* CK(CPK)-192* AlkPhos-201*
TotBili-0.5
CK-MB-6 cTropnT-0.10*
pO2-142* pCO2-41 pH-7.48* calTCO2-31* Base XS-7 Intubat-NOT
INTUBA
.
.
([**2111-8-4**]) CHEST X-RAY:
Bedside AP examination labeled "upright at 8:35" is compared
with two views dated [**2111-5-8**]. There is cardiomegaly with rounded
LV enlargement and thoracic aortic tortuosity, as before. There
is no pulmonary vascular congestion or pleural effusion. Linear
scarring involving the left more than right lung base is
unchanged over the series of recent studies, with no new
airspace process. There is stable prominence of the central
pulmonary arteries which may reflect underlying pulmonary
hypertension.
.
[**2111-8-15**] 10:22AM BLOOD WBC-17.3*# RBC-4.36 Hgb-11.1* Hct-36.1
MCV-83 MCH-25.4* MCHC-30.6* RDW-20.4* Plt Ct-170
.
[**2111-8-15**] 10:22AM BLOOD Neuts-75* Bands-14* Lymphs-6* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
.
[**2111-8-16**] 10:10AM BLOOD WBC-7.8# RBC-4.50 Hgb-11.6* Hct-38.0
MCV-84 MCH-25.9* MCHC-30.6* RDW-20.3* Plt Ct-167
.
[**2111-8-16**] 10:10AM BLOOD Neuts-82.1* Lymphs-13.3* Monos-3.0
Eos-1.3 Baso-0.3
.
[**2111-8-17**] 06:15AM BLOOD WBC-6.0 RBC-4.29 Hgb-11.1* Hct-35.4*
MCV-83 MCH-25.9* MCHC-31.3 RDW-19.7* Plt Ct-144*
.
[**2111-8-17**] 06:15AM BLOOD Neuts-71.2* Lymphs-17.7* Monos-5.4
Eos-5.3* Baso-0.3
.
[**2111-8-16**] 10:10AM BLOOD ALT-20 AST-34 LD(LDH)-199 AlkPhos-116
TotBili-0.3
.
[**2111-8-14**] 08:20AM BLOOD CK-MB-6 cTropnT-0.10*
Brief Hospital Course:
Briefly this is a 53 yo Female with HIV (?off HAART wbc of 1.3,
last CD4 of 217 [**12-8**]), CHF, AVNRT, HTN, HepC, Asthma/COPD (on
4L home O2, still smoking), LIP, ESRD on HD, who was transferred
on day of admission from dialysis with chills, SOB [**2-3**] way
through HD.
.
1. Respiratory distress: Patient with significant baseline
pulmonary disfunction secondary to asthma/COPD, LIP, CHF on home
O2 and still smoking who presented with acute SOB in addition to
chronic SOB/DOE. CXR was negative for acute pulmonary edema or
focal consolidation. Pt received enoxaparin, methylprednisolone,
vancomycin and ceftazadime in the ED. Upon arrival, no evidence
of acute respiratory distress. Pt was satting 100% on 4LNC (home
level). On the floor, the patient had no symptoms of respiratory
distress, and was satting 93-97 on room air. She only became
short of breath upon exertion.
.
# ID: Patient presented with fever, leukopenia, and bandemia.
Because the patient is immunocompromised and at risk for
infections, blood and urine cultures were obtained as she was
covered empirically with vancomycin and ceftazadime. Gentamicin
was then started, and ceftazadime and vancomycin were
discontinued. She was afebrile with a white count of 7.8 on the
floor. The empiric treatment in the ED may have had an effect.
Per ID consult recommendations, gentamicin was discontinued.
During her course, her bandemia resolved, and her white count
continued to fall. She had no fevers, chills, nausea, or
vomiting. There was never any growth from any of her cultures.
.
# HIV: Followed by Dr. [**Last Name (STitle) 724**]/[**Doctor Last Name 4888**]. ID was consultd,
recommended continuing pt on her prior HAART regimen (abacavir,
nevirapine, ddI) despite possibly not being adherent to these
meds, the theory being that these medications would suppress her
wildtype virus and allow for genotyping of likely mutations at
her outpatient clinic. We continued outpt regimen and carefully
monitored for possible reonstitution syndrome given pt may not
have been taking HAART as outpt. Patient is scheduled for
outpatient follow up with [**Hospital6 **] ID on [**2111-8-20**].
.
# ESRD: On HD. Had fever/chills during HD raising concern for
transient bacteremia. Renal team followed patient during
admission and HD was continued as scheduled for M/W/F. She
received HD at [**Hospital1 18**] on the morning of [**8-17**].
.
# HTN: Continued on outpatient regimen, imdur and diltiazem
.
On day of discharge pt was ambulating without difficulty. She
was afebrile with WBC of 6, no bands, VSS. Pt is to follow up
at [**Hospital1 2177**] with Dr. [**Last Name (STitle) **], he has been notified of her hospital
course with us.
Medications on Admission:
Medications on admission: per [**Name (NI) **], pt does not remember
ALBUTEROL 90 mcg/Actuation--2 puffs by mouth [**Hospital1 **] to qid
Abacavir 300 mg--1 tablet(s) by mouth twice daily
BACTRIM DS 160-800 mg--1 tablet(s) by mouth every monday
wednesday and friday
DILTIAZEM HCL 360 mg--1 capsule(s) by mouth daily
IBUPROFEN 600 mg--One tablet(s) by mouth q 6 hours as needed for
pain
IMDUR 60 mg--1 tablet(s) by mouth daily
NEPHROCAPS 1 mg--1 capsule(s) by mouth daily
NEVIRAPINE 200 mg--1 tablet(s) by mouth twice a day
PERCOCET 5 mg-325 mg--One to two tablet(s) by mouth q 4-6 hours
as needed for pain
PHOSLO 667 mg--3 tablet(s) by mouth tid with food
PREDNISONE 5 mg--1 tablet(s) by mouth daily
SEROQUEL 25 mg--1 tablet(s) by mouth at bedtime
SYNALAR 0.01 %--apply to scalp qd to [**Hospital1 **]
TRIAMCINOLONE ACETONIDE 0.1 %--Apply twice daily to affected
areas for up to 2 weeks/month max twice a day as needed for
avoid face and folds
VICODIN 5 mg-500 mg--[**2-3**] tablet(s) by mouth 4-6 hours as needed
for pain
VIDEX EC 125 mg--1 capsule(s) by mouth daily
.
.
Medications at time of transfer:
Lidocaine 5% Ointment 1 Appl TP ONCE
Abacavir Sulfate 300 mg PO BID
Nephrocaps 1 CAP PO DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Nevirapine 200 mg PO BID
Bisacodyl 10 mg PO/PR DAILY:PRN
Oxycodone-Acetaminophen [**2-3**] TAB PO Q4H:PRN
Calcium Acetate [**2105**] mg PO TID W/MEALS
PredniSONE 5 mg PO DAILY
Diltiazem Extended-Release 360 mg PO DAILY
Quetiapine Fumarate 25 mg PO QHS:PRN
Didanosine EC 125 mg PO DAILY
Senna 1 TAB PO BID:PRN
Docusate Sodium (Liquid) 100 mg PO BID
Sulfameth/Trimethoprim DS 1 TAB PO QMWF
Heparin 5000 UNIT SC TID
Vancomycin 1000 mg IV ONCE Duration: 1 Doses Order date: [**8-15**] @
1813
Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
.
Discharge Medications:
1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: Two (2)
PUFFS Inhalation [**Hospital1 **] to qid prn as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*3*
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMWF ().
Disp:*15 Tablet(s)* Refills:*3*
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
6. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4 hours PRN as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
8. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
Disp:*30 Tablet(s)* Refills:*2*
11. Didanosine 125 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*
12. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Respiratory Distress
ESRD on HD
Discharge Condition:
GOOD
Discharge Instructions:
You were admitted for an episode of pain with fever, low blood
pressure and an abnormal white blood cell count. You were
treated with antibiotics and have not been found to have any
evidence of ongoing infection. Please take all medications as
prescribed. You have an appointment scheduled with the [**Hospital **]
clinic at [**Hospital6 **]. Please call your doctor or
return to the emergency room if you experience fevers,
lightheadedness, shortness of breath or for any other concerning
symptoms
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2111-9-7**] 10:40 CARDIOLOGY
.
You have an appointment scheduled at the [**Hospital 2177**] [**Hospital **] clinic:
DR [**Last Name (STitle) **] THURSDAY [**2111-8-20**], anytime after 3pm (they know you
are coming)
Phone: [**Telephone/Fax (1) 106117**], please call if you have questions of if you
need to reschedule
|
[
"403.91",
"585.6",
"786.09",
"424.0",
"042",
"425.4",
"428.0",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12625, 12631
|
6259, 8962
|
369, 375
|
12719, 12726
|
4503, 6236
|
13277, 13732
|
3845, 4013
|
10805, 12602
|
12652, 12698
|
9014, 10782
|
12750, 13254
|
4028, 4484
|
277, 331
|
403, 2311
|
2355, 2838
|
2854, 3829
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,203
| 134,071
|
33791
|
Discharge summary
|
report
|
Admission Date: [**2164-4-14**] Discharge Date: [**2164-4-25**]
Date of Birth: [**2110-5-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Fall down stairs
Major Surgical or Invasive Procedure:
On [**2164-4-15**]: posterior cervical laminectomy C4-C7.
2. Posterior thoracic laminectomy T4-T5.
3. Posterior cervico-thoracic arthrodesis C3-T9.
4. Posterior cervico-thoracic instrumentation C3-T9.
5. Application of local autograft.
6. Cortical cancellous allograft.
History of Present Illness:
53-year-old male who fell down 15 steps by report while
intoxicated. He was brought to an area hospital and subsequently
transferred to the [**Hospital1 1444**] for full trauma evaluation.
On his arrival he was found to exhibit flaccid paralysis of
bilateral upper extremities, but demonstrated some sacral
sensory sparing and distal lower extremity strength 3/5 in
the gastrocnemius soleus complex, [**Last Name (un) 938**], tibialis anterior. He
underwent imaging including fine-cut CT and MRI of his entire
spine. This identified an undisplaced fracture of the C2
pars into the body, involving the foramen transversarium
without vertebral injury as well as a C3 spinous process
fracture, evidence of previous C4 and C5 spinal process
fractures, severe subaxial spondylosis with ligamentum flavum
buckling causing severe central as well as foraminal subaxial
stenosis and a non-displaced C4 injury with increased STIR
signal. Thoracic imaging identified T3 spinous process fracture
with posterior ligamentous complex disruption, a T4 burst
fracture with retropulsion, and a minimally displaced T7
compression fracture with increased STIR signal.
Past Medical History:
HTN
Back surgery
Social History:
+EtOH
Supportive family
Family History:
Noncontributory
Physical Exam:
Upon admission:
98.4, 63, 136/57, 16, 100% on FIO2 0.35.
TV 700, PEEP 5, PS 10.
GENERAL APPEARANCE: The patient is a thin man, intubated and
sedated.
NECK: A cervical spinal collar is in place.
LUNGS: Clear to auscultation bilaterally anteriorly.
HEART: S1, S2, regular, without murmurs.
ABDOMEN: Soft, without palpable masses or splenomegaly.
EXTREMITIES: No peripheral edema.
NEUROLOGIC: The patient is sedated and does not respond to
voice
or withdraw to pain. He has hyperreflexia of upper extremities
and 2+ patellar reflexes.
SKIN: There are no petechiae or ecchymoses and no visible oozing
from IV lines.
Pertinent Results:
Upon admission:
[**2164-4-14**] 09:32PM GLUCOSE-107* UREA N-14 CREAT-0.7 SODIUM-143
POTASSIUM-4.3 CHLORIDE-116* TOTAL CO2-18* ANION GAP-13
[**2164-4-14**] 09:32PM CALCIUM-7.8* PHOSPHATE-4.1 MAGNESIUM-2.6
[**2164-4-14**] 09:32PM WBC-4.4 RBC-2.85* HGB-9.5* HCT-29.3* MCV-103*
MCH-33.2* MCHC-32.3 RDW-15.4
[**2164-4-14**] 09:32PM PLT COUNT-32*
[**2164-4-14**] 09:32PM PT-17.5* PTT-34.9 INR(PT)-1.6*
[**2164-4-14**] 09:32PM FIBRINOGE-112*
[**2164-4-14**] 03:49PM TYPE-ART PO2-242* PCO2-35 PH-7.32* TOTAL
CO2-19* BASE XS--7
[**2164-4-14**] 04:30AM ASA-NEG ETHANOL-310* ACETMNPHN-5.0
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-4-14**] 04:43AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CHEST (PORTABLE AP) [**2164-4-24**] 4:02 AM
CHEST (PORTABLE AP)
Reason: eval for interval changes
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with recent trach/PEG placement s/p multilevel
spinal fractures
REASON FOR THIS EXAMINATION:
eval for interval changes
HISTORY: Multilevel spinal fractures, to assess for
cardiopulmonary disease.
FINDINGS: In comparison with the study of [**4-23**], there is
improvement in the diffuse bilateral pulmonary changes extending
outward from the hilum, consistent with decreasing pulmonary
venous pressure. The cardiac size remains within normal limits.
The costophrenic angles are now more sharply seen. Metallic
devices and support monitoring devices remain in place. The IVC
filter is again noted.
IMPRESSION: Improving pulmonary vascular status.
CT HEAD W/O CONTRAST [**2164-4-21**] 9:16 AM
CT HEAD W/O CONTRAST
Reason: Acute intracranial process?
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with hypertension breaking through
supratherapeutic doses of benzodiazepines and opioids
REASON FOR THIS EXAMINATION:
Acute intracranial process?
CONTRAINDICATIONS for IV CONTRAST: None.
HEAD CT WITHOUT CONTRAST.
INDICATION: 53-year-old man with hypertension, breaking-through
supratherapeutic doses of benzodiazepines and opioids. Rule out
acute intracranial process.
COMPARISON: [**2164-4-14**].
CT HEAD WITHOUT INTRAVENOUS CONTRAST: There is no acute
intracranial hemorrhage, edema, shift of normally midline
structures, or hydrocephalus. The density values of the brain
parenchyma are within normal limits.
Since prior examination, there has been development of extensive
mucosal thickening involving the imaged maxillary sinuses, right
greater than left, as well as air-fluid levels of sphenoid sinus
and opacification of mastoid air cells. Nondisplaced right
occipital condyle flap fracture is incompletely imaged.
IMPRESSION:
1. No evidence of acute hemorrhage or edema.
2. Interval development of sinus disease.
CT CHEST W/CONTRAST [**2164-4-14**] 5:08 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: ? INJURY
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with s/p fall 15stairs +loc +etoh
REASON FOR THIS EXAMINATION:
please eval for acute injury
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 53-year-old male after fall while intoxicated with
concern for traumatic injury of the torso.
COMPARISON: No prior.
TECHNIQUE: MDCT axial images of the chest, abdomen, and pelvis
after Optiray IV contrast with multiplanar reformats.
CT OF THE CHEST WITH IV CONTRAST: The heart and great vessels of
the chest opacify well. There is no evidence of mediastinal
hematoma. There is no pericardial fluid. Circumferential
atherosclerotic calcification is noted throughout the aorta.
Dependent opacity is noted of both lower lobes which may simply
represent atelectasis but is concerning for aspiration. There is
no pleural fluid or pneumothorax.
CT OF THE ABDOMEN WITH IV CONTRAST: In the peripheral right
hepatic lobe is noted a 3.4 x 2.7 cm triangular-shaped area of
relative low attenuation of the hepatic parenchyma. There is a
suggestion of a tiny amount of adjacent subcapsular fluid. A
small round subcentimeter hypodense focus of the left hepatic
lobe is too small to characterize. The background hepatic
attenuation is somewhat heterogeneous suggesting underlying
chronic liver disease. There is mild gallbladder wall thickening
possibly due to liver disease, but no adjacent fluid or stones.
The spleen, adrenal glands, kidneys, stomach, and
intra-abdominal large and small bowel are unremarkable.
Incidental note is made of pancreas divisum. There is no free
intraperitoneal gas or fluid. Several mildly enlarged
retroperitoneal lymph nodes are noted measuring up to 11-mm on
short axis.
Atherosclerotic calcification is noted at the origins of the
celiac, SMA, and [**Female First Name (un) 899**].
CT OF THE PELVIS WITH IV CONTRAST: The rectum, prostate, seminal
vesicles, and pelvic loops of bowel and bladder are
unremarkable. There is a Foley catheter within the urinary
bladder.
BONE WINDOWS: An acute wedge compression fracture is noted of T4
with retropulsion of bone causing moderate central canal
stenosis. Also noted is a minimally displaced fracture through
the spinous process of T3 which extends into the bilateral
transverse processes.
IMPRESSION:
1. Acute wedge compression fracture of T4 with retropulsion of
bone causing moderate central canal stenosis. Minimally
displaced fracture involving the transverse and spinous
processes of T3.
2. 3.4 cm hypodense region of the peripheral right hepatic lobe
with suggestion of tiny amount of adjacent subcapsular fluid is
suspicious for laceration in a patient s/p trauma. Subcentimeter
low density focus of the left hepatic lobe not fully
characterized and relation to trauma uncertain.
3. Dependent consolidation of the lower lobes. This may
represent atelectasis but is concerning for possible aspiration.
4. Heterogenous attenuation of the background hepatic parenchyma
suggests underlying liver disease.
5. Several mildly enlarged retroperitoneal lymph nodes of
uncertain significance.
6. Pancreas divisum.
Brief Hospital Course:
He was admitted to the Trauma Service. Orthopedic Spine Surgery
was consulted given his multiple spine injuries. Because of
pancytopenia a Hematology consult was urgently placed; it was
recommended that he be given a platelet transfusion and it was
they felt that surgery should not be delayed. His most recent
CBC as of [**4-25**] as follows:
WBC RBC Hgb HCT MCV MCH MCHC RDW PLT Ct
7.7 2.93* 9.1* 28.0* 96 31.0 32.4 19.0* 89*
Once this clearance was given he was taken to the operating room
for posterior cervical laminectomy C4-C7, posterior thoracic
laminectomy T4-T5, posterior cervico-thoracic arthrodesis C3-T9,
posterior cervico-thoracic instrumentation C3-, application of
local autograft, and cortical cancellous allograft. His JP
drains were eventually removed. There were no intraoperative
complications. He was later fitted with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36323**] brace
(cervical & TLSO) which is to be worn at all times.
Postoperatively he was taken to the Trauma ICU where he was
followed closely. He remained intubated and sedated. He was
placed on Ativan per CIWA protocol. Nutrition consult was
obtained and tube feedigns were initiated early. The decision
was made after team/family discuassions for a tracheostomy and
PEG placment in preparation for rehabilitation. An IVC filter
was also placed given his high risk for PE. His sedation was
weaned and although he did open his eyes he has been not
interactive. He does grimace to painful stimuli and withdraws
from the stimulus bilateral upper extrmemties, response is quite
weak.
His pain is being controlled with a Clonidine patch prn
Oxycodone. He was placed on a bowel regimine as well.
Physical and Occupational therapy were consulted and have
continued to work with him. Social work was also closely
involved; providing emotional support to patient and family.
He will follow up with Dr. [**Last Name (STitle) 1007**], Orthopedic Spine Surgery, in
the next 3-4 weeks.
Discharge Medications:
1. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML's PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
EVERY OTHER DAY (Every Other Day).
4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
7. Oxycodone 5 mg/5 mL Solution Sig: [**5-19**] ML's PO Q3H (every 3
hours) as needed for pain.
8. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) ML's PO
every 4-6 hours as needed for fever or pain.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical three
times a day: Appy to scrotal/peri rectal area as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold fro HR <60; SBP <110.
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Dose
Injection four times a day as needed for per sliding scale: See
attached sliding scale.
12. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
13. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) MG Intravenous DAILY (Daily) for 2 weeks.
14. Nafcillin 2 gram Piggyback Sig: Two (2) GM's Intravenous
every six (6) hours for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital
Discharge Diagnosis:
s/p Fall
Right occipital condyle fracture, nondisplaced
C2 Fracture right lateral mass
C3 Spinous fracture
T3 Spinous process fracture
T4 Compresson fracture w/ mild retropulsion/canal narrowing
Respiratory failure
Pancytopenia
Discharge Condition:
Good
Discharge Instructions:
You must continue to wear the [**Location (un) 36323**] brace at all times.
Followup Instructions:
Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], Spine Surgery, in [**3-13**] weeks.
Call [**Telephone/Fax (1) 1228**] for an appointment.
Completed by:[**2164-8-31**]
|
[
"571.2",
"721.7",
"E878.1",
"401.9",
"806.00",
"V46.11",
"427.89",
"303.90",
"910.0",
"486",
"E880.9",
"790.29",
"801.00",
"284.1",
"286.9",
"924.00",
"997.3",
"806.20",
"806.25"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"81.03",
"96.04",
"38.93",
"31.1",
"33.23",
"03.53",
"81.64",
"96.72",
"96.6",
"38.7",
"81.05",
"43.11",
"38.91",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
12119, 12190
|
8538, 10527
|
330, 602
|
12462, 12469
|
2567, 2569
|
12593, 12804
|
1879, 1896
|
10550, 12096
|
5463, 5513
|
12211, 12441
|
12493, 12570
|
1911, 1913
|
274, 292
|
5542, 8515
|
630, 1782
|
2584, 3411
|
1804, 1822
|
1838, 1863
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17
| 161,087
|
51783
|
Discharge summary
|
report
|
Admission Date: [**2135-5-9**] Discharge Date: [**2135-5-13**]
Date of Birth: [**2087-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Ampicillin / Remeron
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pressure/cardiac tamponade/ cardiogenic shock
Major Surgical or Invasive Procedure:
emergent sternotomy for pericardial window [**2135-5-9**]
History of Present Illness:
Underwent min. inv. PFO closure in [**12-11**]. Had emergent admission
on [**5-9**] for hypotension, pericardial effusion , pleural effusion
and chest pain for several days. Did not resolve with pain med
and had increasing SOB. Admitted to ER for emergent eval. and
bedside TTE. Started on dopamine drip for hypotension.
Past Medical History:
s/p min. inv. closure of Patent foramen ovale [**12-11**]; History of
Stroke/TIA; Depression; Anxiety; Borderline Hyperlipidemia;
Herniation of Cervical Discs; Patella-Femoral Syndrome; s/p
Bunionectomies
Social History:
Denies tobacco. Admits to occasional ETOH. She is an employee of
the [**Hospital1 18**] in the Neuro-Pysch Department. She is married with two
children. She denies IVDA and recreational drugs.
Family History:
Father underwent CABG at age 72. Cousin died of an MI at age 46.
Physical Exam:
pt. in distress
SBP 70- 80's
lungs CTA
tachycardic, RR, no murmur or rubs
palpable pedal pulses
Pertinent Results:
[**2135-5-11**] 08:40AM BLOOD WBC-11.3* RBC-3.62* Hgb-9.9* Hct-28.8*
MCV-80* MCH-27.3 MCHC-34.3 RDW-14.4 Plt Ct-413
[**2135-5-9**] 11:45AM BLOOD Neuts-86.5* Lymphs-7.0* Monos-5.2 Eos-1.2
Baso-0.2
[**2135-5-11**] 08:40AM BLOOD Plt Ct-413
[**2135-5-11**] 08:40AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-136
K-3.7 Cl-102 HCO3-24 AnGap-14
[**2135-5-9**] 11:45AM BLOOD CK(CPK)-26
[**2135-5-9**] 11:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
Brief Hospital Course:
Admitted through ER as above and referred to CT [**Doctor First Name **] for
emergent pericardial window/pericardectomy via sternotomy, as
the patient was hypotensive.This was performed by Dr. [**Last Name (STitle) 1290**]
on [**5-9**]. Transferred to CSRU in stable condition on phenylephrine
and propofol drips. Extubated and awoke neurologically intact.
Beta blockade started on POD #1 and transferred out to the floor
to start increasing her activity level. Mediastinal tubes
removed on POD #1. Crepitus was noted on anterior chest wall
after pleural tubes removed on POD #2. Beta blockade also
titrated up. Crepitus improved and CXR confirmed. She made good
progress and was discharged to home with VNA services on POD #4.
Medications on Admission:
ASA 325 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 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:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. 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*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 3 days.
Disp:*3 Packet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p emergent pericardial window via sternotomy [**2135-5-9**]
cardiogenic shock/tamponade
s/p Min inv. PFO closure [**12-11**]
s/p CVA
anxiety/depression
cervical disc herniation
patella-femoral syndrome
borderline hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
may shower over incision and gently pat dry
no lotions, creams or powders on incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness or drainage
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] (PCP) in [**2-7**] weeks
follow up with Dr. [**Last Name (STitle) **] (Card)in [**3-11**] weeks
follow up with Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2135-5-13**]
|
[
"458.9",
"311",
"272.4",
"722.0",
"785.51",
"423.9",
"511.9",
"719.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.31",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
3679, 3728
|
1867, 2596
|
348, 409
|
4002, 4011
|
1411, 1844
|
4270, 4532
|
1214, 1280
|
2664, 3656
|
3749, 3981
|
2622, 2641
|
4035, 4247
|
1295, 1392
|
257, 310
|
437, 759
|
781, 987
|
1003, 1198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,172
| 120,051
|
49115
|
Discharge summary
|
report
|
Admission Date: [**2111-12-25**] Discharge Date: [**2112-1-7**]
Date of Birth: [**2055-11-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Ibuprofen / Ciprofloxacin
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
pneumonia
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
56 y/o M with alcoholic cirrhosis, s/p orthotopic liver
[**First Name3 (LF) **] [**2109-5-28**], and on sirolimus and post-[**Year (4 digits) **]
course complicated by diarrhea, malnutrition and recurrent MDR
Pseudomonas pneumonias (most recently [**2111-9-28**]) now
transferred from OSH intubated with HCAP complicated by
respiratory failure. He had recently been discharged from rehab
to home [**11-24**]. But 3 days PTA, he reported worsening SOB and
productive cough and admitted to NWH where he was found to be in
hypoxic respiratory failure with acidosis and intubated. He was
treated with vanco and imipenem initially and subsequently
amikacin was added. His sputum cx revealed moderate pseudomonas
and staph. He was also received 1 unit PRBCs for anemia and HCT
drop 33->23 but was guaiac negative.
.
At present patient just got extubated therefore did not take
detailed history sedated and therefore unable to provide
history. His rapamycin was at 3.0 mg daily and more recently his
levels were stable with last level being at range (9) on [**2111-12-16**]. His recent doppler US on [**12-21**] was unremarkable.
.
ROS: Unable to obtain.
Past Medical History:
- Alcoholic cirrhosis, s/p orthotopic Liver [**Month/Year (2) **] [**2109-6-6**],
[**2109-6-23**] exploration for hematoma and fluid collection, last
liver biopsy [**2111-12-18**] with no acute cellular rejection but
nonspecific findings and marked iron deposition
- H/o malnutrition on TFs
- Prior ESLD c/b ascites, hepatorenal syndrome, grade II
esophageal varices and portal gastropathy, candidal and
bacterial (SBP) peritonitis Post-[**Month/Day/Year **] course has been
complicated by diarrhea and malnutrition s/p extensive workup
that has not found a cause.
This diarrhea is controlled with cholestyramine, Imodium,
tincture of opium, and he has [**12-31**] bowel movements a day.
- Recurrent UTIs: Most recent cultures ([**2110-5-7**]) grew pan
sensitive kleb pnemonia and corynebacterium, but in the past has
grown out resistant strains of pseudomonas sensitive only to
meropenem, amikacin.
- History of Torsades while on ciprofloxacin.
- Of note: recent hospitalization [**4-4**] w/ multiple episodes of
VT/torsades s/p magnesium & cardioversion x2. At that time
thought [**12-30**] to meds (Reglan, celexa, lyrica and Bactrim) and
contribution from congenital long QTc. QTc was 499-536 despite
holding meds and given daily magnesium and potassium.
- Cardiology evaluated him ad thought not a candidate at that
time for implantable device given recent infections. Followed as
outpatient by cardiology thought pt stress cardiomyopathy,
recommended avoiding zofran.
- Anemia with baseline Hct 27-30
- Hydroureteroephrosis/Urinary retention: Seen by [**Month/Day (2) **] as
outpatient. Most recent OMR note: secondary to recurrent
infections and that intermittent catheterization led to
hydronephrosis. Managed w/ indwelling foley.
- Colorectal cancer (stage unknown) s/p colectomy in [**11/2108**]
- Cervical stenosis
- History of C Diff colitis
- History of depression
- BPH
- Chronic pancytopenia
- Recurrent PsA:[**2111-10-17**] [**Hospital1 18**] culture data for Pseudomonas
([**Last Name (un) **] to amikacin, intermediate to cefepime, ceftaz, meropenem,
resistant to cipro, gentamycin, zosyn, tobramycin‎) as
well as culture data from [**Hospital1 **] [**Hospital1 8**] [**11-11**] (Pseudomonas
S to Amikacin, I to Meropenem, R to Cefepime, Ceftaz, Cipro,
Gent, Imi, Levoflox, Zosyn, and Tobra)
.
PSH: (from OMR)
s/p colectomy in [**11/2108**]
s/p OLT [**2109-6-6**],
s/p exlap for hematoma and fluid collection [**2109-6-23**]
s/p exlap/LOA [**8-4**]
s/p exlap/LOA/washout, temp closure [**8-4**]
s/p exlap/abd closure, cmpt separation [**8-4**]
s/p trach [**8-4**]
s/p R hip fx [**2110-1-23**]
Social History:
Lives with daughter, recently [**Name2 (NI) 103054**] from rehab. Wife died
[**2111-8-28**]. Has not had any ETOH use in "years." Smoking
history: 1/2ppd for 20 yrs, quit over 5 years ago. No illicit
drug use. Uses wheelchair at home but able to do transfers
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.9 103 118/77 22
GEN: Comfortable, intubated, sedated, following commands,
cachectic
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no jvd,
no carotid bruits, Dobhoff in place
RESP: Coarse rhonchorous BS bilaterally R>L anteriorly. No
wheezes
CV: RR, slightly tachy. S1 and S2 wnl, no m/r/g
ABD: Scaphoid. Well-healed scars. ND, +bs, soft, nt, no masses
or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Sedated, arousable, following commands, 5/5 strength hand
grip and wiggles toes bilaterally. PERRL
.
DISCHARGE PHYSICAL EXAM
VS: 99.5 79-93 118-155/85-90 20 99% on RA
Gen: comfortable appearing, cachectic man
HEEN: PERRL, EOMI, anicteric, MMM, OP clear, Dobhoff in place
RESP: Coarse BS clearing somewhat with cough, Decreaed BS at R
base posteriorly
CV: RRR, nl s1 and s2, no m/r/g
ABD: Scaphoid, soft, NTND, +bs
EXT: WWP, no c/c/e
SKIN: no rashes/jaundice
NEURO: A and Ox3. CN II-[**Doctor First Name 81**] intact. Strength and sensation
grossly intact.
Pertinent Results:
ADMISSION LABS:
[**2111-12-25**] 05:59PM BLOOD WBC-7.3 RBC-2.99* Hgb-8.9* Hct-26.2*
MCV-88 MCH-29.6 MCHC-33.8 RDW-16.5* Plt Ct-141*
[**2111-12-25**] 05:59PM BLOOD Neuts-73* Bands-20* Lymphs-4* Monos-2
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2111-12-25**] 05:59PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2111-12-25**] 05:59PM BLOOD PT-13.2 PTT-31.4 INR(PT)-1.1
[**2111-12-25**] 05:59PM BLOOD Ret Aut-2.2
[**2111-12-25**] 05:59PM BLOOD Glucose-96 UreaN-50* Creat-1.3* Na-139
K-3.9 Cl-108 HCO3-23 AnGap-12
[**2111-12-25**] 05:59PM BLOOD ALT-56* AST-44* LD(LDH)-157 AlkPhos-141*
TotBili-0.5
[**2111-12-25**] 05:59PM BLOOD Albumin-2.4* Calcium-8.3* Phos-3.0 Mg-2.2
Iron-43*
[**2111-12-25**] 05:59PM BLOOD calTIBC-96* VitB12-1047* Folate-GREATER
TH Hapto-396* Ferritn-9525* TRF-74*
[**2111-12-26**] 05:39AM BLOOD Triglyc-187*
[**2111-12-25**] 05:59PM BLOOD Amkacin-10.9*
[**2111-12-25**] 06:40PM BLOOD Type-[**Last Name (un) **] pO2-94 pCO2-42 pH-7.36
calTCO2-25 Base XS--1 Comment-GREEN TOP
[**2111-12-26**] 05:39AM BLOOD rapmycn-6.0
.
.
MICROBIOLOGY
[**2111-12-25**] 6:00 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2111-12-28**]**
MRSA SCREEN (Final [**2111-12-28**]): No MRSA isolated.
.
[**2111-12-25**] 5:59 pm BLOOD CULTURE: No Growth
.
[**2111-12-25**] 6:15 pm BLOOD CULTURE: No Growth
.
[**2111-12-25**] 7:40 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2111-12-29**]**
GRAM STAIN (Final [**2111-12-25**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2111-12-29**]):
SPARSE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
.
[**2111-12-27**] 2:44 pm BLOOD CULTURE: No Growth.
.
IMAGING:
CHEST (PORTABLE AP) Study Date of [**2111-12-25**] 5:58 PM
IMPRESSION: AP chest compared to [**9-19**] through [**10-18**]:
Widespread pulmonary opacification is more pronounced today than
at anytime since [**9-19**]. Large relatively confluent areas of
opacification in both lower hemithoraces look like right lower
lobe collapse and possible large left fissural pleural
collection. There is also more vascular congestion and clear
interstitial edema, as well as an increase in small-to-moderate
bilateral pleural effusion relative to [**10-17**]. In this
case, a chest CT scan would be very helpful in determining which
abnormalities are pleural, which are pulmonary, and whether
there is bronchial obstruction warranting bronchoscopy. Heart
size is normal. ET tube is in standard placement and a feeding
tube passes into the stomach and out of view.
.
DISCHARGE LABS
[**2112-1-6**] 05:42AM BLOOD WBC-4.7 RBC-2.75* Hgb-8.4* Hct-25.1*
MCV-91 MCH-30.6 MCHC-33.6 RDW-18.2* Plt Ct-295
[**2112-1-6**] 05:42AM BLOOD PT-13.1 PTT-29.0 INR(PT)-1.1
[**2112-1-6**] 05:42AM BLOOD Glucose-116* UreaN-35* Creat-1.3* Na-137
K-5.2* Cl-103 HCO3-28 AnGap-11
[**2112-1-6**] 05:42AM BLOOD ALT-54* AST-54* AlkPhos-131* TotBili-0.2
[**2112-1-6**] 05:42AM BLOOD Albumin-3.0* Calcium-8.9 Phos-3.3 Mg-2.1
[**2112-1-5**] 05:09AM BLOOD rapmycn-8.7
[**2112-1-4**] 05:40AM BLOOD rapmycn-5.8
[**2112-1-3**] 06:00AM BLOOD rapmycn-6.5
[**2112-1-1**] 06:25AM BLOOD rapmycn-5.2
[**2111-12-28**] 07:15AM BLOOD HEREDITARY HEMOCHROMATOSIS MUTATION
ANALYSIS-NEGATIVE
Brief Hospital Course:
56M s/p orthotopic liver [**Month/Day/Year **] [**2108**] with post [**Year (4 digits) **]
course c/b chronic diarrhea, malnutrition, and recurrent MDR
Pseudomonas pneumonias transferred from OSH with resp failure
and HCAP.
# Hypoxic respiratory failure/HCAP: The patient was transferred
from OSH to the MICU with HCAP and respiratory failure.
Diagnosis of HCAP with possible aspiration or pneumonitis.
Sputum from the OSH showed MDR pseudomonas and staph aureus.
Sputum culture from here likewise grew MDR pseudomonas. He was
started on IV vancomycin, meropenem and amikacin on [**2111-12-24**]. The
amikacin was stopped and he continued on vancomycin until [**2111-12-31**]
and meropenem until [**2112-1-6**]. Legionella and penumococcal urinary
antigens were negative as was influenza DFA. The patient was
extubated without difficulty and was saturating well on nasal
cannula. All blood cultures were negative. He was transferred
to the liver [**Month/Day/Year **] service. Given concern for aspiration
pneumonia had speech and swallow consult. Swallow evaluation
was positive for gross aspiration. The patient was made NPO.
Later, video swallow as repeated and the patient was placed on a
diet of Soft solids and thin liquids with 2 swallows per
bite/sip, alternating bites and sips, and chin tuck for liquids.
He will follow-up with speech/swallow as an outpatient. At the
time of discharge he was breathing comfortably on room air.
# Anemia/Pancytopenia: The patient has a recent baseline hct of
28. During his hospitalization his hct slowly trended down to
23. He was not transfused. He was on stool guaiac positive in
the ICU but without evidence of gross bleeding. B12, folate,
ferritin all elevated and suggestive of anemia of inflammation.
He is on darbopoietin weekly. His iron supplementation was
stopped as liver biopsy from [**2111-12-18**] showed iron deposition in
Kuppfer cells/macrophages and mild deposition in hepatocytes.
Hereditary hemochromatosis gene was checked and found to be
negative. Hematocrit at the time of discharge was 24.6.
# Orthotopic Liver [**Month/Day/Year 1326**]: Patient recently underwent U/S
guided liver biopsy [**2111-12-18**] for elevated transaminases with
nonspecific findings and marked iron deposition. Stopped iron
supplementation. Hereditary Hemochromatosis Mutation was
checked and found to be. LFTs were stable at the time of
discharge. He continues on sirolimus at 2 mg daily. Sirolimus
levels prior to discharge were consistently 5.8-6 with a level
of 7.0 on the day of discharge.
.
# Urinary Tract Infection: On the OSH urine culture patient had
a Klebsiella UTI. He has a chronic indwelling foley for urinary
retension and history of UTIs. He finished a course of
meropenem as above.
.
# Malnutrition: The patient was on home tube feeds and vitamins.
Nutrition was consulted. As above, he was NPO after initially
failing video swallow, but this was changed following repeat
video swallow (please see HCAP section above)
.
# Chronic diarrhea: The patient has had chronic diarrhea since
his liver [**Month/Day/Year **] of unclear etiology. He was continued on
tincture of opium and was not having diarrhea during this
hospitalization.
.
# Chronic pain: The patient has chronic lower back and leg pain.
He was continued on home fentanyl patch, amitriptyline,
lidocaine, and po dilaudid. His oxycodone was stopped and he
was started on oxycontin. As an outpatient his oxycontin should
be transferred to an increased dose of the fentanyl patch or
vice versa with dilaudid for breakthrough pain.
.
# Chronic Renal Insufficiency: The patient has a baseline
creatinine of 1.1. He had mild acute kidney injury on admission
that resolved with IV fluids. His creatinine on the day of
discharge was 1.3.
.
# Code Status: Full Code
.
# PENDING LABS: There were no pending labs at the time of
discharge.
Medications on Admission:
Medications at home: (Per Dr.[**Name (NI) 948**] recent note [**2111-12-11**])
Dilaudid 4mg q6h prn pain
amitriptyline 50 mg PO qhs
Darbepoetin 200 mcg injected subcutaneously every week
Fentanyl 12 mcg patch applied every 72 hours
Lidocaine patch 5% applied once a day
Remeron 15 mg 2 tablets at night
Tincture of opium 10 mg/mL 1 mL up to 3 times per day as needed
Oxycodone 5 mg 1.5 tablets as needed
Sirolimus 3 mg per day
Calcium with vitamin D 1 tablet twice a day
Ferrous sulfate 325 mg per day
Multivitamin 1 tablet per day
Thiamine 100 mg per day
Discharge Medications:
1. amitriptyline 25 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO HS (at
bedtime).
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day/Year **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
3. darbepoetin alfa in polysorbat 200 mcg/0.4 mL Syringe [**Month/Day/Year **]:
One (1) injection Injection qThurs ().
4. sirolimus 1 mg/mL Solution [**Month/Day/Year **]: Two (2) mg PO DAILY (Daily).
5. fentanyl 12 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. therapeutic multivitamin Liquid [**Month/Day/Year **]: One (1) Tablet PO
DAILY (Daily).
7. thiamine HCl 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
8. mirtazapine 15 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO HS (at
bedtime).
9. opium tincture 10 mg/mL Tincture [**Month/Day/Year **]: Ten (10) Drop PO Q6H
(every 6 hours) as needed for diarhhea.
10. Colace 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO twice a day:
hold for loose stools.
11. senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO twice a day: hold
for loose stools.
12. guaifenesin 1,200 mg Tab, Multiphasic Release 12 hr [**Month/Day/Year **]: One
(1) Tab, Multiphasic Release 12 hr PO twice a day.
13. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet [**Month/Day/Year **]: One
(1) Tablet PO twice a day.
14. oxygen
Supplemental Oxygen. 2-3 L continuous pulse-dose for portability
as needed. Diagnosis: Pneumonia
15. nebulizer & compressor Device [**Month/Day/Year **]: One (1) nebulizer
Miscellaneous ONCE.
Disp:*1 nebulizer* Refills:*0*
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) nebulizer treatment Inhalation every
six (6) hours as needed for shortness of breath or wheezing.
Disp:*30 vials* Refills:*2*
17. oxycodone 20 mg Tablet Extended Release 12 hr [**Month/Day/Year **]: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*2*
18. hydromorphone 4 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H (every
6 hours) as needed for breakthrough pain. Tablet(s)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 21645**]Healthcare
Discharge Diagnosis:
Primary Diagnoses: Health Care Associated Pneumonia, Aspiration
Pneumonia, Urinary Tract Infection
Secondary Diagnoses: Alcoholic cirrhosis status post orthotopic
Liver [**Hospital **], malnutrition, aspiration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for problems with your
breathing. You were found to have both a pneumonia and a
urinary tract infection. You were treated with antibiotics.
You initially were admitted to the medical intensive care unit
and put on a breathing machine. You were able to be
successfully taken off the breathing machine and transferred to
the liver [**Hospital **] service. You continued to recover. As
part of your work-up your swallowing was evaluated. It was
discovered that you routinely swallow food and drinks into your
lungs which is likely causing your recurrent pneumonias. Your
swallowing problems may have been worsened by your recent
intubation. You will need swallowing therapy and to limit your
diet to Soft solid foods and thin liquids. While eating please
swallow twice per bite and twice per sip and alternate bites
with sips. Tuck your chin while taking in liquids. Sit UPRIGHT
while eating or drinking.
.
The following changes were made to your medications:
Decrease your sirolimus dose to 2 mg daily.
Stop oxycodone.
Start oxyCONTIN.
Start Albuterol as needed.
Start oxygen as needed.
Increase Dilaudid.
.
It was a pleasure taking care of you.
Followup Instructions:
Department: [**Hospital **]
When: WEDNESDAY [**2112-1-13**] at 10:00 AM
With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,869
| 154,424
|
46861
|
Discharge summary
|
report
|
Admission Date: [**2159-11-19**] Discharge Date: [**2159-11-23**]
Date of Birth: [**2094-7-21**] Sex: F
Service: SURGERY
Allergies:
Codeine / ciprofloxacin in D5W / Bactrim / Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
[**2159-11-19**]: Repair of strangulated incisional hernia with mesh.
History of Present Illness:
65yF with history of ventral hernia after lap chole in [**2151**] who
woke up today at 10AM with abdominal pain. She noticed that her
hernia was out and she tried numerous times to reduce it as she
had been shown in the past but to no avail. Her abdominal pain
persisted, worsened and she also developed nausea with no
emesis. She then presented to the ER for evaluation. She has
had prior episodes of incarceration of her hernia but has been
reducible when visiting the ER. She currently reports [**9-17**]
pain associated with nausea. The patient began complaining of
worsening pain and then was uncooperative with further
history/interview. The remainder of her medical history is
taken from the OMR. She verbally consented to surgery but
refused to participate in the discussion of surgical
risks/benefits and alternatives and her brother, therefore,
provided consent.
Past Medical History:
Past Medical History: CAD/MI s/p multiple stents (>5),
hypothyroidism, hypercholesterolemia, HTN, cervical polyps,
cholecystitis s/p lap chole, arthritis, ventral hernia, kidney
stones/pyelonephritis, depression/anxiety
.
Past Surgical History: Lap chole ('[**51**]), cystoscopy,
hysterosocopy/D&C
Social History:
Patient is single and lives alone. Patient previously worked as
a social worker. Social history is significant for the absence
of current tobacco use. There is no history of alcohol abuse
Family History:
No family history of premature CAD
Physical Exam:
Physical Exam on Admission
Vitals: 95.2 50 113/56 18 100% RA
GEN: Alert/oriented, during history taking, the patient
complained of pain and refused to answer further questions
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended. +umbilical hernia with overlying skin
changes - skin with blue/black hue. Extremely tender to
palpation over hernia - no attempt at reduction given
appearance.
Remainder of abdominal exam without tenderness.
Ext: No LE edema, LE warm and well perfused
.
Physical Exam on Discharge:
Vitals: 97.8 78 106/54 18 99RA
Gen: NAD
Resp: CTAB
CV: RRR, no m/r/g
Abd: Soft, non-tender, nondistended. Vertical midline incision
with staples in place, mild serosanguineous output from central
aspect of incision. No erythema or induration
Pertinent Results:
[**2159-11-19**] 03:36PM BLOOD Lactate-1.4
[**2159-11-21**] 04:11AM BLOOD Lactate-2.9*
[**2159-11-21**] 12:40PM BLOOD Lactate-1.7
[**2159-11-22**] 03:52AM BLOOD Lactate-0.8
[**2159-11-19**] 01:45PM BLOOD Glucose-204* UreaN-16 Creat-0.7 Na-135
K-4.7 Cl-101 HCO3-23 AnGap-16
[**2159-11-22**] 03:39AM BLOOD Glucose-132* UreaN-14 Creat-0.5 Na-136
K-4.1 Cl-104 HCO3-28 AnGap-8
[**2159-11-21**] 08:47AM BLOOD PT-12.7* PTT-24.3* INR(PT)-1.2*
[**2159-11-19**] 01:45PM BLOOD WBC-13.6* RBC-5.38 Hgb-15.3 Hct-45.8
MCV-85 MCH-28.4 MCHC-33.4 RDW-13.9 Plt Ct-286
[**2159-11-20**] 04:47AM BLOOD WBC-24.6*# RBC-4.78 Hgb-14.0 Hct-41.8
MCV-87 MCH-29.3 MCHC-33.5 RDW-14.1 Plt Ct-333
[**2159-11-22**] 03:39AM BLOOD WBC-14.3* RBC-3.54* Hgb-10.2* Hct-31.7*
MCV-89 MCH-28.9 MCHC-32.3 RDW-13.9 Plt Ct-219
Brief Hospital Course:
The patient was admitted to the acute surgery service on [**11-19**]
in the setting of an incarcerated/strangulated ventral hernia.
Patient was taken to the OR on HD#1 from the ED for a ventral
hernia repair with mesh. Intra-operatively, the bowel was found
to be congested but viable upon return to the abdomen. Patient
tolerated the procedure well and was taken to the PACU in stable
condition before transfer to the floor (CC6) for further
management.
.
Neuro: Post-operatively, the patient received morphine IV with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
.
CV: On admission, patient's po medications were held and pt was
maintained on IV lopressor. Home medications were resumed POD1.
The patient was stable from a cardiovascular standpoint; vital
signs were routinely monitored.
.
Pulmonary: Patient was maintained on supplemental O2 postop.
She required 3L NC through POD3. Pulmonary toilet including
incentive spirometry and early ambulation were encouraged.
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. NGT was removed POD1. Her diet was
advanced to regular POD1, which was tolerated well. On evening
of POD1 patient noted to have multiple bloody BMs concerning for
bowel compromise. Lactate was sent and found to be 2.9. She
was transferred to the SICU for concern of compromised bowel and
closer monitoring. Patient made NPO. Lactate was trended and
returned to [**Location 213**] POD3. Clears re-instated POD2 and tolerated
well. Patient continued to have dark, maroon BMs POD2 though
less frankly bloody than POD1. These had tapered off by POD3
and patient was advanced to regular diet for xfer to floor. She
was advised to follow up with her PCP and obtain [**Name Initial (PRE) **] colonoscopy
as an outpatient. On discharge her vertical midline incision had
minimal to moderate serous oozing, for which VNA was arranged.
Her incision was non-indurated without signs of infection.
.
Foley was removed on POD#1. Patient voided appropriately.
Intake and output were closely monitored.
.
ID: Pre-operatively, the patient was given appropriate
antibiotic prophylaxis. WBC from 13->23 POD0->1. This
continued w WBC 24 on POD2. This accompanied concern for
compromised bowel. As lactate/bowel function normalized, WBC
was 10 on POD3. The patient's temperature was closely watched
for signs of infection.
.
HEME/Prophylaxis: Hct was monitored as per above. On plavix for
hx DES (last [**2155**]). Plavix was held on POD1 [**1-10**] immediate
postop and was not resumed POD2 [**1-10**] bloody BMs. As BMs tapered
off, plavix resumed POD3. Heparin was initially given though
held in setting bloody BMs. It was resumed POD3. Patient
encouraged to get up and ambulate as early as possible.
.
At the time of discharge on [**2159-11-23**], the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. Visiting nurses were arranged to assist her with
dressing changes, and she was instructed to follow up with her
PCP to arrange outpatient colonoscopy, and in [**Hospital 2536**] clinic.
Medications on Admission:
plavix 75mg', crestor 20mg', ranexa 500mg'', ASA 325mg',
Endur-Acin 250mg'', mitroglycerin 0.2mg/hr 1 patch', lopressor
50mg'', levothyroxine 200mcg', sertraline 50mg', metformin
500mg', MVI, fishoil, VitB12 500mcg', Vitamin B6
100mg', Lactobacillus acidophilus, vitD3 1,000U'
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO BID (2 times a day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Endur-Acin 250 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO BID (2 times a day).
6. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
11. morphine 15 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 3 weeks: Take with stool softener. Do not drive while
taking.
Disp:*40 Tablet(s)* Refills:*0*
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day
for 3 weeks.
Disp:*42 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Strangulated ventral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you experienced
abdominal pain at home. You were found to have an abdominal
hernia, which was repaired with mesh successfully.
Post-operatively, you had some bloody bowel movements, and were
monitered closely in the ICU. Your bloody bowel movements
resolved, and you should follow up with your PCP (Dr. [**First Name (STitle) 807**],
appointment made below) and receive a colonoscopy in the near
future. Please follow up in the acute care surgery clinic as
scheduled below. Visiting nurses will come help you with your
daily dressing changes, and may remove your staples 10-14 days
after your operation (anytime between [**Date range (3) 99432**]).
.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Date range (3) 5059**] at your next visit.
Don't lift more than 20-25 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
.
YOUR INCISION:
Your visiting nurses may remove your staples in [**9-21**] days.
Otherwise, your staples may be removed with you follow up in the
acute care surgery clinic in [**1-11**] weeks.
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your [**Date Range 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Date Range 5059**].
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Date Range 5059**].
.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
.
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
.
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 99433**],MD
Specialty: Internal Medicine
When: Wednesday [**12-5**] at 12:30pm
Location: [**Hospital **] MEDICAL PHYSICIANS, P.C.
Address: [**University/College 808**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 823**]
.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2159-12-13**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**], MD
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2159-11-23**]
|
[
"412",
"V13.02",
"998.11",
"V13.01",
"414.01",
"V45.82",
"311",
"401.9",
"300.00",
"552.21",
"E878.8",
"272.0",
"578.1",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.51"
] |
icd9pcs
|
[
[
[]
]
] |
8264, 8322
|
3568, 6846
|
331, 403
|
8394, 8394
|
2763, 3545
|
14239, 14988
|
1855, 1892
|
7173, 8241
|
8343, 8373
|
6872, 7150
|
8545, 14216
|
1578, 1633
|
1907, 2473
|
2501, 2744
|
276, 293
|
431, 1311
|
8409, 8521
|
1355, 1555
|
1649, 1839
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,596
| 174,074
|
10471
|
Discharge summary
|
report
|
Admission Date: [**2133-7-6**] Discharge Date: [**2133-7-28**]
Date of Birth: [**2075-1-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Lyphoma care, transfer from [**Hospital **] Hospital
then pneumoperitoneum due to gastric perforations
Major Surgical or Invasive Procedure:
Brain biopsy
Exploratory Laparotomy for gastric perforation
History of Present Illness:
Mr [**Known lastname 34578**] is a 58yoM with a history of B-cell non-Hodgkin's
Lymphoma who presented to [**Hospital3 934**] Hospital on [**2133-6-26**]
with fever and hypotension. He recently had developed bad
mucositis [**1-14**] round 3 of CHOP, and had some difficulty
swallowing. He was found to have a LUL cavitating lesion, was
started on Zosyn and voriconazole and admitted to the ICU. He
was not intubated. A BAL was done and showed mold, with
suspicion of Aspergillus (outside record does not state why
aspergillus suspected). He improved on zosyn/voriconazole, and
repeat CXR on [**7-2**] showed improvement in LUL infiltrate, but
large right sided pleural effusion. Thoracentesis was performed
and 1.5L fluid was drained. Pt's course was also complicated by
hypernatremia up to Na+ 160, resistant to treatment. MRI of the
brain was ordered, and showed among other findings increased
uptake in the pituitary stalk, concerning for pituitary
involvement with diabetes insipidus. MRI also significant for
multiple lesions in leptomeningeal and posterior parietal
compartments, involvement of cerebellum. Given possible
infectious process, it was decided that an LP should be done,
but because of risk of herniation pt was transferred to [**Hospital1 18**].
The patient states that he is overall doing well. He does have a
cough that is sometimes productive and feels SOB. He denies
recent fevers, chills, or night sweats. Denies specific pain. No
N/V. Has diarrhea but states that this is a chronic problem, no
[**Name2 (NI) **] or mucous. He does not feel confused.
Since he has been in [**Hospital1 18**], he has received Methotrexate x 2
days and last [**Hospital1 **] level today was 0.13 and high dose
dexamethasone that has been tapered to 8mg Qday. He was also
diagnosed with b/l DVT and an IVC filter was placed.
During a routine CXR on [**2133-7-19**] he was found to have a fair
amount of pneumoperitoneum bellow the diaphragm, this study was
repeated on [**7-21**] and the findings were unchanged. Of note this
was his first x-ray since his CT scan on [**7-8**] which was negative
for pneumoperitoneum. Today he denied abdominal pain,nausea,
emesis SOB, CP, night sweats chills or hematochezia. His last BM
was this am. However he complains of fatigue and weakness. He
had an ECHO in [**2133-5-26**] per report gross nl with mild left
ventricular hypertrophy and estimated EF of 60%.
Past Medical History:
- Non-hodgkin's lymphoma, on CHOP, followed by Dr [**First Name (STitle) **] with 3/8
cycles completed
- Diabetes insipidus
- Hypernatremia [**1-14**] diabetes insipidus
- Hypothyroidism
- Anemia of chronic disease
- Aspergillus pneumonia
- Adrenal insufficiency
- Hypokalemia
- Pleural effusion
- Hypertension
- Thrush
- Hyperlipidemia
- Coronary artery disease
Social History:
Married. Lives w wife. [**Name (NI) 1139**]: [**2-13**] cigars/day x 30 years, quit
[**4-22**]. EtOH: rare. Previously employed by USPS.
Family History:
Grandparents w DM2, no fam hx thyroid or endocrine problems
Physical Exam:
Admission:
GENERAL: NAD
HEENT: AT/NC, PERRL, membranes slightly dry, oral thrush
NECK: Supple, no lymphadenopathy
CARDIAC: Regular rate and rhythm, 2/6 systolic murmur on left
sternal border
RESPIRATORY: crackles in bilateral lung bases, no wheezes
ABDOMEN: Normoactive bowel sounds, soft, non tender, non
distended and without hepatosplenomegaly.
SKIN: Warm, dry, and intact without rash, petechiae or bruise.
EXTREMITIES: No edema, cyanosis, or clubbing
Neuro: A+Ox3, no focal deficits although some problems with
cerebellar testing. Trouble with finger to nose test at end of
pointing.
Pertinent Results:
Admission labs:
[**2133-7-6**] 05:45PM FIBRINOGE-809*
[**2133-7-6**] 05:45PM PT-12.6 PTT-22.6 INR(PT)-1.1
[**2133-7-6**] 05:45PM PLT SMR-NORMAL PLT COUNT-203
[**2133-7-6**] 05:45PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-3+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2133-7-6**] 05:45PM NEUTS-87* BANDS-1 LYMPHS-3* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-1* NUC RBCS-1*
[**2133-7-6**] 05:45PM WBC-12.6* RBC-3.05*# HGB-9.5*# HCT-29.9*#
MCV-98 MCH-31.2 MCHC-31.8 RDW-24.4*
[**2133-7-6**] 05:45PM ALBUMIN-3.0* CALCIUM-8.8 PHOSPHATE-3.7
MAGNESIUM-1.9
[**2133-7-6**] 05:45PM ALT(SGPT)-127* AST(SGOT)-99* LD(LDH)-461* ALK
PHOS-178* TOT BILI-0.2
[**2133-7-6**] 05:45PM estGFR-Using this
[**2133-7-6**] 05:45PM GLUCOSE-88 UREA N-16 CREAT-1.1 SODIUM-145
POTASSIUM-4.6 CHLORIDE-115* TOTAL CO2-21* ANION GAP-14
[**2133-7-7**] 12:00AM FIBRINOGE-701*
[**2133-7-7**] 12:00AM PT-12.5 PTT-22.8 INR(PT)-1.0
[**2133-7-7**] 12:00AM PLT COUNT-200
[**2133-7-7**] 12:00AM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL STIPPLED-1+ MACROOVAL-OCCASIONAL
[**2133-7-7**] 12:00AM NEUTS-78* BANDS-3 LYMPHS-10* MONOS-7 EOS-1
BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-3*
[**2133-7-7**] 12:00AM WBC-12.2* RBC-2.88* HGB-9.2* HCT-27.9* MCV-97
MCH-32.1* MCHC-33.1 RDW-24.0*
[**2133-7-7**] 12:00AM b2micro-3.6*
[**2133-7-7**] 12:00AM ALBUMIN-2.9* CALCIUM-8.7 PHOSPHATE-3.8
MAGNESIUM-2.0 URIC ACID-2.1*
[**2133-7-7**] 12:00AM ALT(SGPT)-124* AST(SGOT)-86* LD(LDH)-449* ALK
PHOS-178* TOT BILI-0.2
[**2133-7-7**] 12:00AM GLUCOSE-64* UREA N-18 CREAT-0.9 SODIUM-143
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14
[**2133-7-7**] 12:00AM GLUCOSE-64* UREA N-18 CREAT-0.9 SODIUM-143
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14
MRI [**2133-7-6**]: There is a 1.5 x 1.4 cm area of abnormal signal
intensity, appears hypointense on T1 and hyperintense on T2 and
FLAIR sequences, appears bright on diffusion-weighted sequence
with corresponding low ADC values. Diffuse homogeneous
enhancement is seen within the lesion on the postcontrast scans.
There are multiple nodular and linear areas of leptomeningeal
enhancement in bilateral cerebellar hemispheres, right parietal
cortex, and the optic chiasm. There is no hydrocephalus or
midline shift. The ventricles and sulci are normal in caliber
and configuration. No acute intracranial hemorrhage or
infarction is seen. Intracranial flow voids appear normal.
IMPRESSION: Nodular areas of enhancement seen in the right
periventricular
white matter and involving the optic chiasm. Multiple other
linear and
nodular areas of leptomeningeal enhancement are seen in
bilateral cerebellar hemispheres and in the right parietal lobe.
Given the clinical history of non-Hodgkin's lymphoma, imaging
findings suggest lymphomatous involvement of the CNS.
CT abdomen [**7-7**]: FINDINGS: A Port-A-Cath terminates in the
superior vena cava. Coronary artery calcifications are present.
A stent is present in the left anterior descending coronary
artery. The heart is at the upper limits of normal size. There
is no pericardial effusion. An enlarged subcarinal lymph node
measures up to 22 x 16 mm in axial dimensions (3:27). A left
upper mediastinal lymph node measures 11 mm in diameter. A right
upper paratracheal lymph node measures 25 x 18 mm (3:14); an
adjacent one measures 8 mm. Small-to-moderate pleural effusion
is present on the right, free flowing and of low density. A
trace effusion is present on the left.
In the left upper lobe, there is a large cavitating mass with
a thick
irregular enhancing rim. The lesion measures 73 x 52 mm in axial
dimensions and is contiguous with bronchovascular thickening
that tracks towards the hilum. The patient has mild-to-moderate
emphysema as well. An ill-defined nodule along the left major
fissure has a base measuring up to 13 mm with a height of 5 mm
(3:31). Mild interstitial changes are noted in the periphery of
the left lower lobe.
In the right lung, there are a number of ill-defined irregular
pulmonary
nodules, the majority of which are pleural-based. These show
avid enhancement as well in most cases. A representative nodule
along the right lower lobe medial pleural surface measures 14 x
10 mm in diameter. These nodules are non-specific. There is also
a more patchy ill-defined consolidative and ground-glass opacity
in the right lower lung suggesting atelectasis or perhaps
infectious or inflammatory pneumonitis. This is also a focal
band-like opacity in the left lower lobe suggestive of
atelectasis.
CT OF THE ABDOMEN: Within the liver, there are several
well-defined hypodense lesions. All of these are in the left
lobe (3:43 and 45). The largest measures 13 mm in diameter and
is low in density, suggestive of a simple cyst. These are too
small to entirely characterize, however, but are probably
benign. The gallbladder, pancreas, spleen and right adrenal
appear within normal limits.
There is a widespread infiltrative abnormality throughout the
central
retroperitoneum that fully encases the aorta and inferior vena
cava, although these are patent. It encases bilateral duplicated
main renal arteries as well as the left renal vein and small
lumbar vessels. It tracks superiorly and closely approaches the
splenic vein and infiltrates the retroperitoneal fat, which
shows increased attenuation that obscures the left adrenal
gland.
An extensive, more dense central mesenteric mass measuring
approximately 82 x 46 mm in axial dimensions (3:71) encases but
does not splay or narrow multiple mesenteric arteries and veins
passing through it.
There is an aneurysm of the lower abdominal aorta, with rim
calcification and thrombus measuring up to 32 x 28 mm in axial
dimensions. There is also a fusiform aneurysm of the right
common iliac artery with peripheral
calcification and thrombus of 29 mm in diameter. These are fully
encased by mostly hypoenhancing infiltrative soft tissue,
although immediately anterior to the lower aorta, a rim of
enhancing tissue that measures 24 x 7 mm in axial dimensions
(3:79) is also noted and may represent an area of persistent
lymphoma.
Scattered diverticula are present throughout the colon. The
bladder is
substantially distended. Each kidney demonstrates moderate
hydronephrosis
with surrounding fat stranding and ureters pass through the
region of high
attenuation. Although it is possible that hydronephrosis is
secondary to
bladder distention, the possibility that the ureters are blocked
by
retroperitoneal fibrosis associated with malignancy should be
considered. The upper left ureter, upstream of the area of more
dense area of retroperitoneal infiltarion, shows enhancement
that may be inflammatory or potentially due to malignant
infiltration.
CT OF THE PELVIS: There is an expansile nearly occlusive
thrombus in the left common femoral vein. The external and
common iliac veins do not appear involved with thrombus but are
probably narrowed somewhat by the presence of the
retroperitoneal mass. A deep inguinal lymph node on the left
measures 24 x 13 mm in axial dimensions (3:108). A left external
iliac node measures 14 x 22 (3:100). A deeper pelvic sidewall
lymph node of 15 x 25 mm (3:97) is also noted, worrisome for
active lymphoma. The prostate is small with calcifications. The
seminal vesicles are unremarkable. Vascular calcifications are
widespread. There is no ascites.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
Mild
degenerative changes are present along the lower lumbar spine. A
small
sclerotic focus along the right iliac crest is nonspecific but
most likely due to a small bone island. Lower thoracic
interspaces are mildly narrowed and irregular with small
anterior osteophytes.
[**2133-7-19**] CXR
New pneumoperitoneum highlights the presence of ascites. The
large left upper lobe abscess has not grown, but continues to
cavitate and there may be a new small nodule in the right mid
lung just above the elevated right
hemidiaphragm. Moderate right pleural effusion largely posterior
has
increased. There is no pulmonary edema or other widespread
pulmonary
abnormality. Heart size is normal and there is no evidence of
mediastinal
venous engorgement. A right subclavian infusion port ends in the
mid SVC.
Findings were discussed by telephone with Dr. [**First Name (STitle) **] at the time
of this
dictation.
Brief Hospital Course:
Mr [**Known lastname 34578**] is a 58yoM with a history of B-cell non-Hodgkin's
Lymphoma who presented to an OSH with fever and hypotension,
found to have CNS lesions and a cavitating lung infiltrate,
transferred to [**Hospital1 18**] for further care.
Since he has been in [**Hospital1 18**], he has received Methotrexate x 2
days and last [**Hospital1 **] level today was 0.13 and high dose
dexamethasone that has been tapered to 8mg Qday. He was also
diagnosed with b/l DVT and an IVC filter was placed. During a
routine CXR on [**2133-7-19**] he was found to have a fair amount of
pneumoperitoneum below the diaphragm, this study was repeated on
[**7-21**] and the findings were unchanged. Of note this was his first
x-ray since his CT scan on [**7-8**] which was negative for
pneumoperitoneum.
A surgical consult was called and given the new finding of
pneumoperitoneum, he was taken urgently to the operating room
for exploration of a potential GI tract perforation. Several
holes were found in the stomach in the operating room, and these
were repaired. Please refer to Dr.[**Name (NI) 34579**] operative dictation
for additional details. He had a feeding j-tube placed at this
time as well. Post-operatively, he was admitted to the Trauma
ICU for further care.
On POD 1, he remained stable after his procedure, continuing to
make slow improvements. His NGT remained to low continuous wall
suction. He was restarted on his heparin drip, leucovorin and
Vitamin A were added to his regimen per his oncology team. He
was dosed with stress dose steroids for the OR and this was
weaned per protocol.
On POD 2, he was transfused one unit of PRBCs for a downward
trending Hct to 24. This was done in the setting of a device
malfunction causing him to receive 22,000 units of Heparin in a
bolus dose instead of the usual basal rate. After
identification of the problem, he was reversed with Protamine 50
mg and a head CT was performed to ensure no evidence of
intracranial bleed -- it was negative. Tube feeds through the
J-tube were started at 10 cc/hr.
On POD 3, Mr. [**Known lastname 34578**] was on goal tube feeds, he was started on
oxycodone and tylenol and his hydrocortisone taper was
continued. He was hemodynamically stable and recovering well; he
was transferred out to the floor. On POD 4, his steroid taper
was discontinued. Due to peristent low NGT output and patient
preference, his NGT was removed. He remained afebrile with
stable vital signs.
On POD 5, Mr. [**Known lastname 34578**] developed relatively sudden onset
tachycardia to the 120s and hypotension to a systolic of 70s.
He was fluid resuscitated with several IVF boluses and his
pressures were stabilized. A CXR done at the time showed
significant amount of free air -- over the amount one would
normally expect as residual from the laparotomy four days ago.
He was transferred back to the ICU for further care and started
on pressors to maintain his [**Known lastname **] pressure.
A meeting was held with Dr. [**Last Name (STitle) **], the critical care team and
the family. The family expressed preferences to make the
patient DNR/DNI but not to withdraw care -- but also not to
escalate. He was maintained on pressors until he could be
appropriately weaned with the decision to refrain from turning
pressors back on should the need arise. It was also decided to
refrain from further lab draws.
On POD 6, his pressor wean was continued and he was started on a
morphine drip for comfort. He remained tenous but overall
hemodynamically stable. Mental status waxed and waned through
the day with several periods of lucency.
On POD 7, another family meeting was held. His DNR/DNI status
was continued. The family expressed preference for home hospice
and decisions were made to make arrangements for discharge on
POD 8 ([**7-28**]) for hospice care.
Unfortunately, on POD 8, [**2133-7-28**] Mr. [**Known lastname 34580**] vitals began
trending down and it was agreed that he may not survive an hour
long trip to home hospice. At 10:50 pm [**2133-7-28**] Mr. [**Known lastname 34578**]
passed away in his room with his family by his side. Death was
confirmed by 2 minutes of no spontaneous respiration or pulse.
Pupils were not reactive. The family did not want an autopsy.
Death certificate was signed.
Medications on Admission:
Medications (confirmed per d/c summary from OSH and pt):
- Tylenol 650mg PO q4 PRN pain
- Heparin SQ 5000 units tid
- Voriconazole 300mg PO q12
- Lorezepam 0.5mg PO q4 PRN anxiety
- Prednisone 10mg PO qdaily
- Procrit 40,000 units on Thursday
- Allopurinol 300mg PO daily
- Zosyn 3.375g IV q6h
- Nystatin swish and swallow
- Omeprazole 40mg PO daily
- Potassium Chloride 40mEq PO daily
- HCTZ 12.5mg PO daily
- Levoxyl 50mcg PO daily
- Viscous lidocaine 2% solution PRN mouth pain
Home meds discontinued at outside hospital (confirmed with
patient):
- metoprolol XR 25mg PO BID
- lipitor 40mg PO daily
- multivitamin 1 tab PO daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspergillus pneumonia
Diabetes insipidus
Hydronephrosis [**1-14**] ureter compression from lymphoma
Lymphoma with brain involvement (#### type of lyphoma pending)
Left common femoral deep vein thrombosis, s/p IVF filter
placement
Gastric Perforation
Discharge Condition:
pt expired
Discharge Instructions:
Pt expired
Followup Instructions:
Pt expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2133-7-29**]
|
[
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"484.6",
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"253.5",
"255.41",
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"453.42",
"305.1",
"V45.82",
"202.82",
"412",
"202.83",
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"202.81",
"112.0",
"414.01",
"V87.41",
"285.29",
"401.9",
"272.4",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"03.31",
"93.59",
"99.25",
"88.51",
"54.21",
"96.6",
"01.13",
"46.39",
"44.41"
] |
icd9pcs
|
[
[
[]
]
] |
17627, 17636
|
12600, 16914
|
404, 466
|
17929, 17942
|
4145, 4145
|
18001, 18150
|
3459, 3520
|
17598, 17604
|
17657, 17908
|
16940, 17575
|
17966, 17978
|
3535, 4126
|
262, 366
|
494, 2902
|
4162, 12577
|
2924, 3289
|
3305, 3443
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,763
| 142,729
|
20527+57172
|
Discharge summary
|
report+addendum
|
Admission Date: [**2165-5-7**] Discharge Date: [**2165-5-13**]
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
man with history of coronary artery bypass graft, pacemaker,
Type 2 diabetes, chronic obstructive pulmonary disease, who
was recently admitted for acute cholangitis with failed
endoscopic retrograde cholangiopancreatography attempt and
biliary drain placement who returns with acute renal failure
and repeat endoscopic retrograde cholangiopancreatography.
Since the patient's recent discharge he has been readmitted
to [**Hospital 1562**] Hospital with acute renal failure. At the time
of that admission he had a creatinine of 5.5 which was likely
due to dehydration. Given the concern for continued
cholangitis, the patient received Gentamicin during that
admission. His creatinine rose to 6.6 and at the time of
transfer to [**Hospital6 256**] it was 5.5.
Since his discharge on [**4-24**], the patient has been using
Levofloxacin and Flagyl for cholangitis and Escherichia coli
positive blood cultures at a prior outside hospital. The
patient was transferred to [**Hospital6 2018**] for endoscopic retrograde cholangiopancreatography.
During that procedure, he became hypoxic with oxygen
saturation dropping into the 70s and was intubated at the
time of the procedure. The procedure was completed
successfully with stent placement and removal of percutaneous
drainage tube. He was then transferred to the Intensive Care
Unit on ventilatory support. The patient's desaturation was
likely due to medications received during the procedure and
the patient was easily weaned from the ventilator in the
Intensive Care Unit. Upon awakening from the sedation, the
patient denied fever or chills. The patient also denied
abdominal pain but did report prior right-sided pain which
had not recurred. The patient denied any urinary symptoms.
He reports improvement in his jaundice. The patient did
report some dysarthria and memory difficulties which were
still present but improved since the last admission.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Chronic obstructive pulmonary disease.
3. Coronary artery disease, status post coronary artery
bypass graft 15 years prior.
4. Cholangitis, recent discharge on [**4-24**]. Stent
placement on [**5-7**].
5. Pacemaker secondary to bradycardia.
6. History of gallstones.
7. Question of aortic stenosis.
8. Neuropathy.
9. History of bladder cancer.
10. History of transient ischemic attacks.
11. Acute renal failure.
12. Carotid bruits.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: Insulin NPH 50 q. AM; insulin regular 8
q. AM, 12 q. PM; Protonix 40 q. day; Aspirin 325 q. day,
stopped [**5-8**]; Levofloxacin 250 q. day; Flagyl 500 t.i.d.;
Pentoxifylline 400; Valsartan 160; Gabapentin 300 t.i.d.;
Detrol 2 mg q. day; Metoprolol XL 75 q. day; Multivitamin q.
day.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.9, heart
rate 120, blood pressure 182/74, respirations 30, sating 100%
on ventilatory support. On original admission the patient
was intubated, however, at extubation was alert and awake.
Head, eyes, ears, nose and throat: Pupils equal, round and
reactive to light and extraocular movements intact. Mucous
membranes were moist. Cardiovascular: Regular rhythm,
tachycardiac, normal S1 and S2. Pulmonary revealed clear to
auscultation bilaterally. Abdomen was soft, nontender,
nondistended. Extremities revealed 2+ bilateral lower
extremity edema and also revealed swelling diffusely in the
right upper extremity, good pulses throughout. Neurologic:
The patient was alert and oriented times three after
extubation. Cranial nerves were grossly intact. The patient
was moving all extremities.
LABORATORY DATA: Prior culture data files from the 16th,
Enterococcus coagulase negative Staphylococcus, and vial from
the 9th grew Enterococcus. Chest x-ray had a question of
left lower lobe infiltrate versus atelectasis but chronic in
appearance since [**4-16**]. Electrocardiogram revealed a paced
rhythm at 120 beats/minute. Laboratory values on admission
revealed white count 15.1, hematocrit 39, platelets 230.
Chem-7 with sodium 139, potassium 5.5, chloride 110,
bicarbonate 15, BUN 70, creatinine 5.6. AST was 30, ALT 31,
LDH 272, CK 42, alkaline phosphatase 218, total bilirubin
1.4, amylase 78, lipase 51, albumin 3.2.
HOSPITAL COURSE: 1. Gastrointestinal - The patient with
recent cholangitis. Endoscopic retrograde
cholangiopancreatography on this admission showed a
nonbleeding 2 cm ulcer in the anterior bulb of the duodenum
and also revealed an ulcerated major papilla. A biliary
stent was placed during this procedure and percutaneous
biliary drain was removed. The patient was continued on
empiric antibiotics of Levofloxacin and Flagyl, though no
further biliary cultures were obtained. The patient's liver
function tests remained stable post endoscopic retrograde
cholangiopancreatography. He was continued on Levofloxacin
and Flagyl for nine days post procedure.
2. Gastrointestinal - Diarrhea, patient with diarrhea after
this admission. Given the patient's recent history of
antibiotics the patient's stool was checked for Clostridium
difficile and culture samples were negative at the time of
discharge.
3. Acute renal failure - Patient with renal failure, likely
originally due to dehydration and subsequent with acute
tubular necrosis, possibly from medications received. The
patient's renal function improved both with time and with
intravenous hydration. All medications were renally dosed.
The patient's baseline creatinine was 0.8. The patient did
have a renal ultrasound which showed no evidence of
obstruction for post renal cause of his acute renal failure.
The patient's urine sediment and laboratory data were
consistent with components of dehydration as well as likely
acute tubular necrosis. The renal team consulted on this
patient throughout his hospitalization and followed him
through this admission. The patient's creatinine was
improving significantly at the time of discharge, however,
this should be monitored carefully as an outpatient to ensure
resolution of his acute renal failure.
4. Neurologic - The patient with some confusion and
dysarthria on admission. Per report of the patient and
family this has improved since his last admission. The
patient's dysarthria was likely secondary to dry mouth post
intubation and confusion possibly secondary to a recent
infection and sedation. The patient did have a head
computerized tomography scan to rule out bleed which revealed
no evidence of acute intracranial hemorrhage. It did show
evidence for prior small lacunar infarct. The patient's
mental status improved throughout his hospitalization.
5. Cardiac - The patient with a history of coronary artery
disease. His aspirin was held at the time of this admission
given that he had evidence of a large ulceration in his
duodenum and with guaiac positive stool. The patient was
continued on his beta blocker. The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] and
Hydrochlorothiazide were held given his renal failure.
6. Pump - The patient had an echocardiogram on this
admission given the aggressive hydration due to dehydration
and echocardiogram revealed left atrial and left ventricular
dilation and ejection fraction of 30%. It also revealed
global left ventricular hypokinesis, 1 to 2+ aortic
regurgitation and 2+ mitral regurgitation. Care was given
with giving the patient's fluids and his oxygen saturations
remained stable.
7. Blood pressure - Patient with hypertension, and his
Hydrochlorothiazide and [**Last Name (un) **] had been held during this
admission. The patient was continued on the beta blocker and
in addition to this was given Hydralazine for blood pressure
control. Hydralazine was keeping the blood pressure within
good control, however, will consider switching as an
outpatient for more convenient dosing as the patient's renal
function improves.
8. Anemia - The patient had a baseline hematocrit of
approximately 34. This decreased to 30 during this
admission, likely secondary to rehydration. In addition, the
patient did have guaiac positive stools and evidence of a
duodenal ulcer, given that the patient's hematocrit dropped
below 30 during this admission and had a history of coronary
artery disease, he was transfused 1 unit. On discharge the
hematocrit was stable.
9. Right upper extremity swelling - The patient had right
upper extremity swelling on admission and ultrasound showed
superficial clot in the brachial and basilic vein. The
patient was not anticoagulated given the presence of ulcer on
film as well as guaiac positive stools and the fact that the
clot was superficial and not truly representative of deep
venous thrombosis. This should be monitored as an outpatient
closely.
10. Diabetes mellitus - The patient was kept on insulin drip
on the Intensive Care Unit. On transfer to the floor, he was
given a regular insulin sliding scale. As the patient began
to take better p.o., his insulin NPH was restarted. The
patient was discharged on a lower dose than he takes at home
and this should be increased as an outpatient as his p.o.
intake continues to increase.
11. Heme - Patient with elevated INR on admission to 6.3.
This was due to malnutrition, as the patient responded well
to Vitamin K. The patient was given Vitamin K during this
admission and the INR returned to 1.3 at the time of
discharge.
12. Gastrointestinal, duodenal ulcer - Appreciated at the
time of scope, although this was nonbleeding during scope,
the patient did have guaiac positive stools. The patient's
hematocrit although decreased during this admission likely
due to hydration did not represent or suggest acute active
blood loss. The patient was given Protonix b.i.d. for ulcer,
he also had Helicobacter pylori checked which was negative.
The patient should continue on Protonix and follow up as an
outpatient.
13. Fluids, electrolytes and nutrition - Patient with
significant malnutrition at the time of admission and low
albumin as well as evidence of Vitamin K deficiency as
represented by his increased INR. The patient's diet was
advanced and he was given supplements to his diet. The
patient will continue with Nutrition, maintaining a cardiac
and diabetic diet at the time of discharge.
14. Hypoxia - Patient with hypoxic respiratory failure on
admission. This was likely due to the sedation received
during the procedure. He was easily extubated and weaned
from the ventilator. He was given nebulizers prn and
encouraged to use an incentive spirometer. The patient also
may likely have significant sleep apnea as he is overweight
and this should be pursued as an outpatient. The patient's
tachycardia resolved as he was restarted on his medications
and oxygenations but off of the ventilator there was no
evidence for pulmonary embolus.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Cholangitis.
2. Status post biliary stent placement.
3. Hypoxia secondary to respiratory failure.
4. Acute renal failure.
5. Anemia.
6. Malnutrition.
7. Diabetes.
8. Hypertension.
DISCHARGE MEDICATIONS:
1. Calcium acetate 2 tablets b.i.d.
2. Levofloxacin 250 q.o.d. for two days.
3. Multivitamin q. day.
4. Albuterol and Ipratropium nebulizers prn.
5. Flagyl 500 t.i.d. for two days.
6. Miconazole powder prn.
7. Hydralazine 20 mg p.o. q. 6 hours.
8. Pantoprazole 40 p.o. b.i.d.
9. Metoprolol 75 mg p.o. b.i.d.
10. Regular insulin sliding scale.
11. Insulin NPH 15 units q. AM
FOLLOW UP PLANS: The patient will follow up with his primary
care physician within one week following discharge. In
addition to this, the patient will follow up with
gastroenterologist and renal doctors.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 12502**]
MEDQUIST36
D: [**2165-5-12**] 15:57
T: [**2165-5-12**] 15:54
JOB#: [**Job Number 54922**]
Name: [**Known lastname **], [**Known firstname 10275**] M Unit No: [**Numeric Identifier 10276**]
Admission Date: [**2165-5-7**] Discharge Date: [**2165-5-13**]
Date of Birth: [**2085-1-7**] Sex: M
Service: [**Company 112**]
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Cholangitis.
2. Status post biliary stent placement.
3. Hypoxia secondary to respiratory failure.
4. Acute renal failure.
5. Anemia.
6. Malnutrition.
7. Diabetes.
8. Hypertension.
DISCHARGE MEDICATIONS:
1. Calcium acetate 667 mg two tablets po t.i.d. with meals.
2. Levofloxacin 250 mg po q.o.d. times seven days.
3. Acetaminophen 325 mg one to two tabs po q 4 to 6 hours
prn.
4. Multivitamin one capsule po q day.
5. Ipratropium one nebulizer q 6 hours prn shortness of
breath.
6. Albuterol sulfate one nebulizer inhaled q 6 hours prn.
7. Heparin 5000 units subq q 8 hours until ambulatory.
8. Flagyl 500 mg po t.i.d. times seven days.
9. Miconazole powder one application b.i.d. prn.
10. Pantoprazole 40 mg po 12 hours.
11. Metoprolol 75 mg po b.i.d.
12. Insulin Lispro subq as directed per sliding scale.
13. NPH insulin 22 units subcutaneous q.a.m.
14. Hydralazine 25 mg po q 6 hours.
FOLLOW UP: The patient is encouraged to call his primary
care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to schedule a follow up
appointment within a week following discharge. The patient
has a follow up appointment with renal with Dr. [**Last Name (STitle) 2955**] and
Dr. [**First Name (STitle) **] on [**2165-6-4**] at 3:30 p.m. He also has an a
follow up appointment with GI with Dr. [**Last Name (STitle) **] on [**2165-7-15**] at 3:00 p.m.
[**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**]
Dictated By:[**Last Name (NamePattern1) 831**]
MEDQUIST36
D: [**2165-5-13**] 11:39
T: [**2165-5-13**] 11:42
JOB#: [**Job Number 10277**]
|
[
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"E930.8",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"51.87",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12530, 12722
|
12745, 13446
|
11070, 11262
|
4411, 10967
|
2621, 2927
|
13458, 14237
|
131, 2073
|
2942, 4393
|
2095, 2599
|
12424, 12509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,660
| 104,983
|
29535
|
Discharge summary
|
report
|
Admission Date: [**2143-4-3**] Discharge Date: [**2143-4-5**]
Date of Birth: [**2093-11-21**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Abdominal Pain, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 year old female with HIV (Last CD4 500's, VL undetect), BLE
paralysis, h/o DVT, and h/o rectal cancer with multiple
complications with ostomy, nephrostomies, and multiple
SBO's/ileus who presented to the ED with vomiting and SOB. She
is being transferred the the [**Hospital Unit Name 153**] for hypotension.
.
She is frequently admitted to OMED for SBO's. She occasionally
can manage this at home with bowel rest and IV fluids. Over the
past 5 days, she again developed nausea, vomiting, abdominal
pain, and liquid output from her ostomy. She therefore stopped
eating and took IV fluids at home. She felt slightly better
last night and had dinner, but then had recurrence of her
abdominal pain. She also had the new onset of shortness of
breath. Also reports poor urine output x 1 day.
.
She was taken to [**Hospital1 **]. She was found to be 92% on room
air. She refused an NG tube as it makes her vomiting worse.
Labs were notable for creatinine of 3.8 (from baseline of 0.8),
hyperkalemia, and hyponatremia. CXR was reportedly clear with
possible linear atelectasis. KUB was unremarkable. UA showed
WBC and bacteria, but at her baseline. ECG was significant for
QTc prolongation to 514. There was concern for PE given her
SOB/hypoxia and paralysis, and she was empirically started on a
heparin gtt for PE (no CTA given ARF). She was given 2L IVF.
She had a large amount of emesis (1L) and her shortness of
breath resolved. She was given a dose of ceftriaxone and
transferred to our ED.
.
In our ED, initial vitals were 97.6 90 108/70 18 100% 4L. She
had a renal ultrasound that showed no hydronephrosis and
nephrostomy tubes in place. LENIs were negative for DVT. She
was signed out to OMED, and then became hypotensive to the
80's/40's. She was started on levophed and SBP increased to the
130's. Her HR dropped to the 40's initially but improved to
60-70. She was given vancomycin and zosyn and 1.7 more liters
of IVF (for a total of 3.7L). She has had 700cc output from her
nephrostomy tubes. She continues on a heparin gtt. She has a
20g PIV and a port. Her current vitals are afebrile, 130/70,
65, 100%3L.
.
Currently, she has no complaints--she states that her ileostomy
output increased shortly after her arrival to the [**Location (un) 620**] ED and
that her abdominal pain symptoms began to resolve gradually
since then. She states that her abdominal pain is currently at
baseline and that she would like to start advancing her diet.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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.
Past Medical History:
ONCOLOGIC HISTORY:
# Rectal cancer:
- late [**2139**]: 6 months of intermittent rectal bleeding, rectal
pressure and a sensation of incomplete emptying.
- [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and
a 2.5 cm distal rectal mass arising from the anal verge in the
posterior rectum with a large area of induration.
- [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring
4.8 x 3.8 cm, bulging posteriorly into the presacral space and
anteriorly towards the uterus. There were enlarged lymph nodes
in the perirectal fat adjacent to the mass, a 9-mm enhancing
lymph node in the left pelvic sidewall, and enhancing lymph
nodes
in the right external iliac region. There was also a 7-mm
hypodensity in the caudate lobe of the liver. Rectal ultrasound
on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3
disease. There were at least four abnormal perirectal lymph
nodes seen on MRI, in addition to multiple bilateral enlarged
pelvic sidewall lymph nodes, concerning for extensive disease.
- [**2141-2-20**]: began chemoradiation
- [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia,
and abdominal cramping
- [**2141-3-13**]: 5-FU was restarted at a reduced dose
- [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal
skin changes, diarrhea, and electrolyte abnormalities.
- [**Date range (3) 70844**]: Radiation was also held
- [**2141-3-27**]: 5-FU was restarted at a further reduced dose
- [**2141-3-31**]: completed radiation
- [**2141-4-3**]: completed chemotherapy
- [**Date range (3) 70845**]: hospitalized for bowel rest and the
initiation of TPN due to presumed radiation enteritis.
- [**2141-5-31**]: found to be HIV positive and began on HAART
- [**Date range (1) 70846**]: required hospitalization for an SBO, underwent
laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed
severe radiation-induced acute ischemic enteritis. She recovered
from this surgery, but continued to require TPN.
- [**7-/2141**]: Once her CD4 count had recovered, she underwent
laparotomy, lysis of adhesions, ileal resection,
proctosigmoidectomy, colonic jejunal pouch to near-anal
anastomosis with EEA, takedown splenic flexure, resection of
ileostomy and creation of new end-ileostomy. Pathology from the
surgical specimen revealed no residual carcinoma and all 14
lymph nodes sampled were free of disease.
- [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis
showed no evidence of recurrence.
- [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen
near the anastomatic site, new since the earlier study. Local
recurrence cannot be excluded, although possibly the appearance
is associated with endoluminal debris."
.
OTHER MEDICAL HISTORY:
# HIV.
# Short gut syndrome secondary to bowel surgery for CA.
# Obstructive renal failure from radiation fibrosis, in the past
necessitating b/l nephrostomy tubes.
# Lower extremity neuropathy, likely secondary to radiation
fibrosis, uses a wheelchair since 4/[**2141**].
# Pancreatic insufficiency.
# Anemia.
# Chronic pain.
# LLE DVT: dx [**3-/2142**], was on warfarin.
Social History:
Lives with her husband and 4 children in [**Location (un) 17566**], does not
smoke or drink alcohol. On long-term disability.
Family History:
Her father died at 72 of MI. Her mother alive and well. Remote
family history of breast, colon cancer. Her daughter has
ulcerative colitis.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.8 90 113/75 17 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + 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
DISCHARGE EXAM:
Vitals 98.4 65 71/49 12 93%RA
General Appearance: Well nourished, No acute distress, Thin
Head, Ears, Nose, Throat: Normocephalic, moist mucous membranes
Cardiovascular: RRR, no murmurs
Respiratory / Chest: Clear bilaterally ; port site clean and
dry on R chest
Abdominal: Soft, Non-tender, Bowel sounds present, ileostomy and
nephrostomy c/d/i
Extremities: Warm extremities with no LE edema
Pertinent Results:
Blood Counts
[**2143-4-3**] 10:41AM BLOOD WBC-10.9 RBC-3.53* Hgb-10.7* Hct-33.4*
MCV-95 MCH-30.4 MCHC-32.2 RDW-15.9* Plt Ct-268
[**2143-4-5**] 04:37AM BLOOD WBC-3.8* RBC-2.90* Hgb-8.9* Hct-27.0*
MCV-93 MCH-30.6 MCHC-32.9 RDW-15.8* Plt Ct-240
.
Coags
[**2143-4-3**] 07:35AM BLOOD PT-14.6* PTT-40.3* INR(PT)-1.3*
[**2143-4-5**] 04:37AM BLOOD PT-12.6 PTT-25.7 INR(PT)-1.1
.
Chemistry
[**2143-4-3**] 10:41AM BLOOD Glucose-113* UreaN-32* Creat-2.3*# Na-133
K-3.5 Cl-103 HCO3-17* AnGap-17
[**2143-4-4**] 03:47AM BLOOD Glucose-80 UreaN-20 Creat-1.3* Na-138
K-3.4 Cl-110* HCO3-20* AnGap-11
[**2143-4-5**] 04:37AM BLOOD Glucose-73 UreaN-11 Creat-0.9 Na-137
K-3.9 Cl-108 HCO3-21* AnGap-12
.
Microbiology
[**Hospital1 **]-[**Location (un) 620**] URINE CULTURE [**2143-4-2**]
>100,000 org/ml KLEBSIELLA PNEUMONIAE
AMPICILLIN R >=32
AMP/SULBAM S 4
CEFAZOLIN S <=4
CEFOXITIN S <=4
CEFTAZIDIME S <=1
CEFTRIAXONE S <=1
CIPROFLOXACIN S <=0.25
ERTAPENEM S <=0.5
GENTAMICIN S <=1
IMIPENEM S <=1
LEVOFLOXACIN S <=0.12
PIP/TAZ S <=4
TOBRAMYCIN S <=1
TRIM/SULFA S <=20
.
IMAGING:
[**4-3**] LENIS: Limited examination, with wall-to-wall flow and
augmentation seen in bilateral superficial/deep femoral and
popliteal veins. Calf veins not visualized.
.
[**4-3**] RENAL U/S IMPRESSION: Normal kidneys, with nephrostomy
tubes in expected position.
.
[**4-4**] CT Abd/Pelvis
1. No CT evidence for cystitis; however, evaluation is limited
both by
underdistension of the bladder as well as significant likely
radiation-related changes in the lower pelvis.
2. Unchanged appearance of small bowel loops with focal areas of
thickened
wall and folds likely related to radiation-related changes
without bowel wall dilatation.
Brief Hospital Course:
HOSPITAL COURSE
This is a 49yo F PMHx HIV, rectal CA c/b bilateral nephrostomies
& ileostomy, p/w vomitting, admitted to MICU for hypotension,
found to have UTI, started on antibiotics w clinical
improvement, stable and discharged home.
.
ACTIVE
#. Hypotension / UTI: On admission, patient was found to have
SBPs in the 70s with an intact mental status and without signs
of ischemia / poor perfusion. Patient was fluid resuscitated
and started on levophed given concern for sepsis. On review of
chart and discussion w PCP, [**Name10 (NameIs) **] was found that patient baseline
pressures were SBP 80s. Patient weaned off pressors and
pressures remained in 80s-90s during daytime hours, dipping into
70s at night. Patient was found to have a Klebsiella UTI based
on cultures from [**Hospital1 **]-[**Location (un) 620**]. She was was initially treated with
Daptomycin and Zosyn given recent VRE and Klebsiella UTIs, once
sensitivities returned, abx were narrowed to cefpodoxime.
.
#. Vomiting: Patient reported vomitting prior to admission,
which had resolved by the time of admission w subsequent
increase in her ostomy output to baseline. It was uncertain
whether this represented a resolved viral gastroenteritis or
ileus (as she has a history of ileus).
.
#. Acute renal failure: Creatinine was elevated to 3.8 on
admission from baseline of 0.8. Urine lytes were c/w prerenal
state, and Cr trended down w fluid resuscitation. No signs of
obstruction on renal ultrasound. Given patient's b/l
nephrostomy tubes, case was discussed w urology who did not
believe additional management was warranted. At discharge Cr
was 0.9.
.
INACTIVE
#. Rectal cancer: No evidence of recurrence by CT [**11/2142**] or CEA
[**2143-2-12**].
.
# HIV: Last CD4 534, VL <48 copies on [**2143-3-21**]. Continued
outpatient antiretrovirals.
.
TRANSITIONAL
1. Code - Patient remained full code
2. Pending - At discharge, admission blood cultures remained
pending. Discharge summary was faxed to PCP to alert that these
values would need to be followed up.
3. Transfer of Care - Patient scheduled for follow-up w PCP who
was notified of the details of this admission via email.
4. Barriers to Care - Per PCP, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] baseline low SBPs
(80s-90s), should be kept in mind when treating future
infections so as not to over aggressively treat
Medications on Admission:
1. abacavir-lamivudine 600-300 mg once a day.
2. ritonavir 100 mg DAILY
3. darunavir 400 mg Tablet [**Name Initial (NameIs) **]: Two (2) Tablet PO DAILY (Daily).
4. methadone 5 mg Tablet: Alternate two (10mg) and three (15mg)
tabs every six hours.
5. hydromorphone 4 mg: Four (4) Tablet PO Q2H prn pain
6. pregabalin 150 mg [**Hospital1 **]
7. loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID
8. diphenoxylate-atropine 2.5-0.025 mg Tablet [**Hospital1 **]: 1 Tablet PO
three times a day as needed for High ostomy output (>5L).
9. ondansetron 4 mg Tablet q8h prn
10. lansoprazole 30 mg Daily
11. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) [**Hospital1 **]: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
12. pentoxifylline 400 mg Tablet Extended Release [**Hospital1 **]: One (1)
Tablet Extended Release PO three times a day: Compounded with
vitamin E 100 Units.
13. zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS prn
14. mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS prn
15. lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO HSprn.
16. cyanocobalamin (vitamin B-12) 1000 mcg (Daily).
17. ergocalciferol (vitamin D2) 50,000 unit once a week.
18. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
19. magnesium oxide 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
20. magnesium sulfate 4 % IV infuse 2g if Mg <1.5.
Discharge Medications:
1. abacavir-lamivudine 600-300 mg Tablet [**Hospital1 **]: One (1) Tablet PO
once a day.
2. ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
3. darunavir 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
4. methadone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours): Alternate with 15mg for every 6 hour dosing.
5. methadone 5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Q 12H (Every
12 Hours): Alternate with 10mg dose for every 6 hour dosing.
6. Dilaudid 4 mg Tablet [**Hospital1 **]: Four (4) Tablet PO q2.
7. pregabalin 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a
day.
8. loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times a
day as needed for diarrhea.
9. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
10. magnesium oxide 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3
times a day).
11. cyanocobalamin (vitamin B-12) 500 mcg Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
12. ergocalciferol (vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1)
Capsule PO 1X/WEEK (WE).
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) [**Last Name (STitle) **]: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
15. ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
16. magnesium sulfate 4 gram/100 mL Piggyback [**Last Name (STitle) **]: Two (2) gram
Intravenous once: if Mg<1.5.
17. zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia.
18. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime
as needed for insomnia.
19. lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
20. diphenoxylate-atropine 2.5-0.025 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO three times a day.
21. cefpodoxime 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every
12 hours) for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Urinary Tract Infection
Secondary:
HIV
Short gut syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Mrs. [**Known lastname 70847**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the ICU with low blood
pressure. You were briefly given IV medications to increase
your blood pressure, and antibiotics to treat a urinary tract
infection. You improved and are now ready for discharge.
During this hospitalization the following changes were made to
your medications:
-STARTED cefpodoxime (to be continued for a total of 14 days)
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: FRIDAY [**2143-4-12**] at 11:40 AM
With: [**First Name8 (NamePattern2) 3679**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"042",
"041.3",
"344.9",
"276.8",
"V44.6",
"579.3",
"276.1",
"V44.2",
"599.0",
"V10.06"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15663, 15712
|
9497, 11866
|
299, 306
|
15824, 15824
|
7764, 9474
|
16478, 16993
|
6660, 6804
|
13368, 15640
|
15733, 15803
|
11892, 13345
|
15989, 16455
|
6819, 7335
|
7351, 7745
|
235, 261
|
2831, 3211
|
334, 2813
|
15839, 15965
|
3233, 6499
|
6515, 6644
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
807
| 121,760
|
26992
|
Discharge summary
|
report
|
Admission Date: [**2140-5-9**] Discharge Date: [**2140-6-22**]
Date of Birth: [**2064-4-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Anorexia, nausea/vomiting
Major Surgical or Invasive Procedure:
-R inguinal lymph node biopsy ([**5-11**])
Exploratory lap/open CCY/liver biopsy/pancreatic
biopsyx/peri-portal lymph node biopsy ([**5-23**])
Exploratory-lap/washout/GJ tube ([**5-26**])
History of Present Illness:
76yM diagnosed with a pancreatic head mass [**2-22**] s/p stenting
presents with 3 weeks of nausea, vomiting and anorexia. Pt
states that he has not been able to take anything by mouth for
the past three weeks due to decreased appetite and more
recently, nausea and vomiting. He reports a 50lb weight loss in
the last 3 months. He also c/o vague diffuse bandlike abdominal
pain. Otherwise, no fevers, normal bowel movements. He presents
for further evaluation of his pancreatic head mass and
rehydration.
Past Medical History:
HTN
ITP
multiple orthopedic procedures
pancreatic head mass s/p stenting x 2
Social History:
live with wife, retired engineer, 7 children, 13 grand
children, hx of smoking, no etoh, no drugs, Independent on all
ADL, IADLs except financing (wife does that).
Family History:
not contributory
Physical Exam:
Gen elderly NAD
Heent eomi, perrl, oropharynx without erythema/exudate
Neck supple
CV rrr
Resp CTA bilaterally
Abd soft NTND
Ext bilateral groin with palpable lymph nodes, no LE edema
Neuro aao x 4
Pertinent Results:
Sinus rhythm
Consider left atrial abnormality
Left axis deviation
T wave changes are nonspecific
Since previous tracing of [**2140-4-18**], no significant change
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
61 178 104 [**Telephone/Fax (2) 66345**] -51 42
CT ABD W&W/O C [**2140-5-10**] 11:40 AM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: please evaluate lympadenopathy
Field of view: 42 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with panc head mass, lympadenopathy
REASON FOR THIS EXAMINATION:
please evaluate lympadenopathy
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 75-year-old male with pancreatic head mass and
lymphadenopathy. Evaluate lymphadenopathy.
COMPARISON: [**2140-4-17**] CT abdomen and pelvis.
TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis
were performed without IV contrast. Multiphasic scans were then
obtained of the abdomen and pelvis.
CT ABDOMEN WITHOUT AND WITH IV CONTRAST: Bibasilar dependent
atelectasis. No pleural effusions. No focal liver lesions
identified. Pneumobilia is again seen and stable. Hyperemic
gallbladder wall with small amount of surrounding
low-attenuation density likely representing fluid is also
unchanged. A stent is seen extending from the distal common bile
duct into the duodenum. The head, body, tail of the pancreas are
unremarkable. Spleen is within normal size limits and contains
multiple punctate low-attenuation lesions too small to
characterize.
The right kidney contains multiple low attenuation lesions too
small to characterize. The previously seen hypovascular left
kidney lesion is decreased in size likely secondary to interval
core biopsy.
As previously described there is extensive lymphadenopathy seen
surrounding the pancreatic head and extending retroperitoneal in
the periaortic region extending to the bifurcation of the
iliacs. A representative node is seen on series 4, image 48. It
is left periaortic, measures 21 mm and is unchanged compared to
previously measuring 20 mm. No free air or free fluid. Multiple
scattered, nonpathologically enlarged mesenteric nodes. Small
bowel and large bowel are unremarkable.
CT PELVIS WITH IV CONTRAST: The urinary bladder, rectum are
unremarkable. There are multiple pathologically enlarged nodes
bilaterally within the inguinal region. A representative node
seen on series 4, image 76 measures 17 mm and node is located
lateral to the left external iliac artery. Large prostate again
noted, unchanged with periureteric edema/filling defect on the
right upon insertion into the right hemitrigone. As mentioned
previously these raise possibility of a possible bladder base
lesion and recommend correlation with cystoscopy. Unchanged
bilateral fat containing inguinal hernias and extensive iliac
nodal lymphadenopathy unchanged.
BONE WINDOWS: No suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. Extensive lymphadenopathy unchanged compared to prior study
from three weeks ago. Findings consistent with systemic process
such as lymphoma. Less likely to represent diffuse metastatic
disease. Percutaneous biopsy can easily be achieved in various
locations including retroperitoneum and external iliac chain
specifically within the left external iliac region as marked on
scan and indicated above.
2. Left renal lesion significantly decreased in size, likely
secondary to prior biopsy. Lymphoma still a strong consideration
within differential.
3. Multiple low attenuation lesions within right kidney, too
small to characterize.
3. Right bladder base lesion. As previously described recommend
cystoscopy for further evaluation.
4. Multiple unchanged splenic lesions too small to characterize.
5. Liver lesions too small to characterize on prior study, not
definitely seen on todays scan.
SPECIMEN SUBMITTED: lymph node for immunophenotyping.
Procedure date Tissue received Report Date Diagnosed
by
[**2140-5-11**] [**2140-5-12**] [**2140-5-23**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/kg
Previous biopsies: [**Numeric Identifier 66346**] LYMPH NODES, LEFT INGUINAL.
[**Numeric Identifier 66347**] KIDNEY NEEDLE BX.
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda,
and CD antigens 5, 19, and 45.
RESULTS:
Due to paucicellular nature of the specimen, a limited panel is
performed to determine B-cell clonality.
B cells are scant but appear polyclonal and do not co-express
CD5.
INTERPRETATION
Non-specific lymphoid profile; no phenotypic evidence of
lymphoma in specimen. Correlation with clinical findings and
morphology (see separate report) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas as due to
topography, sampling or artifacts of sample preparation.
Note: This test was performed using analyte specific reagents
(ASRs). These ASRs have not been cleared or approved by the US
Food and Drug Administration (FDA). However, the FDA has
determined that such clearance or approval is not necessary .
This test was developed and its performance characteristics
determined by the Flow Cytometry Laboratory at [**Hospital1 771**], which is licensed by CLIA to perform
high complexity tests. This test was used for clinical
purposes; it should not be regarded as for research.
Clinical: Rule out lymphoma.
Gross: lymph node for immunophenotyping.
CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST
Reason: r/o stroke. Pls perform this if Head CT w/o contrast is
nega
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with Lymphoma workup in progress with acute
changes in Mental status; r/o stroke. Pls perform this if Head
CT w/o contrast is negative.
REASON FOR THIS EXAMINATION:
r/o stroke. Pls perform this if Head CT w/o contrast is
negative.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Rule out stroke.
TECHNIQUE: CTA of the head with and without contrast and
reconstructions.
COMPARISONS: Subsequent MRI of [**2140-5-15**] showing normal diffusion.
FINDINGS: No intracranial hemorrhage, mass effect, shift of
normally midline structures or CT evidence of acute ischemia
seen. There are hypodensities in the region of the left internal
capsule and subcortical region of the left insular region
consistent with old ischemic infarctions. There are mild
periventricular hypodensities consistent with chronic small
vessel angiopathy. Vascular calcifications are seen within the
intracranial portions of the internal carotid arteries and both
vertebral arteries. There is opacification of several ethmoid
air cells on the left. The reminder of the visualized portions
of the paranasal sinuses and mastoid air cells are well
pneumatized. The bony structures and surrounding soft tissue
structures appear unremarkable.
CT ANGIOGRAM: No areas of hemodynamically significant stenosis
are seen. There is no evidence of aneurysms or dissections. A
fenestrated basilar artery is seen.
IMPRESSION:
1. No CT evidence of acute ischemia. Old lacunar infarcts in
left internal capsule and insular subcortical regions.
2. Unremarkable CT angiogram without areas of stenosis, aneurysm
or dissection. Incidental note is made of a fenestrated basilar
artery.
OBJECT: R/O SEIZURE IN A PATIENT WITH CONFUSION.
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
FINDINGS:
ABNORMALITY #1: Focal [**3-20**] Hz mixed delta and theta frequency
slowing
was seen involving left temporal region broadly.
ABNORMALITY #2: Bursts of generalized [**1-18**] Hz delta frequency
slowing
were seen throughout the recording.
BACKGROUND: In the most awake-appearing portions of this
tracing, a
well-formed 11-11.5 Hz alpha frequency background was seen with
low
voltage beta frequency activity superimposed.
HYPERVENTILATION: Was contraindicated.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as the
test was
requested as a portable study.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 72 bpm.
IMPRESSION: This is an abnormal EEG due to the presence of focal
slowing seen involving the left temporal region suggesting a
subcortical
abnormality in this area; neuroimaging is recommended.
Additionally,
the presence of bursts of generalized slowing is suggestive of a
mild
encephalopathy of toxic, metabolic, or anoxic etiology. No
evidence of
ongoing seizures is seen.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 7495**] B.
MR HEAD W & W/O CONTRAST [**2140-5-15**] 4:22 PM
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: Please assess for DWI lesion and CNS malignancy w/
MRI/MRA w
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with lymphoma & stroke
REASON FOR THIS EXAMINATION:
Please assess for DWI lesion and CNS malignancy w/ MRI/MRA w/
gadolinium
CLINICAL INFORMATION: Lymphoma and stroke.
MRI OF THE BRAIN WITH GADOLINIUM.
There are scattered T2 high-signal intensity foci in the
periventricular white matter and centrum semiovale consistent
with microvascular angiopathy. There is some increased signal on
the FLAIR sequence in the region of the calcarine cortex on the
left raising the question of a meningeal lesion. There is no
evidence of abnormal diffusion in this area. The tensor images
do not extend all the way to the vertex. There is a focal area
of abnormal signal on the susceptibility sequence in the left
subcortical parietal white matter without mass effect or
abnormal surrounding signal consistent with a cavernoma but
possibly reflecting hemorrhage from other source. There is no
evidence of a focal extra-axial lesion or fluid collection.
Ventricles and sulci are mildly prominent consistent with mild
brain atrophy. There is increased signal in the ethmoid sinuses.
There is no evidence of abnormal contrast enhancement.
IMPRESSION: Abnormality of left calcarine cortex, possibly
reflecting a meningeal process such as lymphomatous infiltration
orperhaps earlier ischemia. The absence of contrast enhancement
mitigates against tumor.
A lesion in the left parietal lobe probably a cavernoma. See
above discussion. Ethmoid sinus disease. Brain atrophy.
MRA OF THE CIRCLE OF [**Location (un) **] AND ITS MAJOR TRIBUTARIES
There is no evidence of aneurysm or flow abnormality.
IMPRESSION: Negative MRA of the circle of [**Location (un) 431**].
CT ABDOMEN W/CONTRAST [**2140-6-4**] 3:24 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: ?abscess ?fistula, please perform w/po and iv contrast
thank
Field of view: 42 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with panc head mass, lympadenopathy s/p ex lap
w/takeback now w/draining wound
REASON FOR THIS EXAMINATION:
?abscess ?fistula, please perform w/po and iv contrast thanks
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 75-year-old with a reported pancreatic head mass,
post recent exploratory laparotomy on [**5-25**], now with
draining anterior abdominal wound. Assess for fistula.
TECHNIQUE: MDCT images of the abdomen after the administration
of oral and 100 cc of IV contrast. Coronal and sagittal
reformatted images were obtained.
COMPARISON: [**5-10**] and [**2140-4-17**].
CT OF THE ABDOMEN AFTER ADMINISTRATION OF ORAL AND IV CONTRAST:
There are new bilateral pleural effusions with associated
atelectasis. There is a new small pericardial effusion. New
small amount of ascites is seen in the upper abdomen. The liver,
spleen, pancreas, and adrenals are unremarkable. Cysts are seen
in both kidneys, unchanged from the prior study. Cortical defect
is seen in the mid portion of the left kidney at the site of a
prior renal mass. Previously noted tiny splenic hypodensities
are not appreciated on this examination due to timing of
contrast administration. A biliary stent is present. There has
been interval placement of a percutaneous G-J tube terminating
in the proximal jejunum.
Since the prior examination, the patient has undergone
laparotomy with skin staples present. Soft tissue stranding and
small amount of fluid are seen anterior to the left lobe of the
liver. Posterior to the second staple in the upper abdomen,
there appears to be a small fistula between the subcutaneous
soft tissues in the anterior peritoneal cavity (series 2, image
25). Another tubular-appearing area of inflammatory changes
possibly representing a fistula is seen more inferiorly (series
2, image 45). A small fat-containing ventral hernia is seen near
the inferior staple line (series 2, image 52). Inflammatory
changes and stranding are seen throughout the subcutaneous soft
tissues of the anterior abdominal wall, posterior to the
incisional line. No free air is seen in the abdomen, and there
is no obvious a fistulous connection with the bowel. No evidence
of oral contrast extravasation is seen. Numerous small
mesenteric lymph nodes are identified throughout the abdomen and
larger paraaortic nodes, unchanged from the prior examinations.
CT OF THE PELVIS WITH ORAL AND IV CONTRAST: Diverticula are seen
throughout the sigmoid colon without evidence of diverticulitis.
The rectum, bladder and visualized distal ureters are normal in
appearance. The prostate is enlarged and contains several focal
calcifications. No fluid is seen in the pelvis. Deep pelvic and
bilateral inguinal lymphadenopathy is unchanged from the prior
study.
Osseous structures demonstrate mild degenerative changes in the
thoracic and lumbar spine with vacuum phenomenon and osteophyte
formation.
Multiplanar reformatted images confirm the above findings.
IMPRESSION:
1. Interval exploratory laparotomy. There are inflammatory
changes seen in the subcutaneous soft tissues extending the
length of the incision. There appears to be a fistula between
the soft tissues of the anterior abdominal wall and the anterior
abdominal cavity posterior to the second staple. No
enterocutaneous fistula is identified but CT is insensitive for
excluding small fistulas. There may be a second small fistulous
connection more inferiorly as described above.
2. Stable appearance of mesenteric, retroperitoneal, pelvic, and
bilateral inguinal lymphadenopathy.
3. No pancreatic head mass identified.
[**2140-5-26**] 9:04 am SWAB Site: ABDOMEN
Source: Abdominal incision.
**FINAL REPORT [**2140-5-30**]**
GRAM STAIN (Final [**2140-5-26**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2140-5-30**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
GRAM NEGATIVE ROD #1. MODERATE GROWTH.
GRAM NEGATIVE ROD #2. MODERATE GROWTH.
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
.
[**2140-6-13**]
ERCP
Impression: 1. Erythema of the mucosa was noted in the stomach
body and fundus. These findings are compatible with gastritis.
2. A previously placed plastic stent at the ampulla and a GJ
tube were visualized. Both the stent and the GJ tube were
confirmed to be in place fluoroscopically.
3. The previously placed plastic stent was removed using a
snare.
4. Cholangiogram revealed a 3 cm stricture at the distal common
bile duct. There was mild post-obstructive dilation of the
common hepatic duct. In addition, the left intrahepatic duct did
not fill with contrast very well. However, no obvious stricture,
filling defects, and masses were appreciated in the intrahepatic
ducts.
5. A 6 cm by 10 Fr Cotton [**Doctor Last Name **] biliary stent was placed
successfully across the common bile duct stricture. Clear bile
was seen draining into the duodenum subsequently.
Recommendations
1. Repeat ERCP in two months. Consider placement of metal
wallstent if patient's prognosis is poor as a result of
progression of Castleman's disease.
Brief Hospital Course:
Patient was admitted to the general surgery service and IV
hydration was administered. He was restarted on his home
medications and kept NPO. He was found to have bilateral
inguinal lymphadenopathy and on HD2 a R inguinal lymph node
biopsy was performed. There were no complications and the
patient returned to the floor from the recovery area. The
patient was allowed to eat a regular diet as he wished, a PICC
line was placed for home TPN. On HD 3 the patient was
transferred to the hematology/oncology service.
.
On [**5-13**], a code stroke was called for this patient. He was noted
to have acute onset of a primarily motor aphasia, with anomia,
inability to repeat, and only intermittently fluent speech. Also
has a mild R facial droop and perhaps some evidence of a field
cut on the R. He was perseverative and inattentive. He had a
?left MCA territory stroke without bleed. He was seen emergently
by neurology and it was decided to give him TPA. Patient was
transferred to [**Hospital Unit Name 153**], then neuro-ICU. Repeat Head CT done for
worsening headache was negative. Language and rest of deficits
returned to [**Location 213**]. He began eating so TPN was stopped. Patient
was transferred to neurology floor on [**5-15**]. He underwent
carotid dopplers which were negative and had head MRI, official
read pending (prelim read negative for stroke). EEG showed left
temporal slowing. He also had a LP [**5-16**] which showed 2WBC, 1RBC,
Prot 32 Gluc 73, cytology was also sent. Patient thought to have
?embolic CVA vs seizure d/o. Transferred back to BMT service for
further workup.
.
After transfer to BMT service patient waited while lymph node
biopsy from inguinal node results were pending, these were
inconclusive and he was transferred to surgery for ex-lap
washout, CCY, GJ tube, and more biopsies. A Peri-portal lymph
node biopsy showed atypical lymphadenopathy with findings
consistent with multicentric Castleman's disease, HHV8 negative.
OR cultures grew out Hafnia Alvei, Serratia Marcescens, and
enterococcus sp. He was started on Vancomycin and Levofloxacin.
His JP drain was pulled on POD 7. He continued to have fevers
post-operatively which improved with antibiotic use. His
abdominal incision was draining serosanginous fluid, frequently
saturating his dressings. At this time his tube feedings were
held and he was made NPO due to nausea and vomiting. As bowel
function improved, tube feedings were advanced to goal.
An Abdominal CT was performed to assess the wound drainage and
it appeared to be a fistula between the soft tissues of the
anterior abdominal wall and the anterior abdominal cavity
posterior to the second staple. Dressing changes continue and
the drainage slowed gradually. He was transferred to the
Heme/Onc service for steroid treatment of his Castleman's
Disease.
.
On transfer to the BMT service, LFT's were found elevated. GI
service was reconsulted and ERCP was performed. On [**2140-6-13**] a new
stent was placed on the common bile duct obtaining drainage to
the duodenum. Patient should have a repeat ERCP in 2 months.
Patient also had delirum in this setting, with + hallucinations
and agitation. Neurology was consulted who felt that it was not
consistent with a seizure like activity, no focal findings, and
felt that a metabolic etiology was more likely. All possible
mental stauts changes medications were discontinued. Treatment
was also started [**2140-6-15**] with Rituxan.
On [**2140-6-16**], patient's mental status cleared returning to his
baseline.
.
For the treatment of his Castleman's disease patient was given
Rituxan and steroids. He received his dose of retuxan on [**2140-6-15**]
and also IV steroids. Patient was given a second dose of rituxan
on day of discharge. He will continue on high dose steroids for
two weeks 50 mg prednisone until [**7-1**].
Patient will be seen in clinic on [**6-30**] to decide further
course.
He tolerated this therapy well.
.
After physical therpay evaluation, it was decided that he was
safe to be discharged home.
Medications on Admission:
metoprolol 50', enalapril 10', prozac
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
3. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
5. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 9 days: Last dose [**7-1**].
Disp:*9 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA - [**Location (un) 932**]
Discharge Diagnosis:
-pancreatic head mass
-bilateral inguinal lymphadenopathy
-anorexia
Discharge Condition:
-stable
Discharge Instructions:
-please come to the emergency room if you have fever >101.4F,
nausea or vomiting, shortness of breath, severe or persistent
abdominal pain or bleeding or persistent redness around your
surgical site
-do not drive while taking pain medications
-take a stool softener while taking pain medications
-you may shower normally but keep your surgical site clean and
dry
Followup Instructions:
-Please follow up with Dr. [**Last Name (STitle) **] in [**2-19**] weeks after discharge.
Call [**Telephone/Fax (1) 1231**] for an appointment.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 540**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2140-6-21**] 4:00
** PLEASE HAVE YOUR PCP SEND [**Name Initial (PRE) **] REFERRAL TO DR. [**Last Name (STitle) 540**] **
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2140-7-4**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2140-7-4**] 10:00
Completed by:[**2140-6-24**]
|
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"401.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"52.12",
"99.28",
"51.22",
"50.12",
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"96.6",
"97.05",
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"38.93",
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icd9pcs
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[
[
[]
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22970, 23030
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340, 530
|
23142, 23152
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1613, 2087
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1362, 1380
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22032, 22947
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23051, 23121
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21970, 22009
|
23176, 23541
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1395, 1594
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275, 302
|
12511, 17887
|
558, 1064
|
1086, 1164
|
1180, 1346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,417
| 155,561
|
23682
|
Discharge summary
|
report
|
Admission Date: [**2169-11-22**] Discharge Date: [**2169-12-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
dyspnea, nausea, vomiting
Major Surgical or Invasive Procedure:
Intubation/Extubation
[**First Name3 (LF) **]
RIJ central venous line placement, removal
PICC placement
History of Present Illness:
This is an 85yo F with a h/o choledocholithiasis, HTN, renal CA,
and dementia who presented to [**Company 191**] today with dyspnea and
vomiting. History is mainly taken from that visit note. The
patient had onset of n/v yesterday after eating fried shrimp the
prior day. She took "nausea relief" from CVS with improvement,
although had anorexia. In addition, the patient has had dyspnea
with minimal exertion associated with nonproductive cough and
chronic orthopnea. She has also experienced weakness and 2 mild
falls (no trauma or LOC). She has had diarrhea four to five
times a day, although may have chronic diarrhea. Per family
report, patient also had chest pain, although patient could not
confirm. She had a fever of 100.9 at home that improved to 97.6.
She was sent to the ED for eval.
.
In the ED, labs showed tbili 9.9 with transaminitis, anion gap
acidosis, lactate 4.5, bandemia 18% of 4.8 and creat 2.6 from
1.3 baseline. CXR was clear. Due to report of COPD history, she
initially received combivent and methylprednisolone, as well as
ASA and ceftriaxone. Once labs revealed a septic picture, she
received vanc and pip-tazo. SBP was upper 80s to low 90s and a
RIJ was placed and the patient received 3L IVF. While undergoing
RUQ U/S, she became acutely dyspneic with new opacities on CXR.
She was tiring on [**Last Name (LF) 597**], [**First Name3 (LF) **] was intubated and sedated. The U/S
showed CBD 25mm and sludge/sludge ball and GI plans to take for
[**First Name3 (LF) **] in the am. Prior to transfer, vitals were: 101.3 119
118/103 25 99%. However, after signout, she was started on
norepinephrine.
.
On the floor, the patient is intubated and sedated. She is
unable to answer questions.
Past Medical History:
Primary kidney CA s/p cyberknife
Choledocholithiasis s/p [**First Name3 (LF) **] with sphincterotomy in [**2165**]
Dementia
B12 deficiency
Hypertension
Osteoporosis
CKD
[**Doctor Last Name 933**] disease, s/p RAI
Follicular lymphoma of the small intestine, in remission
?Chronic diarrhea
Social History:
The patient is married and is accompanied to this visit today by
her husband as well as by one of her three children ([**Female First Name (un) 24743**]).
She lives in [**Location 15005**] and remains quite active around the house.
She has a distant trivial smoking history,
having quit more than 30 years ago. She does not consume
alcohol.
Family History:
There is no family history of malignancies or inflammatory bowel
disease.
Physical Exam:
(ADMISSION PHYSICAL EXAM)
Vitals: BP: 94/53 P: 90 R: 26 O2: 98% on FiO2 40%
General: Intubated, sedated, not responsive
HEENT: PERRL, MMM, ETT in place
Neck: RIJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no edema
(DISCHARGE SUMMARY)
Vitals: BP: 139/57 P: 80 R: 22 O2: 94% on room air
General: Sitting up in bed, eating breakfast, no acute distress
HEENT: PERRL, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales;
occasional 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 edema
Pertinent Results:
Admit Labs:
[**2169-11-21**] 08:47PM PLT SMR-LOW PLT COUNT-140*
[**2169-11-21**] 08:47PM WBC-4.8 RBC-3.97* HGB-12.7 HCT-37.3 MCV-94
MCH-31.8 MCHC-33.9 RDW-14.3
[**2169-11-21**] 08:47PM NEUTS-71* BANDS-18* LYMPHS-7* MONOS-0 EOS-0
BASOS-0 ATYPS-1* METAS-3* MYELOS-0
[**2169-11-21**] 08:47PM ALBUMIN-3.9
[**2169-11-21**] 08:47PM CK-MB-5 cTropnT-0.02* proBNP-5614*
[**2169-11-21**] 08:47PM LIPASE-20
[**2169-11-21**] 08:47PM ALT(SGPT)-206* AST(SGOT)-163* CK(CPK)-182*
ALK PHOS-183* TOT BILI-9.9* DIR BILI-6.8* INDIR BIL-3.1
[**2169-11-21**] 08:57PM LACTATE-4.5*
[**2169-11-22**] 07:35AM FIBRINOGE-515*
[**2169-11-22**] 10:07AM D-DIMER-[**Numeric Identifier 31597**]*
[**2169-11-22**] 11:00AM FDP-10-40*
ECHO [**2169-11-22**]
This study was compared to the prior study of [**2165-12-23**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically
ventilated. Cannot assess RA pressure.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Estimated cardiac
index is normal (>=2.5L/min/m2). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular
calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PERICARDIUM: Trivial/physiologic pericardial effusion.
CXR [**2169-11-21**]:
UPRIGHT AP VIEW OF THE CHEST: Study is slightly limited due to
patient
motion. The cardiac, mediastinal, and hilar contours are stable,
with
unchanged enlargement of the pulmonary arteries, compatible with
underlying hypertension. Prominent epicardial fat pad is again
noted. The lungs are grossly clear without focal consolidation,
pleural effusion or pneumothorax. There appears to be
hyperinflation of the lungs, stable from prior. Degenerative
changes are seen within the right shoulder. New surgical clips
are also noted within the epigastric region. Multilevel
degenerative changes are present in the thoracic spine.
IMPRESSION: Study is slightly limited due to patient motion. No
gross evidence of pneumonia or congestive heart failure.
RUQ Ultrasound [**2169-11-22**]:
Dilatation of bile ducts, similar to that seen on recent MRI
study performed 2 weeks ago. Again with sludge/stones seen in
CBD, but
distal most CBD and pancreatic head not well visualized. In this
patient with clinical concern for ascending cholangitis,there
are no imaging studies sensitive for this.
[**Month/Day/Year **] [**2169-11-22**]:
The major papilla was intra-diverticular. Pus was seen extruding
from the major papilla. An opening draining bile and pus
consistent with a choledochoduodenal fistula was seen at the
superior portion of the major papilla. Cannulation of the
biliary duct was successful and deep with a sphincterotome using
a free-hand technique. Contrast medium was injected resulting in
complete opacification. A single 2.5-3cm filling defect
consistent witha stone or sludge ball that was causing partial
obstruction was seen at the mid CBD. A 10FR by 5cm double
pigtail biliary stent was placed successfully using a Oasis 10FR
stent introducer kit.
Partial pancreatogram was normal.
EKG [**11-21**]: Sinus rhythm. Since the previous tracing of [**2169-7-27**]
the single beat showing a more leftward axis and right
bundle-branch block morphology is no longer present.
EKG [**11-21**]: Sinus rhythm. Leftward axis. Since the previous
tracing no significant change.
EKG [**11-22**]: Baseline artifact. Sinus rhythm. Since the previous
tracing probably no significant change.
EKG [**11-23**]: Atrial fibrillation with rapid ventricular response.
Low QRS voltage in the precordial leads. Diffuse non-specific T
wave flattening. Compared to the previous tracing of [**2169-7-27**]
atrial fibrillation is new. Decreased QRS voltage is now
evident.
CXR [**11-28**]: Left PICC ends in the upper superior vena cava. The
patient
remains intubated, with the endotracheal tube terminating 3.2 cm
above the
carina. The right internal jugular line ends in the mid superior
vena cava. Left pleural effusion with atelectasis have not
changed. Pulmonary arteries are markedly enlarged, consistent
with pulmonary arterial hypertension. The right lung is clear.
There is no pulmonary edema.
[**2169-11-21**] Blood Culture x 2.
Blood Culture, Routine (Final [**2169-12-1**]):
ANAEROBIC GRAM POSITIVE ROD(S).
NOT RESEMBLING CLOSTRIDIUM SPECIES. UNABLE TO FURTHER
IDENTIFY.
CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C. SEPTICUM.
BETA LACTAMASE INCORRECTLY REPORTED [**2169-12-1**].
TEST NOT ROUTINELY PERFORMED FOR THIS ORGANISM.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier **] [**2169-12-1**]
AT 2:15PM.
Anaerobic Bottle Gram Stain (Final [**2169-11-23**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2169-11-23**] AT 0705.
GRAM POSITIVE ROD(S).
Brief Hospital Course:
Assessment and Plan: 85yo F with a h/o choledocholithiasis, HTN,
renal CA, and dementia who presents with dyspnea and vomiting
complicated by acute respiratory failure and septic shock.
.
# Dyspnea/respiratory failure: Admitted with worsening dyspnea
on exertion, stable orthopnea. Became acutely SOB requiring
intubation in the ED, likely due to metabolic acidosis with
respiratory compensation leading to fatigue. Repeat CXR showed
increased bilateral opacities suggesting pulmonary edema. Heart
failure was considered her BNP elevation and history of
orthopnea, although she has no known heart failure and ECHO was
not particularly concerning for CHF ([**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, LVEF >
55%). Viral DFA was negative, pneumonia was less likely in the
absence of sputum and change in CXR. She has smoking history,
but no wheezing or CO2 retention to suggest COPD. Ischemia was
considered given report of chest pain, although EKG negative and
cardiac markers negative. ABG showed good oxygenation and
patient was switched to PSV 10/5 with FiO2 40%. Pt was stable
on pressure support on the vent and sedation was weaned. SBTs
starting [**11-23**] with intention to extubate were unsuccesful (RR
into the 40s, tachycardic), likely secondary to volume overload.
She was diuresed with lasix and repeated almost daily SBTs
continued to show elevated RR and tachycardia. RSBI was 156 on
[**11-29**], but given that she is an elderly female with baseline
tachypnea and small TVs, extubation was attempted on [**11-29**] and
was successful. She was quickly weaned down to 2L NC with O2
sats 95-100%. Of note, RSBI is not likely a good indication of
this patients suitability for extubation given her baseline
tachypnea and small TV and as she did very well s/p extubation
with a pre-extubation RSBI of 156.
.
# Septic shock: Initial WBC with bandemia, elevated lactate,
fever, tachycardia, and pressor requirement. Most likely biliary
source given CBD dilation with sludge and obstructive LFTs in
setting on known choledocholithiasis. [**Month/Year (2) **] was done on [**11-21**] and
showed large amounts of sludge and a sludge ball obstructing
flow in the CBD. Sludge ball/stone in CBD is approx 3 cm long,
so a 5 cm 10 Fr pigtail stent was placed around the sludge ball
to facilitate drainage until a definitive procedure can be
attempted, now scheduled for [**12-28**]. Blood cultures showed G
positive rods and Clostridium species (not perfringens) in
anaerobic culture bottles, but have not yet been speciated. She
was started on broad spectrum antibiotics including Vanc and
Zosyn on [**11-22**], then narrowed to Zosyn with G negative organisms
in blood with plan for 14 day course. A PICC was placed on
[**11-28**]. Pressors were weaned starting [**11-22**] and she has
maintained her BP off pressors. Metoprolol was started on [**11-29**]
and uptitrated.
.
# Atrial fibrillation with RVR. She developed atrial
fibrillation on [**11-23**]. She was initially started on IV
amiodarone with no good response. Her rate remained in
100-120's, and rate control was initiated with metoprolol and
diltiazem on [**11-29**]. On [**11-30**], diltiazem was discontinued and
metoprolol was uptitrated. On [**12-1**], she spontaneously converted
back to normal sinus rhythm.
.
# ARF: Likely related to sepsis (ATN), as well as hypovolemia
from vomiting and diarrhea. Baseline creatinine 1.2-1.4. urine
lytes: Fena: 0.2, FeUrea: 14.9%.
She was rescuscitated with D5 1/2 NS with 3 amps of bicarb
followed by NS PRN to maintain CVP > 10. Cr returned to
baseline by [**11-26**].
.
# Anion gap acidosis: Most likely related to elevated lactate,
initially 4.5 improved consistently with IVF, now 1.7. No
history of ingestion and no clear offenders on med list. Glucose
not c/w DKA, BUN not c/w uremia.
.
FEN: Pt was initially kept NPO then provided with full
fibersource tube feeds at 30 ml/hr. In anticipation of
extubation and question of whether she would be able to pass
speech and swallow immediately, her OG tube was changed to an NG
tube on [**11-27**]. She was evaluated by speech and swallow and her
diet changed to regular full, which she tolerated well.
.
She was called out of the ICU on [**11-30**].
FLOOR COURSE:
On the floor, she continued to do well. She spontaneously
converted from atrial fibrillation back to NSR on [**12-1**]. Her
oxygen was weaned, and she was seen by physical therapy, who
recommended rehab. The remainder of her blood pressure
medications from home were held and should be re-added as an
outpatient. She was discharged to rehab on [**12-2**] in stable
condition, not on oxygen, and tolerating PO.
.
On the floor, she was noted to have frequent stools (3-4 per
day). Per her daughter, this is chronic and has been going on
for months. A C. difficile study on [**11-27**] was negative, and her
abdominal exam is benign. This warrants further workup as an
outpatient, and she was instructed to make an appointment to see
her primary care doctor as an outpatient once discharged from
rehab.
Medications on Admission:
(PER OMR)
ALENDRONATE [FOSAMAX] - 70 mg weekly
AMLODIPINE [NORVASC] - 10 mg once a day
CHLORTHALIDONE - 25 mg QAM
CITALOPRAM - 20 mg at bedtime
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit monthly
LISINOPRIL - 40 mg once a day
MEMANTINE [NAMENDA] - 10 mg twice daily
METOPROLOL SUCCINATE [TOPROL XL] - 100 mg once a day
POTASSIUM CHLORIDE - 20 mEq twice a day
ASCORBIC ACID [VITAMIN C] - (OTC) - 500 mg once a day
CYANOCOBALAMIN - 1,000 mcg once a day
MULTIVITAMINS WITH MINERALS - 1 capsule once a day
Discharge Medications:
1. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 4 days.
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
6. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
7. Ascorbic Acid 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO DAILY (Daily).
8. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: PICC care
per protocol.
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): Discontinue if
ambulatory.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] [**Hospital1 189**]
Discharge Diagnosis:
Septic shock
Cholangitis s/p [**Hospital1 **]
Acute renal failure
Respiratory failure
Discharge Condition:
Stable, on room air, normal vital signs, tolerating PO diet.
Discharge Instructions:
You were admitted to the hospital because you were having
difficulty breathing and vomiting; you were found to have a
fever and abnormal labs. You were intubated and placed on a
mechanical ventilator, and you underwent an [**Hospital1 **] on [**2169-11-23**].
You slowly got better, and you will need to complete a 14 day
course of intravenous antibiotics.
.
If you develop worsening fevers, chills, abdominal pain,
breathing difficulty, bleeding, chest pain, shortness of breath,
or other concerning symptoms, please seek medical attention
immediately. Please keep all of your follow up appointments and
take all of your medications as prescribed.
Followup Instructions:
You have follow up on [**12-28**] with the [**Month/Year (2) **] team for removal of
your biliary stent:
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2169-12-28**] 9:00
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2169-12-28**] 9:00
.
Please make a follow up appointment with your primary care
doctor, Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **], within 1 week of discharge from rehab.
|
[
"584.9",
"518.81",
"287.5",
"038.9",
"202.00",
"427.31",
"733.00",
"785.52",
"276.2",
"995.92",
"576.1",
"294.8",
"574.91",
"189.0",
"585.9",
"276.52",
"242.00",
"403.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"51.87",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
15988, 16058
|
9054, 14120
|
289, 395
|
16187, 16249
|
3873, 9031
|
16946, 17468
|
2825, 2900
|
14682, 15965
|
16079, 16166
|
14146, 14659
|
16273, 16923
|
2915, 3854
|
224, 251
|
423, 2138
|
2160, 2450
|
2466, 2809
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,804
| 124,636
|
7899
|
Discharge summary
|
report
|
Admission Date: [**2177-9-24**] Discharge Date: [**2177-9-27**]
Date of Birth: [**2118-9-18**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Lipitor
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
congestive heart failure
Major Surgical or Invasive Procedure:
Ultrafiltration by CHF solutions, removal of approximately 13
liters of fluid
History of Present Illness:
This is a 58 year old man wiuth a history of CHF, DM, and
hypertension who was electively admitted for subacute CHF
exacerbation and ultrafiltration. He reports a 20 pound weight
gain over the last 1-2 months, increasing LE edema, and
increasing SOB so that he can barely conduct ADL's. He denies
fever, abd pain, dysuria.
Past Medical History:
CHF (EF of 50% by echo on [**8-9**])
DDD Pacemaker for sick sinus node in [**March 2176**]
Afib, paroxysmal
Type II diabetes mellitus
pulmonary sarcoid, diagnosed [**2151**]
HTN
Hypercholesterolemia LDL 106 [**7-9**]
CRI (baseline Cr of 2.7)
hypothyroidism s/p excision of thyroid nodule
OSA, on BiPAP
s/p cervical spine surgery
history of elevated CK's
Left hallux ulcer
MGUS
Raynaud's
Chronic sensorimotor neuropathy
Social History:
Prior stock broker, out of work since ICU admission in [**2174**]
Married with two children
Denies tobacco, alcohol, drugs
Family History:
Father with history of diabetes, diagnosed age 75
Mother with valve surgery at age 70
Brother with history of spinal stenosis
Physical Exam:
V: 96.7 BP 157/83 R22 HR 60 O2 90% RA
Gen: sitting in bed, speaking in full sentences
HEENT: PERRL, MMM, OP clear
Neck: JVP >15 cm
Resp: CTA bilaterally except scattered crackles R base
CV: RRR nl S1s2 no M
Abd: Soft, obese, NTND
Ext: 3+ edema to legs, small 1 cm open ulcers on shins
Pertinent Results:
137 101 85 /
------------- 135
4.4 25 4.0 \
Ca: 9.1 Mg: 2.6 P: 5.3
ALT: 31 AP: 50 Tbili: 0.6 Alb: 4.4
AST: 48 LDH: 247
\ 9.3 /
8.8 ----- 299
/ 28.2 \
CXR:
FINDINGS: A right subclavian line is in place, with tip crossing
the midline and terminating in the left upper mediastinum. A
left-sided pacemaker is in unchanged position, with dual
electrodes. The electrode leads also course to the left of the
mediastinum. These findings are suggestive of a left-sided SVC.
The heart size and mediastinal contours are unchanged, with mild
cardiomegaly. There is bibasilar atelectasis and a small right
pleural effusion. The left costophrenic angle is excluded from
the radiograph. Minimal haziness of the interstitial markings,
consistent with mild congestive heart failure. The osseous
structures appear unchanged. No pneumothorax.
IMPRESSION
1. Right subclavian venous access catheter with tip terminating
in the upper
portion of a left-sided SVC. No pneumothorax.
2. Mild cardiomegaly and mild congestive heart failure, slightly
improved.
Small right pleural effusion.
3. Bibasilar atelectasis.
EKG:
Sinus rhythm. First degree A-V delay. Left atrial abnormality.
Left
bundle-branch block. Since the previous tracing of [**2177-8-13**] atrial
pacing is not
evident.
Brief Hospital Course:
1. CHF: The patient was admitted electively for ultrafiltration
as he was chronically total body overloaded with fluid.
Approximately 13 liters of fluid were removed with the CHF
solutions ultrafiltration machine over the course of 2 days. His
diuretics were held but toprol was continued. He was not on an
ACE due to renal dysfunction.
2. HTN: The patient was hypertensive while hospitalized. He was
on two separate dihydropyridine calcium channel blockers as an
outpatient. Both of these were discontinued, and hydralazine was
started instead as an afterload reducing [**Doctor Last Name 360**] since an ACE was
contraindicated.
3. CRI: worsening over last months. His creatinine worsensed
from 3.6 at admission to 4.3 at discharge. Renal service was
consulted, who recommended close follow up and possible
dialysis.
4. DMII: patient was on a sliding scale involving 70/30 insulin
sliding scale in the morning and NPH sliding scale in the
evening. This was continued along with his prandin.
5. anemia: The patient had chronic anemia likely [**1-6**] CRI. He is
on outpatient epogen at home. His hemoglobin was stable.
6. Peripheral neuropathy: His amitriptyline and neurontin were
continued.
7. Raynauds: His nifedipine was discontinued due to possible
exacerbation of CHF from nifedipine.
Medications on Admission:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK
(MO,WE,FR).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO QD (once a day).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Nortriptyline HCl 25 mg Capsule Sig: Three (3) Capsule PO HS
(at bedtime).
7. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
8. Fenofibrate Micronized 160 mg Tablet Sig: One (1) Tablet PO
qd ().
9. Prandin 2 mg Tablet Sig: Two (2) Tablet PO three times a day.
10. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
11. Folplex 2.2 2.2-25-0.5 mg Tablet Sig: One (1) Tablet PO qd
().
12. Norvasc
13. nifedipine
Discharge Medications:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK
(MO,WE,FR).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO QD (once a day).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Nortriptyline HCl 25 mg Capsule Sig: Three (3) Capsule PO HS
(at bedtime).
7. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
8. Fenofibrate Micronized 160 mg Tablet Sig: One (1) Tablet PO
qd ().
9. Prandin 2 mg Tablet Sig: Two (2) Tablet PO three times a day.
10. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
11. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
12. Folplex 2.2 2.2-25-0.5 mg Tablet Sig: One (1) Tablet PO qd
().
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure
acute on chronic renal failure
raynaud's syndrome
hypothyroidism
diabetes mellitus
peripheral neuropathy
Discharge Condition:
pt was ambulating, eating, having BM and feeling much better
than at admission. He was eager to go home.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1000 ml
Mild activity as tolerated.
Please take all of your medications with the following changes:
your bumex, norvasc, and nifedical have been discontinued.
Hydralazine has been added to control your blood pressure, if
you get a rash from this medication please stop it immediately
and call your PCP.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and the heart failure clinic in the
next week. They will contact you for follow up.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] from Nephrology within 1 week
([**Telephone/Fax (1) 817**].
Follow up with Dr. [**Last Name (STitle) **],[**First Name3 (LF) 251**] D. [**Telephone/Fax (1) 250**] as needed.
You already have these scheduled appointments:
Provider: [**Name10 (NameIs) 454**],NINE DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8
Date/Time:[**2177-9-30**] 8:00
Provider: [**First Name8 (NamePattern2) 1775**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2177-10-1**] 4:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2177-10-8**]
11:40
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
[
"518.0",
"244.0",
"V58.67",
"285.21",
"428.0",
"584.9",
"403.91",
"428.30",
"357.2",
"135",
"250.60",
"272.0",
"443.0",
"517.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.78",
"93.90",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6417, 6423
|
3091, 4391
|
313, 393
|
6597, 6703
|
1792, 3068
|
7175, 8348
|
1344, 1471
|
5375, 6394
|
6444, 6576
|
4417, 5352
|
6727, 7152
|
1486, 1773
|
249, 275
|
421, 745
|
767, 1188
|
1204, 1328
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,910
| 158,333
|
34163
|
Discharge summary
|
report
|
Admission Date: [**2102-4-16**] Discharge Date: [**2102-4-19**]
Date of Birth: [**2084-5-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Gunshot wounds to left neck and shoulder
Major Surgical or Invasive Procedure:
[**2102-4-16**] Endotracheal intubation
[**2102-4-16**] Flexible bronchoscopy & Endoscopy
(esophagogastroduodenoscopy)
[**2102-4-18**] Extubation
History of Present Illness:
17 yo male s/p gunshot wound x2 to neck and left shoulder at
about
midnight. He was taken to an area hospital and was intubated for
airway
protection. Per EMS report, he was awake and able to speak with
no obvious respiratory distress. He was then transferred to
[**Hospital1 18**] for further care.
Past Medical History:
Denies
Family History:
Noncontributory
Pertinent Results:
Upon admission:
[**2102-4-16**] 02:35AM GLUCOSE-105 LACTATE-1.5 NA+-140 K+-4.0
CL--101
[**2102-4-16**] 02:35AM HGB-15.4 calcHCT-46 O2 SAT-65
[**2102-4-16**] 02:25AM UREA N-17 CREAT-1.0
[**2102-4-16**] 02:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2102-4-16**] 02:25AM WBC-14.3* RBC-5.08 HGB-14.8 HCT-42.6 MCV-84
MCH-29.1 MCHC-34.7 RDW-12.8
[**2102-4-16**] 02:25AM PLT COUNT-233
[**2102-4-16**] 02:25AM PT-13.9* PTT-26.5 INR(PT)-1.2*
RADIOLOGY Final Report
CTA NECK W&W/OC & RECONS [**2102-4-16**] 2:53 AM
[**2102-4-16**] CTA NECK W&W/OC & RECONS
The aortic arch, brachiocephalic artery, common carotid
arteries, subclavian arteries, and vertebral arteries as well as
the internal and external carotid arteries bilaterally are all
normal with no evidence of dissection, occlusion, or
pseudoaneurysm formation.
Soft tissue air is seen within the neck with small defects of
the skin seen bilaterally. There is subcutaneous fat stranding,
thickening of the platysma muscles, and hemorrhage within the
soft tissues of the neck bilaterally, but worse in the left
side. There is a comminuted fracture of the angle of the left
mandible. Comminuted fracture of the left side of the hyoid bone
is also seen. There is blood/fluid within the vallecula
bilaterally. Fractures of the submandibular glands are seen
bilaterally, worse on the left side.
The internal and external jugular veins bilaterally are patent.
There is no extravasated contrast. Small amount of air is seen
within the anterior jugular vein.
The cervical spine appears normal.
There is an endotracheal tube and an orogastric tube in place.
There is mucosal thickening of the left maxillary sinus and the
right sphenoid air cell as well as a few left anterior ethmoid
air cells. Left-sided nasal septal spur is seen.
The visualized lung apices are clear.
IMPRESSION: No evidence of vascular injury in the neck.
Bullet track through the neck with comminuted fracture of the
angle of the left mandible as well as the left hyoid bone.
Fractures of the submandibular glands bilaterally. Soft tissue
hemorrhages of the neck as described above.
CHEST (PORTABLE AP) [**2102-4-18**] 9:11 AM
PORTABLE CHEST RADIOGRAPH: ETT and nasogastric tube are again
seen, relatively unchanged position. Cardiac and mediastinal
contours appear stable. Pulmonary vascularity is unchanged. No
new focal consolidations or pleural effusions.
IMPRESSION: No significant change from prior.
Brief Hospital Course:
He was admitted to the Trauma Service. ENT and OMFS were
consulted given his injuries. He underwent flexible bronchoscopy
and endoscopy (esophagogastroduodenoscopy). He was taken to the
Trauma ICU for close monitoring; he remained intubated for
several days and was eventually extubated without incident. He
was placed on a soft diet and will remain on this until
clearance from OMFS whom he will see in follow up as outpatient.
Social work and the Center for Violence Prevention and Recovery
were consulted and he and his family were provided with
information pertaining to counseling services post
hospitalization.
Medications on Admission:
Denies
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Gunshot wound to left neck and left shoulder
Left hyoid and angle of mandible fractures
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills,
increased jaw pain, difficulty swallowing, shortness of breath,
chest pain, nausea, vomiting, diarrhea and/or any other symptoms
that are concenring to you.
Adhere to a soft diet; avoid excessive chewing because of your
jaw injury.
Take your medication as prescribed.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery next week in clinic,
call [**Telephone/Fax (1) 6429**] for an appointment.
Follow up with Dr. [**First Name (STitle) **], Oral Maxillo Facial Surgery in [**12-14**]
weeks as directed. Call [**Telephone/Fax (1) 274**] for an appointment.
Completed by:[**2102-4-19**]
|
[
"802.35",
"874.8",
"920",
"782.3",
"807.6",
"880.00",
"E965.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"33.22",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4493, 4499
|
3440, 4060
|
358, 506
|
4635, 4642
|
921, 923
|
5024, 5354
|
885, 902
|
4117, 4470
|
4520, 4614
|
4086, 4094
|
4666, 5001
|
274, 320
|
534, 839
|
937, 3417
|
861, 869
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,133
| 102,634
|
32783
|
Discharge summary
|
report
|
Admission Date: [**2106-3-12**] Discharge Date: [**2106-4-13**]
Date of Birth: [**2032-12-19**] Sex: M
Service: SURGERY
Allergies:
Bactrim / Ace Inhibitors
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2106-3-17**] tracheostomy recannulated at bedside
[**2106-3-25**] temporary right IJ dialysis line placed
[**2106-4-6**] bedside left thoracentesis
[**2106-4-10**] right IJ tunnelled hemodialysis catheter placed
History of Present Illness:
73 year old male recently admitted to [**Hospital1 18**] for dysphagia
work-up, admitted to acute care hospital in [**State 108**] for
evaluation and treatment of possible pneumonia. Work-up
included sputum cx/bronchial washings which showed pseudomonas
and MRSA and [**Last Name (LF) 23087**], [**First Name3 (LF) **] report; pt. was treated with Linezolid,
Ceftaz, and empiric Fluc. CT chest [**3-5**] showed patchy areas of
consolidation bilaterally. Bronchial washing/biopsy [**3-9**] showed
edema and mild chronic inflammation. Pt. was transferred to
[**Hospital1 18**] by medical air transport for further evaluation and
treatment.
Review of systems: + SOB, no CP, no headaches, no abdominal pain
Past Medical History:
CABG x 3 vessel [**2090**], RUL lobectomy [**2094**], Right
hemicolectomy w/ primary anastomosis ([**4-21**]), LGIB requiring
end
ileostomy and colonic mucus fistula ([**6-21**]), trach/PEG for
prolonged hospital stay ([**6-21**]), ileostomy takedown ([**10-22**])
c/b anastomotic leak requiring anastomotic resection and
revision
3 days later. Percutaneous drain placed in abdominal fluid
collection [**2105-12-16**].
Social History:
Pt is married for 54 years. Has 2 grown children. Spends 3months
a year in [**State 108**]. He lives with his wife in [**Name (NI) 5936**], MA.
Denies ETOH since [**2105-5-15**], Quit Tobacco in [**2091**].
Family History:
Non-contributory
Physical Exam:
T 97.6 HR 77afib BP125/79 RR19 100%on CPAP+PS 0.40
NAD
trach in place
irregularly irregular rhythm, 2/6 systolic murmur
coarse breath sounds b/l
abd: soft, NT/ND
extr: no edema
Pertinent Results:
on admission:
[**2106-3-12**] 10:05PM BLOOD Glucose-95 UreaN-75* Creat-3.6* Na-144
K-4.3 Cl-110* HCO3-22 AnGap-16
[**2106-3-12**] 10:05PM BLOOD WBC-5.8 RBC-3.98* Hgb-11.6* Hct-35.5*
MCV-89 MCH-29.1 MCHC-32.7 RDW-17.1* Plt Ct-150
[**2106-3-12**] 10:05PM BLOOD PT-15.0* PTT-32.3 INR(PT)-1.3*
[**2106-3-12**] 10:05PM BLOOD ALT-20 AST-15 AlkPhos-61 Amylase-55
TotBili-0.4
at discharge:
[**2106-4-9**] 01:46AM BLOOD WBC-7.2 RBC-3.33* Hgb-9.7* Hct-30.3*
MCV-91 MCH-29.0 MCHC-31.9 RDW-19.2* Plt Ct-205
[**2106-4-9**] 01:46AM BLOOD PT-16.9* PTT-44.7* INR(PT)-1.5*
[**2106-4-9**] 01:46AM BLOOD Glucose-123* UreaN-59* Creat-4.1* Na-130*
K-5.0 Cl-96 HCO3-22 AnGap-17
[**2106-4-9**] 01:46AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2
[**2106-3-25**] 06:00PM BLOOD HCV Ab-NEGATIVE
[**2106-3-25**] 06:00PM BLOOD HBcAb-NEGATIVE
[**2106-3-25**] 06:00PM BLOOD HEPATITIS Be ANTIBODY-Test
[**2106-3-25**] 06:00PM BLOOD HEPATITIS Be ANTIGEN-Test
Nutrition labs:
[**2106-3-12**] 10:05PM BLOOD Albumin-3.2* Calcium-8.6 Phos-5.2* Mg-1.9
Iron-21*
[**2106-3-12**] 10:05PM BLOOD calTIBC-179* Ferritn-261 TRF-138*
[**2106-3-12**] 10:05PM BLOOD Triglyc-29
[**2106-3-22**] 02:06AM BLOOD calTIBC-170* Ferritn-487* TRF-131*
[**2106-3-22**] 02:06AM BLOOD Albumin-3.1* Calcium-9.1 Phos-4.5 Mg-2.7*
Iron-42*
[**2106-3-29**] 02:59AM BLOOD calTIBC-185* Ferritn-304 TRF-142*
[**2106-3-29**] 02:59AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.3 Mg-2.3
Iron-35*
[**2106-4-4**] 02:57AM BLOOD calTIBC-179* Ferritn-177 TRF-138*
[**2106-4-4**] 02:57AM BLOOD Albumin-2.9* Calcium-8.6 Phos-2.7 Mg-2.0
Iron-42*
Imaging:
[**2106-4-1**] echo: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (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 aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a small pericardial effusion.
The effusion appears circumferential.
IMPRESSION: Dilated left atrium. Mild symmetric left ventricular
hypertrophy with preserved global biventricular systolic
function.
[**2106-4-5**] Renal US: The right kidney measures 11.4 cm and the left
kidney measures 12.2 cm. There is no evidence of hydronephrosis
or renal calculi bilaterally. Both kidneys display diffusely
increased echogenic renal parenchyma. The right kidney contains
a 1.7 x 1.7 x 1.6 cm simple cyst within the lower pole and a
slightly more complex-appearing exophytic cyst measuring 1.6 x
1.7 x 1.1 cm off the upper pole, both of which appear grossly
stable from prior CT examination. Limited evaluation of the
urinary bladder is unremarkable. Incidentally noted is a large
left pleural effusion.
IMPRESSION: No evidence of hydronephrosis or renal calculi
bilaterally. Diffusely increased echogenicity of the renal
parenchyma is consistent with underlying medical renal disease.
[**4-9**] CXR IMPRESSION: 1. Worsening left pleural effusion;
moderate-to-severe with associated worsening left lower lobe
atelectasis.
2. Prior lung intervention with an associated stable peripheral
opacity in the right upper lung. 3. Small stable right pleural
effusion.
4. Tracheostomy tube tip is 7 cm above the carina and the
patient's neck is flexed. Tracheostomy tube can be adjusted if
clinically indicated.
Cytology:
[**4-6**] Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Mesothelial
cells, histiocytes and abundant blood.
Brief Hospital Course:
Mr. [**Known lastname 76336**] was admitted to the general surgery service on
[**2106-3-12**].
On admission, he had a chest xray with small left pleural
effusion left lower lobe opacity concerning for pneumonia. He
was continued on antibiotics including ceftazidime, Linezolid
and fluconazole. The Linezolid was changed to Vancomycin on
[**3-13**]. On admission he had a BUN/Cr of 75/3.6. He was started
on Nutren Renal tube feeds and continued on his home
medications. He was continued with aggressive pulmonary toilet
and sputum cultures were sent which were unremarkable and the
antibiotics were discontinued on [**3-16**]. On [**3-14**] he had increasing
shortness of breath, +accessory muscle use and tachypnea. An
ABG showed respiratory acidosis with a PCO2 of 65 and he was
transferred to the ICU for further management of respiratory
distress. He was intubated after transfer to the ICU for
progressive respiratory distress with improvement of his ABG.
He was also started on zoloft for depression. He was started on
a bicarbonate infusion [**3-15**] secondary to persistently low HC03
levels and given PO bicarb tabs. Nephrology was consulted on
[**3-16**] for increasing creatinine (BUN 83/Cr 4.0) and metabolic
acidosis and he was felt to have acute on chronic renal failure.
His bicarb level improved, however he continued to have
difficulty pressure support, with hypercarbia and acidosis after
attempting to decrease vent settings. His old trach site was
recannulated at the bedside on [**3-17**]. He was also started on
nephramine TPN for renal failure in addition to his tube feeds
which were decreased for a total protein intake of 40-50g daily.
He continued to have agitation/delirium at night, haldol and
xanax were tried for treamtent. He received a 3 day course of
Cipro [**Date range (1) 76337**] for a +UA but had negative urine culture. He was
given intermittent lasix IV on [**3-17**] and started on a lasix IV
drip on [**3-18**] with little improvement in respiratory status and it
was stopped on [**3-22**]. He was found to have an increased TSH level
and his levothyroxine dose was increased. He had continued
increase in his BUN/Cr, although his urine output remained
stable.
He continued to be seen by physical therapy through out his
hospitalization and was out of bed to the chair almost daily and
ambulated well even though he was ventilated. He intermittently
had to be switched to assist control for acidosis. Tube feeds
were held on [**3-23**] and he was continued on nephramine. On [**3-24**],
he was found to be c. diff positive and was started on flagyl
for a 14 day course. On [**3-25**] his BUN/Cr continued to increase
(118/6.8) and it was agreed to start dialysis. A temporary R IJ
dialysis catheter was inserted and he was started on
hemodialysis with slow improvement in his BUN/Cr. He was
restarted on Impact Tube feeds 3/4 strength to goal of 80cc/hr
and his nephramine was stopped. He was continued on dialysis on
Mon/Wed/Fri per nephrology. His urine output trended down and
he was making minimal urine at the time of discharge. He was
continued on pressure support with slow wean of pressure support
attempted with continued failure due to hypercarbia. On [**3-29**] he
was noted to be in atrial fibrillation with rapid ventricular
rate. He had EKG changes which were felt to be nonspecific by
cardiology. Rate control was achieved with IV/PO lopressor,
cardiac enzymes were cycled which were negative, he was given 1
unit packed RBCs and cardiology was consulted. Per Dr. [**Last Name (STitle) 957**],
anticoagulation was not started. An echo was done [**4-1**] which
showed a dilated left atrium, LVEF>55% and LVH. Psychiatry was
consulted on [**3-30**] for concerns of depression, suicidal gestures
and night time agitation. He denied any suicidal ideations but
did admit to feeling depressed. Recommendations included xanax
taper, haldol as primary med for delerium and to continue
zoloft. He was eventually maintained on 3mg haldol qHS with
improved nighttime agitation. He was restarted on nephramine on
[**3-31**]. On [**3-31**] he also had a Tmin of 93.1 rectally and he was
pan-cultured. Blood cultures were no growth, however sputum
cultures from [**3-30**] grew pseudomonas on [**4-1**]. He was started on
Vancomycin/zosyn on [**4-1**], which was later found to be resistant
to zosyn and sensitive to meropenem and he was started on a 14
day course of meropenem on [**4-2**]. Pulmonology was consulted on
[**4-2**] at the request of the family, and it was felt that he had
multi-focal respiratory failure secondary to pseudomonas VAP,
muscle weakness and the left pleural effusion causing a
restrictive ventilatory defect. They recommended to do a
thoracentesis of the left lung effusion, which was performed on
[**4-6**] with 1.5L of bloodly pleural fluid drained. Cultures were
negative and cytology showed no malignant cells. He tolerated
the procedure well and post procedure chest xray was improved.
C diff toxin recheck on [**4-6**] was negative. He was continued on
hemodialysis and the vent was slowly weaned. He continued to
have periods of atrial fibrillation and normal sinus. His
nephramine was stopped on [**4-9**] secondary to increasing left
effusion and concern for high fluid intake involvement in its
reaccumulation. He was taken to the operating room on [**4-10**] for
a R IJ tunnelled dialysis catheter. He tolerated the procedure
well. At the time of discharge, his vent settings were PS 5
peep 5, he will continue on meropenem (last day [**4-15**]), continue
on tube feed impact with fiber [**2-16**] strenght at 80ml/hr and
hemodialysis per nephrology. His portable chest x-ray at time
of discharge showed start of re-accumulation of his left sided
effusion. This should be followed with films while in rehab.
Medications on Admission:
Meds on Transfer: LINEZOLID, CEFTAZ, FLUC, xanax, norvasc,
aranesep, welchol, ferrous gluconate, lactobacillus,
levothyroxine 175', megace, metoprolol 50", seroquel
Allergies: sulfa, trimethoprim, ACE inhibitors
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
respiratory failure
acute renal failure
pneumonia
Clostridium difficile infection
atrial fibrillation
malnutrition
Discharge Condition:
stable
Completed by:[**2106-4-12**]
|
[
"599.0",
"V45.81",
"507.0",
"276.1",
"311",
"244.9",
"584.9",
"511.9",
"263.9",
"482.1",
"V10.21",
"V10.11",
"V09.80",
"787.20",
"403.90",
"276.4",
"440.1",
"427.31",
"999.9",
"496",
"482.41",
"585.4",
"008.45",
"518.81",
"285.21",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"39.95",
"38.95",
"99.04",
"34.91",
"96.04",
"00.14",
"38.91",
"31.1",
"38.93",
"96.72",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
12036, 12115
|
5923, 11772
|
305, 521
|
12274, 12311
|
2175, 2175
|
1942, 1961
|
12136, 12253
|
11798, 11798
|
1976, 2156
|
2557, 5900
|
1210, 1258
|
246, 267
|
549, 1191
|
2189, 2543
|
1280, 1700
|
1716, 1926
|
11816, 12013
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,096
| 189,118
|
27056
|
Discharge summary
|
report
|
Admission Date: [**2138-1-12**] Discharge Date: [**2138-1-16**]
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Upper Endoscopy with cauterization of bleeding vessel
PEG tube placement
History of Present Illness:
[**Age over 90 **] year old anaesthesiologist with history of CABG, esophageal
strictures/dismotility, HTN, and CHF with EF 45% presenting with
mahogany stools. The week prior to admission he began to feel a
sense of weakness, fatigue, and dizziness. He stopped taking
his ASA, also had been on Advil for sore foot a week prior. He
started noticing melanic stools the morning prior to admission.
He presented to [**Hospital3 **] where his HCT was found to be 20
from a baseline of 29. He had no nausea or hematemesis. At the
[**Hospital1 46**] ICU his HCT went to 22 after 3 units PRBCs. He has
gotten 3 more units PRBCs prior to arrival in the MICU for a
total of 6 units. He has had 4 bloody BMs today. The GI
physicians at Jordans were hesitant to scope him given his
esophageal stricture so he was transfered here for EGD. His
last colonoscopy was [**11/2133**] which showed diffuse
diverticulosis.
Currently he has no chest pain, he had some abdominal pain
earlier today which has resolved with Fentanyl. He has no
shortness of breath, no nausea. He does note a 20 lb weight
loss over the last few months with no change in diet. He has no
edema, no orthopnea, no PND.
Past Medical History:
1. Esophageal dismotility - treated with botox injections,
eventually requiring PEG placement 5 years ago.
2. Esophageal stricture - unable to pass pediatric endoscopy
tube without dilation
3. Paroxismal atrial fibrillation s/p pacemaker placement for
tachy brady syndrome
4. Ischemic heart disease s/p CABG '[**18**]
5. Aortic stenosis
6. Mitral regurgitation
7. CRI, baseline creatinine 1.6
8. HTN
9. CHF with EF 45%
10. Bladder tumor
Social History:
Retired anesthesiologist who worked for 40 years at [**Hospital1 3325**]. Currently leading very active life. Golfs 3X per
week. Lives at home with wife. [**Name (NI) **] smoking, no EtOH
Family History:
Parents died in their 80s of heart disease
Physical Exam:
Vital signs
Temp 97,7, BP 124/35, P 67 (NSR), RR 16, 100% on 2L NC
Gen: alert, oriented, cachectic appearing male in NAD
HEENT: MM dry, OP clear, PERRL
Lungs: Clear to auscultation bilaterally, decreased BS at right
base
CV: Holosystolic murmer loud at both RUSB and apex
Abd: Concave, thin, non-tender, non-distended, positive BS
Ext: no edema
Neuro: intact
Pertinent Results:
Labs from OSH:
WBC 5.9, HCT 20.5 -> 22.4 (after 3 units), Plt 121
PT 12.9, INR 1.2
Na 140, K 4.9, BUN 110, Creat 1.6 (baseline), Alb 1.6, bili 0.3
Alk phos 36, AST 14, ALT 19
.
[**2138-1-12**] 04:43PM BLOOD WBC-7.8 RBC-3.70* Hgb-11.1* Hct-31.0*
MCV-84 MCH-30.0 MCHC-35.9* RDW-17.3* Plt Ct-121*
[**2138-1-13**] 08:04AM BLOOD Hct-36.6*
[**2138-1-14**] 05:22AM BLOOD WBC-6.5 RBC-3.68* Hgb-10.8* Hct-30.1*
MCV-82 MCH-29.4 MCHC-36.0* RDW-17.6* Plt Ct-90*
[**2138-1-14**] 07:50PM BLOOD Hct-27.8*
[**2138-1-15**] 03:35PM BLOOD Hct-31.2*
[**2138-1-15**] 09:55PM BLOOD Hct-30.6*
[**2138-1-16**] 05:10AM BLOOD WBC-6.1 RBC-3.57* Hgb-10.9* Hct-30.2*
MCV-85 MCH-30.4 MCHC-36.0* RDW-17.5* Plt Ct-106*.
.
echo:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size. There is mild to moderate
regional left ventricular systolic dysfunction with distal
septal and apical hypokinesis as well as basal inferior and
infero-lateral hypokinesis. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
EGD report [**1-12**]:
Fresh blood was found in the duodenal bulb and second portion of
the duodenum. A clot was seen with active bleeding in the second
portion of the duodenum. After 20 cc of 1:10,000 epinephrine was
injected in the area with successful hemostasis, what appears
like a single cratered ulcer with a visible vessel was seen in
the second part of the duodenum. [**Hospital1 **]-CAP Electrocautery was
applied for hemostasis successfully.
Impression: Blood in the stomach Ulcer in the second part of the
duodenum
Recommendations: Protonix 40mg IV BID Continue serial hct. Avoid
NSAIDs.
.
EGD report [**1-15**]:
Previous single ulcer was found in the duodenum s/p bicap with
question of minimal oozing. Impression: Duodenal ulcer
PEG placed.
Brief Hospital Course:
While in MICU, patient transfused 4 more units PRBCs. GI
consulted, underwent EGD through PEG tube site given esophageal
stricture. Found to have blood in bulb and 2nd part of
duodenum. A clot with active bleeding was also found,
hemostasis achieved w/ epi and electrocautery. Hct decreased
from 37-30.8 throughout the day yesterday, now stable at 30-31.
No further episodes of melena.
.
On transfer to the medicine floor, the patient felt somewhat
improved, denied chest pain or shortness of breath, abdominal
pain, or light-headedness. His hematocrit was monitored every 6
hours, and he was transfused 1 more unit overnight given that it
had decreased from 30 to 27, with an appropriate increase the
following day. GI decided to re-scope him to ensure no further
bleeding, the previous lesion had some slight ooze, but did not
require any intervention. A PEG tube was placed without
complication. The patient was continued on the PPI [**Hospital1 **], and did
not have any further episodes of melena or guaiac positive
stool. His hematocrit remained stable. He was provided with
PPN given that he was NPO, and tube feeds were initiated once
his PEG was placed. He was provided IVF and free water boluses
through the PEG tube to help correct his hypernatremia.
Additionally, he noted to have right foot pain on the day prior
to discharge. Plain films were obtained, which suggested gout.
Treatment was discussed, but deferred for now as the patient did
not feel that his pain was intolerable, and he felt it was
improving. Prior to discharge, his ACE was also restarted to
ensure that his blood pressure would tolerate this.
He was evaluated by PT prior to discharge and cleared for a safe
discharge home. He was provided a script for Protonix, but
instructed to substitute Prilosec if unable to afford the
Protonix. He will follow-up with his PCP after discharge, and
was reminded to avoid all aspirin and NSAIDs.
Medications on Admission:
Aspirin
Hytrin 10 mg daily
Quinapril
Vitamins
Brewers yeast
Prune juice
Medications on Transfer:
Protonix drip
Terazosin 5
Discharge Medications:
1. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
2. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous
twice a day: Administer through PEG tube.
Disp:*qs * Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
bleeding duodenal ulcer
bleeding duodenal ulcer
Discharge Condition:
Good
Discharge Instructions:
We have started you on a new medication, pantoprazole, to help
protect your stomach. Please take this medication as
instructed. If this medication is too expensive, you may
substitute Prilosec, which is sold over the counter (same dose,
40mg twice a day). Please do not take any aspirin, ibuprofen or
other NSAIDs.
.
Please call your doctor or return to the hospital if you develop
fevers, chills, chest pain, shortness of breath, or if you start
to have black or bloody stools.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 13266**] for a follow-up appointment
within 1 week of discharge.
|
[
"414.00",
"428.0",
"285.1",
"287.5",
"414.01",
"532.00",
"403.91",
"600.00",
"562.10",
"276.0",
"530.5",
"V45.01",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.6",
"44.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7483, 7489
|
5091, 7024
|
226, 301
|
7582, 7589
|
2638, 5068
|
8119, 8261
|
2200, 2244
|
7199, 7460
|
7510, 7561
|
7050, 7123
|
7613, 8096
|
2259, 2619
|
180, 188
|
329, 1515
|
7148, 7176
|
1537, 1975
|
1991, 2184
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,966
| 112,721
|
12750
|
Discharge summary
|
report
|
Admission Date: [**2162-4-19**] Discharge Date: [**2162-4-29**]
Date of Birth: [**2108-1-21**] Sex: M
Service: SURGERY
Allergies:
adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
1. Irrigation and debridement down to and inclusive of bone
of open ulna and radius fracture.
2. Open reduction internal fixation both-bones forearm
fracture including segmental radius and ulnar shaft.
3. Examination under anesthesia distal radioulnar joint for
joint stability.
History of Present Illness:
54 yo M with a PMH significant for
tardive dyskinesia (? secondary to prolonged Clozapine
exposure),
bipolar disorder, multiple abdominal surgeries (Roux-en-Y
gastric
bybass, distal pancreatectomy, splenectomy, revision of
gastrectomy/choledochojejunostomy), Vit D/Vit B12/testosterone
deficiency, and anemia of chronic disease who presents as
unrestrained driver in MVC. Per report he was unrestrained
driver who struck the highway barrier whereafter his car spun
around 180 degrees. The patient was found on the passenger side
of the car. EMS found the patient confused and unable to answer
questions. They could not obtain IV access and found the patient
to be hypotensive with a systolic pressure blood pressure of 80.
For this an interosseous access was established. Upon arival he
was initially noted to have GCS of 14 with slow speech and was
somnolent. Patient was initially found to not be responsive to
commands, and he did not remember the event. He complained of
left forearm pain, nose pain (fracture nose last week with
planned surgical repain in [**State 531**] in [**3-14**] weeks), and headache.
Dicussion and history per his brother and sister, he had been
recently "stable" with all his medical problems, and returned
from a trip to [**Location (un) **] this past Saturday. He had been living
alone and has a tendencey to either over take medication or
undertake medication when not supervised. He was supposed to go
to physical therapy and had missed his appointment this morning
prior to the accident. His brother states that he had tried to
call him this morning without success. For the past several
months he has been eating very little secondary to nausea and
has
had occasional tongue swelling with taste amplification. He was
recently hospitalized [**Date range (3) 39346**] for altered mental status
and confusion. At that time, he had been experiencing frequent
falls in which he would hit his head. Remeron and Trileptal
were
tapered out of concern that these medications could be
contributing to his altered mental status. Since the patient has
no indication for being on Trileptal with the exception of a
possible history of basilar migraines, we conferred with his
psychiatrist who agreed that this medication was unnecessary and
could be contributing to the patient's falls. Also, a neurology
note from [**2162**] stated explicitly that the patient did not have
basilar migraines. Prior notes have also felt like there was a
large functional component to his neurologic deficits. Also it
is likely that the patient's numerous psychotropic medications
in the setting of his leukocytosis have been attributed to his
unsteady gate. A series of labs were sent off for the workup of
a
toxic metabolic syndrome or a nutritional deficiency which could
cause a peripheral neuropathy. These results came back
negative.
The patients mental status dramatically improved with
antibiotics
and IV hydration during this admission. The patient has been
seen by Dr. [**Last Name (STitle) **] of Neurology for follow-up of Tardive
Dyskinesia. He was last seen in the Movement [**Hospital 6920**] Clinic
on
[**2162-1-21**]. At that time, the patient described persistent teeth
grinding, abnormal movmements of the face and tongue, and
slurred, high pitch speech that worsens at the end of the day.
The patient also reported abnormal leg movements with give-way
weakness throughout his legs. At that time, he had recently
stopped tetrabenazine , which had worked well in the past, due
to
insurance changes.
.
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. basilar migraines
19. Bipolar disorder
Social History:
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.
Pertinent Results:
[**2162-4-19**] 06:55PM GLUCOSE-105* UREA N-14 CREAT-0.7 SODIUM-138
POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-25 ANION GAP-8
[**2162-4-19**] 06:55PM ALT(SGPT)-48* AST(SGOT)-57* ALK PHOS-94 TOT
BILI-0.3
[**2162-4-19**] 06:55PM CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-1.8
[**2162-4-19**] 06:55PM LITHIUM-0.7
[**2162-4-19**] 06:55PM WBC-24.0* RBC-3.18* HGB-9.0* HCT-28.3* MCV-89
MCH-28.2 MCHC-31.8 RDW-16.8*
[**2162-4-19**] 06:55PM PLT COUNT-372
Imaging:
CXR: Bilateral upper lobe opacities (R>L), similar compared to
[**2162-3-14**] studies, no effusion/pneumothorax
CT head: No acute intracranial process. Buckled right nasal bone
fracture.
CT C-spine: No fracture or malalignment
CT Torso: No intrathoracic or intraabdominal injury
Plain Film Forearm: Dispalced segmental fracture of the radius
and fracture of the mid-to-distal ulna.
Plain Film of Hand: Minimally displaced transverse fracture of
the proximal middle finger phalanx with volar displacement of
the distal fracture fragment. Evidence of old hand surgery with
an anchor in the middle phlanx of right thumb
Brief Hospital Course:
He was admitted to the Acute Care Surgery team. Orthopedics
consulted for the fractures in his left forearm and he was taken
to the operating room for repair of these injures.
Postoperatively he was noted to have significant swelling and
was monitored closely for compartment syndrome. His compartments
on exam did remain soft and the swelling decreased significantly
with elevation using a stockinette attached to IV pole.
His right middle finger fracture was evaluated by Hand Surgery.
His finger remained splinted while discussions for operative
repair were underway. Occupational therapy was consulted for
splinting of his extremities.
He was taken to the operating room again on [**2162-4-23**] for repair
of his finger fractures and nasal fracture (of note, was an
exacerbation of an old nasal fracture and elective repair had
been scheduled prior to this injury). Following the procedure,
he desaturated in the PACU requiring re-intubation. This is
believed to be from residual anesthetic. He was admitted to the
SICU. Over the next 24 hours, he was weaned from the ventilator
and extubated without incident. He was bronched prior to
extubation and purulent secretions were found. His chest x-ray
at that time showed bilateral atelectasis with mild hilar
congestion. He was started on Cipro which will continue through
[**4-30**].
He was transferred to the floor the following day
hemodynamically stable. He did require intermittent nasal oxygen
once transferred form the ICU and was continued on nebulizer
treatments.
He was noted with pain control issues postoperatively and was
initially started on MS Contin with oral Dilaudid for
breakthrough pain. Because of some mental status changes felt
likely from the narcotics these were stopped and he was started
on around the clock Tylenol and standing Ultram.
He was also seen by Physical therapy given his history of
frequent falls. It is being recommneded that he go to rehab
after his acute hospital stay.
Medications on Admission:
1. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
2. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day: With meals .
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for nausea.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
6. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Four (4)
Capsule, Ext Release 24 hr PO DAILY (Daily).
7. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO EVERY OTHER DAY (Every Other Day).
14. thiamine HCl 100 mg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
15. tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
16. lithium carbonate 450 mg Tablet Extended Release Sig: One
(1) Tablet Extended Release PO HS (at bedtime).
17. Adderall XR 20 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
18. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Three (3)
Tablet PO twice a day.
19. Pancrelipase 5000 5,000-17,000 -27,000 unit Capsule, Delayed
Release(E.C.) Sig: Twelve (12) Capsule, Delayed Release(E.C.) PO
three times a day: Take with meals .
20. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
21. vitamin E 600 unit Capsule Sig: Two (2) Capsule PO once a
day.
22. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) ml Injection once a month.
23. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as
needed for constipation.
24. guaifenesin 100 mg/5 mL Syrup Sig: [**5-20**] ml PO every six (6)
hours as needed for cough.
25. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) inhalation Inhalation every six (6)
hours as needed for shortness of breath or wheezing
ALL: ‎adhesive bandage / Benzoin / Mastisol Stertip /
Compazine /
gabapentin / Neurontin
Discharge Medications:
1. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Three (3) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS).
2. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Four (4)
Capsule, Ext Release 24 hr PO DAILY (Daily).
3. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
6. oxybutynin chloride 5 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. lithium carbonate 450 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
12. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: Two (2) Capsule, Ext Release 24 hr PO daily ().
13. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 2 days.
14. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Apply to blisters on left forearm [**Hospital1 **] .
15. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Nasal bone fracture
Left ulnar & radius fractures
Right 3rd phalanx fracture
Pneumonia
Discharge Condition:
Awake and alert, conversant w/ some dysathria
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after a motor vehicle crash
where you sustained a broken nasal bone, fractures of your right
middle finger fracture and left arm. Your injuries required
several operations to repair the fractures. It is important
that you do not put any full weight on your left arm and right
hand and be sure to keep your left arm elevated as high as
possible to minimize the swelling.
You are being recommneded for rehab after discharge from the
hospital to help with rebuilding your strength and endurance
from all of your injuries.
Followup Instructions:
*
Department: SPINE CENTER(PLASTIC DEPT APPT.)
When: FRIDAY [**2162-5-7**] at 2:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 39347**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2162-5-11**] at 11:20 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2162-5-11**] at 11:40 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2162-4-28**] at 8:20 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SPINE CENTER
When: FRIDAY [**2162-5-7**] at 2:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 39347**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2162-5-10**] at 8:30 AM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2162-5-12**]
|
[
"E939.3",
"V85.1",
"816.01",
"E879.8",
"E815.0",
"V45.86",
"333.85",
"813.33",
"919.0",
"296.80",
"268.2",
"802.0",
"V88.12",
"E915",
"285.29",
"257.2",
"518.51",
"268.9",
"850.0",
"997.31",
"041.3",
"V45.79",
"263.9",
"300.00",
"355.3",
"933.1",
"356.9",
"346.00",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.14",
"21.71",
"96.71",
"79.62",
"79.32",
"31.42",
"96.04",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12344, 12414
|
6382, 8357
|
366, 659
|
12579, 12695
|
5281, 5852
|
13298, 15113
|
5205, 5262
|
10852, 12321
|
12435, 12558
|
8383, 10829
|
12719, 13275
|
303, 328
|
687, 4234
|
5861, 6359
|
4256, 5013
|
5045, 5189
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,793
| 185,581
|
3610
|
Discharge summary
|
report
|
Admission Date: [**2199-8-10**] Discharge Date: [**2199-8-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Lethargy, hypoxia
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt is a [**Age over 90 **] yo woman with dementia (non-verbal) brought in from
[**Hospital3 2558**] with lethargy and hypoxia (not on baseline O2)
noted this morning. She reportedly sounded congested. O2 sat
there was 69% RA, 79% on 5L NC, T 96.7, HR 120's, BP 129/73. On
arrival in the ED VS were T 99.9 HR 85 BP 130/54 RR 26 (28-30)
Sat 70->improved to high 84% on NRB. ABG showed 7.33/49/62. She
was started on CPAP with improvement to 94%. After 1 hour ABG
showed 7.31/45/74. She was DNR/DNI on arrival however her
daughter and HCP reversed this and requested intubation if
needed. She received 1L NS. Blood cultures were drawn but urine
culture was not sent. She was given 1gm ceftriaxone when CXR
revealed RML consolidation. She was ordered for additional 1gm
vanco iv and zosyn (not clear if they were given). Labs were
significant for troponin of 0.07, potassium 5.9 (on repeat 5.1),
WBC 13.9, lactate 2.6. ECG showed a. flutter at rate of 111. She
was transferred to the [**Hospital Unit Name 153**] for further management.
.
At baseline per daughter she opens eyes, eats (with assistance)
thick liquids and purees. She has had private nursing for the
past 3 years with no infectious complications or bed sores but
prior to that had frequent UTI's, aspiration PNA's and bed
sores. Additionally daughter notes baseline blood pressure 'runs
low.'
Past Medical History:
1. Dementia - non-verbal at baseline and dependent for all
activities of daily living and not ambulatory
2. H/o Syncope
3. Osteoporosis
4. Depression
5. Heel ulcer
6. Incontinence
7. Atrial fibrilation with RVR, not on anticoagulation
8. ? CVA per daughter (multiple small contributing to dementia)
Social History:
Pt lives at [**Hospital3 2558**] is completely dependent for
activities of daily living. Pt is non-verbal at baseline. The
patient is widowed. She has two daughters, one of whom is the
health care proxy [**Name (NI) 16405**] [**Name (NI) 349**] ([**Telephone/Fax (1) 16406**]). The other
daughter lives in [**Name (NI) 4565**].
Family History:
Unknown
Physical Exam:
VS: Tc: 100.2 HR: 84 BP: 120/73 RR: 36 Sat: 96% on 60% hiflow
face mask
Gen: Elderly women lying in bed in NAD. No diaphoresis, no
accessory muscle use. Pt appears awake and alert but does not
communicate.
HEENT: PERRL, EOMI, mm dry
CV: Faint heart sounds, tachycardic, S1, S2, no murmurs, rubs,
gallops
Resp: coarse rhonchi bilaterally, ? RLL rales, no wheezes
Abd: Soft, NT, ND, BS hypoactive, no masses
Ext: No clubbing, cyanosis, edema
Neuro: Pt not moving any extremity spontaneously, withdraws to
pain, right eye with lateral deviation, has minimal gag, no
occulocephalic reflex noted, some spontaneous movement
Skin: intact, no pressure ulcers, echymosis left hand dorsum
Pertinent Results:
Admission labs:
[**2199-8-10**] 10:20AM WBC-13.9* RBC-4.71 HGB-14.1 HCT-44.8 MCV-95
MCH-29.8 MCHC-31.4 RDW-14.8
[**2199-8-10**] 10:20AM NEUTS-86* BANDS-5 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2199-8-10**] 10:20AM GLUCOSE-137* UREA N-38* CREAT-0.9 SODIUM-142
POTASSIUM-5.9* CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
[**2199-8-10**] 10:20AM CALCIUM-9.9 PHOSPHATE-4.3 MAGNESIUM-2.6
[**2199-8-10**] 10:20AM CK-MB-5
[**2199-8-10**] 10:20AM cTropnT-0.07*
[**2199-8-10**] 11:39AM TYPE-ART O2 FLOW-100 PO2-74* PCO2-45 PH-7.31*
TOTAL CO2-24 BASE XS--3 INTUBATED-NOT INTUBA
[**2199-8-10**] 10:37AM LACTATE-2.6*
.
Imaging:
ECHO Study Date of [**2199-8-12**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. There is mild regional left ventricular
systolic dysfunction with infero-lateral akinesis. No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular systolic function is borderline normal. The aortic
root is mildly dilated at the sinus level. The ascending aorta
is mildly dilated. The aortic valve is not well seen. There is
no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. Trivial mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. Compared with the report of the prior
study (images unavailable for review) of [**2196-12-14**], a regional
wall motion abnormality is now detected.
.
CHEST (PORTABLE AP) [**2199-8-14**] 4:50 AM
Pulmonary vascular congestion has improved since [**8-13**], while
small right pleural effusion has increased. Small left pleural
effusion may be present, also increased and left lower lobe
atelectasis remains unchanged. ET tube in standard placement,
nasogastric tube passes below the diaphragm and out of view and
a right-sided central venous catheter tip projects over the low
SVC. No pneumothorax.
.
ECG Study Date of [**2199-8-13**] 9:34:52 AM
Atrial fibrillation with rapid ventricular response
LVH with secondary ST-T changes
Brief Hospital Course:
Pt is a [**Age over 90 **] yo woman with dementia (non-verbal) brought in from
[**Hospital3 2558**] with lethargy and hypoxia and was found to have
paroxysmal atrial flutter with RVR, elevated troponin, MRSA
pneumonia, and pulmonary edema. Pt was intubated and supported
by vasopressors. Pt care shifted to comfort measures only on
[**8-15**] per family.
.
1. Respiratory distress, likely due to PNA and pulmonary edema:
CXR on admission suggested infiltrate in RML. Pt had presented
with low-grade fevers and leukocytosis with L shift and
bandemia. After IVFs for fluid resucitation in an effort to
keep her BP and UOP up, pt was found to have pulmonary edema on
repeat CXR and was intubated for hypoxic respiratory failure.
An ECHO showed new mild regional left ventricular systolic
dysfunction with infero-lateral akinesis with EF of 45% to 50%.
Prior to shifting to comfort care, pt was receiving vancomycin
and zosyn for MRSA pneumonia and furosemide as needed for
respiratory distress. She was also extubated on [**8-15**].
.
2. Hypotension, presumed septic shock from PNA + cardiogenic
component (decreased output during a fib, decreased LV function
on ECHO): Pt required phenylephrine to keep MAP at goal of >60
prior to shifting to comfort care. Upon discharge, she was
maintaining SBP 100s on her own.
.
3. Paroxysmal atrial fibrillation: This ranged from being
rate-controlled on her own to RVR.
.
4. Elevated troponin on admission, likely due to demand
ischemia in the setting of dehydration, hypoxia, and a. fib with
RVR upon at that time: ECG had some concerning changes though
not significantly changed from previous readings. CK, CKMB
index were not elevated x4.
.
5. Hypertension: Pt's SBP remained <120 during her hospital
stay. Her home antihypertensives were held.
.
6. Fluids/electroyltes/nutrition: Pt's electrolytes were
repleted as necessary. She did received tube feedings prior to
shifting to comfort care.
Medications on Admission:
Ipratropium Bromide neb Q6H
Acetaminophen 650 mg Suppository Rectal Q4-6H
Aspirin 81 mg PO DAILY
Metoprolol Tartrate 12.5mg PO BID
Lisinopril 2.5 mgPO DAILY
Natural Tears 1.4 % 1-2OU twice a day prn
Multi-Vitamin PO once a day.
Colace 100 mg PO twice a day
Senna 187 mg PO BID:PRN
mirtazipine 7.5mg po qhs
bisacodyl 10mg supp prn
MOM 30ml po prn
guituss prn
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: [**1-29**] PO Q6H (every 6
hours) as needed for fever.
2. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) as needed for secretions.
3. Morphine 10 mg/5 mL Solution Sig: [**1-29**] PO Q6H (every 6 hours)
as needed for respiratory distress or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Pneumonia
Shock
Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for lethargy and hypoxia. You were found to
have pneumonia and to occasionally have an irregular heart
rhythm. For a time, you required breathing assitance with a
ventilator and medications to support your blood pressure.
After a long discussion with your family members and the social
worker, it was decided that you wished to have your care
centered on comfort.
.
Please use the medications prescribed for your comfort as
needed.
Followup Instructions:
None
|
[
"427.32",
"733.00",
"038.9",
"276.51",
"401.9",
"311",
"294.8",
"427.1",
"785.52",
"482.41",
"518.81",
"410.71",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8063, 8133
|
5347, 7301
|
280, 292
|
8213, 8222
|
3091, 3091
|
8722, 8730
|
2367, 2376
|
7709, 8040
|
8154, 8192
|
7327, 7686
|
8246, 8699
|
2391, 3072
|
223, 242
|
320, 1675
|
3107, 5324
|
1697, 2005
|
2021, 2351
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,387
| 195,180
|
46498
|
Discharge summary
|
report
|
Admission Date: [**2175-9-25**] Discharge Date: [**2175-9-28**]
Date of Birth: [**2103-2-12**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Plavix
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Fatigue, anemia
Major Surgical or Invasive Procedure:
Endoscopy and biopsy; colonoscopy
History of Present Illness:
Ms. [**Known lastname 40946**] is a 72 yoF with h/o post-op DVT [**4-5**] on coumadin
and no prior GIB, who was referred to the ED by her PCP for two
weeks of dizziness and fatigue. She was found to have a Hct of
17 with grossly positive guaiac. She has no melena, but reports
intermittent nausea with nonbilious vomiting over the last few
weeks with the fatigue.
.
VS in the ED were: 99.2, 97/29, 94, 18, 99% on RA. NG lavage was
negative. She was started on 1 unit RBC prior to transfer and
was given 1 L NS.
Past Medical History:
HTN
Hyperlipidemia
Type II Diabetes
Chronic left great toenail fungus/removal nail bed [**2-5**]
Appendectomy
Tonsillectomy
Social History:
[**3-30**] ppd cigarettes, denies IVDU and ETOH.
She lives in [**Location 86**] with her husband.
She is a retired receptionist.
Family History:
One sister, age 66, with diabetes. One brother with diabetes.
Otherwise NC
Physical Exam:
Admission:
VS on arrival to the ICU: 97.7, 119/45, 85, 18, 99% 2LNC
GENERAL: elderly woman, comfortable in bed, pale
HEENT: OP clear, tachy MM, OP clear, conjunctival palor
LUNGS: crackles at bases that clear with cough, no wheezes
CARDIO: RR, loud S2, no murmurs appreciated
ABD: + BS, soft, NTND, no HSM
EXT: trace LE edema
SKIN: pale, no petechiae, no ecchymoses
NEURO: AA, Ox3, CN II - XII grossly normal, gait deferred
.
Discharge:
VS: T: 98.9, BP: 132/60, P:96, RR: 18, 99% RA
GEN: elderly female in NAD
CV: normal S1, loud S2, RRR, no m/r/g
PULM: sparse crackles at bases, CTAB at mid/upper lungs
ABD: BS+, soft, nd, nt
EXT: amputated L hallux with healing stage II ulcer, unstagable
ulcer on dorsum of L foot, 2+ PE over LLE and 1+ over RLE
Pertinent Results:
Hematology:
[**2175-9-28**] 06:35AM BLOOD WBC-9.4 RBC-4.03* Hgb-9.9* Hct-30.9*
MCV-77* MCH-24.7* MCHC-32.2 RDW-19.3* Plt Ct-316
[**2175-9-27**] 05:15PM BLOOD Hct-30.1*
[**2175-9-27**] 06:30AM BLOOD WBC-10.0 RBC-3.79* Hgb-9.2* Hct-28.7*
MCV-76* MCH-24.2* MCHC-31.9 RDW-19.1* Plt Ct-335
[**2175-9-26**] 03:57PM BLOOD Hct-27.5*
[**2175-9-26**] 05:13AM BLOOD WBC-8.6 RBC-3.76*# Hgb-9.1*# Hct-28.3*#
MCV-75*# MCH-24.1*# MCHC-32.1 RDW-18.6* Plt Ct-307
[**2175-9-25**] 04:30PM BLOOD WBC-7.8 RBC-2.49*# Hgb-5.1*# Hct-17.0*#
MCV-68*# MCH-20.6*# MCHC-30.2* RDW-15.5 Plt Ct-459*
[**2175-9-25**] 04:30PM BLOOD Neuts-73.0* Lymphs-21.4 Monos-4.5 Eos-0.4
Baso-0.7
[**2175-9-25**] 04:30PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-3+ Polychr-1+ Spheroc-OCCASIONAL
Ovalocy-NORMAL Tear Dr[**Last Name (STitle) **]1+ Fragmen-OCCASIONAL Ellipto-OCCASIONAL
[**2175-9-27**] 06:30AM BLOOD PT-17.2* INR(PT)-1.5*
[**2175-9-26**] 05:13AM BLOOD PT-21.0* PTT-36.2* INR(PT)-2.0*
[**2175-9-25**] 04:30PM BLOOD PT-38.5* PTT-42.8* INR(PT)-4.0*
[**2175-9-25**] 04:30PM BLOOD Ret Man-3.8*
.
Chemistries:
[**2175-9-28**] 06:35AM BLOOD Glucose-122* UreaN-7 Creat-0.6 Na-139
K-3.6 Cl-103 HCO3-27 AnGap-13
[**2175-9-27**] 06:30AM BLOOD Glucose-166* UreaN-7 Creat-0.6 Na-139
K-3.1* Cl-100 HCO3-28 AnGap-14
[**2175-9-26**] 05:13AM BLOOD Glucose-149* UreaN-22* Creat-0.7 Na-136
K-3.6 Cl-97 HCO3-29 AnGap-14
[**2175-9-25**] 04:30PM BLOOD Glucose-179* UreaN-32* Creat-0.9 Na-131*
K-4.6 Cl-94* HCO3-24 AnGap-18
[**2175-9-25**] 04:30PM BLOOD ALT-13 AST-14 LD(LDH)-171 AlkPhos-60
TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2175-9-28**] 06:35AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.5*
[**2175-9-27**] 06:30AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.6
[**2175-9-26**] 05:13AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.7
[**2175-9-25**] 04:30PM BLOOD TotProt-6.4 Albumin-3.9 Globuln-2.5
Calcium-9.3 Phos-4.7* Mg-1.5* Iron-7*
[**2175-9-25**] 04:30PM BLOOD calTIBC-517* Hapto-171 Ferritn-2.9*
TRF-398*
.
Antibodies:
[**2175-9-28**] 06:35AM BLOOD IgG-729
[**2175-9-27**] 06:30AM BLOOD IgA-271
[**2175-9-27**] 06:30AM BLOOD tTG-IgA-8 antiDGP-3
[**2175-9-26**] 05:38AM BLOOD Lactate-1.4
.
[**2175-9-25**]: ECG:
Sinus rhythm. Indeterminate axis. Low limb lead QRS voltage. Low
inferolateral lead T wave amplitude. Findings are non-specific.
Since the
previous tracing of [**2175-7-4**] ventricular ectopy is absent and
precordial
lead T wave changes appear decreased.
.
[**2175-9-27**]: Duodenal Mucosal Biopsy:
1. Chronic duodenitis with gastric surface mucous metaplasia.
2. Normal villous pattern. No shortening or increased
intraepithelial lymphocytes are seen.
.
[**2175-9-27**]: Upper Endoscopy:
#Esophagus:
Lumen: A sliding small size hiatal hernia was seen. No
esophagitis noted.
#Stomach:
Excavated Lesions A single non-bleeding erosion was noted in
the pylorus.
#Duodenum:
Mucosa: Diffuse continuous nodularity, scalloping, and mosaic
appearance of the mucosa with no bleeding and scalloping folds
were noted in the whole examined duodenum compatible with Celiac
disease. Cold forceps biopsies were performed for histology at
the duodenum.
.
Impression:
Small hiatal hernia
Erosion in the pylorus
Nodularity, scalloping, and mosaic appearance in the whole
examined duodenum compatible with Celiac disease (biopsy)
Otherwise normal EGD to third part of the duodenum
.
[**2175-9-27**]: Colonscopy:
Findings:
-Flat Lesions A few angioectasias that were not bleeding were
seen in the cecum.
-Excavated Lesions Several non-bleeding diverticula were seen in
the descending colon and sigmoid colon.
.
Impression:
Angioectasias in the cecum
Diverticulosis of the descending colon and sigmoid colon
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
#Anemia: was likely the cause of her dizziness and fatigue. Iron
studies and MCV were consistent with iron deficiency likely [**2-28**]
chronic blood loss. Haptoglobin, LDH, Tbili, Dbili were normal
and were not consistent with hemolysis. Lactate was normal and
not consistent with bowel ischemia. In the MICU she was
transfused 3 units of blood. Her hematocrit trended from 17->
28.3->27.5. On transfer to the floor, vital signs were stable
and she showed no signs of ongoing bleeding. Stool gauic was
positive.
.
#. H/O DVT: Pt had DVT in [**4-5**] after l first toe amputation. Had
been on coumadin tx for anti-coagulation. INR on admission was 4
and was reversed to 2 with vitamin K. Patient has had 4 months
of anti-coagulation and risks of further treatment outweigh the
benefits.
.
#. DM: Her home metformin was held while inpatient but was
restarted on discharge. She was given a diabetic diet and
fingersticks were checked QID FS and she was given humalog
insulin sliding scale
.
#. HYPONATREMIA: As low as 131, normalized over the admission.
Was likely secondary to fluid administration.
.
#. COPD asthma:
-continued on albuterol neb prn for asthma
.
#. HTN: At first , her home atenolol, diovan and HCTZ were held
in the setting of hypotension and possible GI bleed. She was
discharged on atenolol 25 mg once a day (prior dose was 50 mg po
qD) and valsartan 80 mg po BID. Her hydrochlorothiazide was
stopped.
.
#. HYPERLIPIDEMIA: She was continued on simvastatin 40 mg QD,
fish oil.
.
#. ANXIETY/DEPRESSION: She was continued on home cymbalta 30 mg
[**Hospital1 **].
Medications on Admission:
Albuterol PRN
Aspirin 325 mg QD
Atenolol 50 mg QD
Coumadin 2.5 mg QD
Cymbalta 30 mg [**Hospital1 **]
Diovan 80 mg [**Hospital1 **]
Fentanyl 50 mcg patch
Fish oil [**Numeric Identifier 890**] mg [**Hospital1 **]
Flovent 2 puffs [**Hospital1 **]
HCTZ 25 mg QD
Hydromorphone 4 mg Q4-6 hours PRN
Metformin 1000 mg [**Hospital1 **]
Metformin 500 mg QD (in addition to the above)
Simvastatin 40 mg QD
Xalatan eye drops QD
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB,
wheezing.
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cymbalta 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
10. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
14. Omeprazole 40 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*
15. Outpatient Lab Work
[**2175-10-3**]
Check CBC
Fax results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8682**] at [**Telephone/Fax (1) 445**].
16. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary
1. Anemia
2. Gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
1. You were admitted to the hospital because you were having
fatigue and dizziness. You doctor checked your labs and you had
a very severe anemia. You were given several units of blood to
raise the levels of your red blood cells. We tested your stool
for blood and it was positive. We were concerned that you were
bleeding from your gastrointestinal tract. Your colonoscopy
showed that no site of active bleeding. The endoscopy of your
stomach and small intestine showed some inflammation that may
have been the cause of the bleeding. We also took a biopsy. We
are still waiting for the results of this biopsy. You will
follow up with the GI specialists to discuss the biopsy results.
You were started on a medication to help with reducing the acid
in your stomach, and you will need to continue this as an
outpatient. You will need to have your hematocrit checked at
next Tuesday, [**10-3**] at your Primary Care Doctor's
office. The directions for this medication are:
Omeprazole 40 mg by mouth daily
2. The following changes were made to your medications:
STOPPED Coumadin
STOPPED Hydrochlorothiazide
DECREASED aspirin from 325 mg to 81 mg once a day
DECREASED atenolol from 50 mg to 25 mg once a day
3. Unless otherwise indicated, it is very important that you
take your medications as prescribed.
4. It is very important that you keep all of your doctors
[**Name5 (PTitle) 4314**].
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 133**]
Appointment: [**Last Name (LF) 2974**], [**2176-10-5**]:45AM
Department: GASTROENTEROLOGY
When: TUESDAY [**2175-10-17**] at 1 PM
With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital Unit Name **] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: TUESDAY [**2175-10-24**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"250.02",
"272.4",
"V49.72",
"493.20",
"V12.51",
"562.10",
"401.9",
"578.9",
"280.0",
"569.84",
"276.1",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
9342, 9400
|
5748, 7330
|
295, 331
|
9488, 9488
|
2041, 5725
|
11054, 11969
|
1181, 1257
|
7796, 9319
|
9421, 9467
|
7356, 7773
|
9639, 11031
|
1272, 2022
|
240, 257
|
359, 871
|
9503, 9615
|
893, 1019
|
1035, 1165
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,955
| 181,913
|
2893
|
Discharge summary
|
report
|
Admission Date: [**2109-7-13**] Discharge Date: [**2109-8-31**]
Date of Birth: [**2051-9-11**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
sent by primary care physician for bruising, plt 7K
Major Surgical or Invasive Procedure:
PICC line placement
bone marrow biopsy
bronchoalveolar lavage
colonic mucosa biopsy
History of Present Illness:
Pt is a 57 yo male with a PMH significant for HTN, h/o basal
cell carcinoma s/p resection 1 year prior, chronic neck/back
pain presents with pancytopenia. The patient reports that over
the last 2 weeks he has noticed increasing fatigue and weakness.
He states that he has also noticed frequent brusing without
apparent trauma. He states that he went to the beach recently
and noticed several large bruises across his torso. He denied
trauma or injuries, no blood in his stool or urine. They were
associated with sheet soaking night sweats 2-3x/week. Pt has
noted some mild weight loss, deceased appetite, but no pruritis.
The patient also reports a headache that began last Tuesday,
reports that intermittent, throbbing that is located the left
side of his head. He has also had some intermittent nausea, but
not vomiting. The patient went to see his PCP [**Last Name (NamePattern4) **] [**2109-7-12**] due to
his continued brusing. He had blood work performed that showed
pancytopenia and was advised to go to the ED.
.
In the [**Hospital Unit Name 153**] the patient reports feeling well. He has complaints
of mild headache, but no numbness or weakness. He denied fevers
or chills. Hem/Onc had recommending starting ATRA and decadron
tonight.
.
ROS: The patient denies any fevers, chills, vomiting, abdominal
pain, diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity edema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes
Past Medical History:
HTN
s/p basal cell resection(chest 1yr ago)
s/p resection of dermal dysplastic lesion on back
"Irregular heart beat"
s/p Cardiac cath->WNL; no stents or atypical findings.
Neck pain- s/p ACDF 10yrs ago(C4-5
Knee pain - s/p multiple bilateral knee scopes
Back pain
Social History:
Smoke: none
EtOH: [**12-7**] glasses of wine per day
Drugs: none
Married - lives at home with wife
[**Name (NI) **]: disabled secondary to [**Last Name **] problem, previously worked in
QA for [**Name (NI) 14006**] electronics
Family History:
Grandfather with [**Name2 (NI) 499**] cancer. No history of leukemia or
lymphoma
Brother with melanoma/squamous cell of the skin
Mother with stroke at 70 and HTN
Physical Exam:
PE on transfer to BMT:
VS Tmax: 99.2 ??????F Tc: 98.9 ??????F HR 71 BP 108/74 RR 16 SaO2 95% RA
Gen: Pleasant, AOx3, well appearing, well nourished, NAD, stiff
HEENT- NC/AT, EOMI, PERRL, Visual fields full, anicteric, MMM,
no oral erythema or exudates
Neck: supple
Cor-RRR, normal S1 + S2, no m/r/g
Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi
Abd- s/nt, mildly distended,, +BS, no rebound or guarding, no
organomegaly,
Skin- multiple large ecchymosis on is abdomen and upper and
lower ext. in various stages of healing
Extremities/Spine: no CVAT, extremities warm and well perfused,
no clubbing, cyanosis, edema
Neurologic: no focal deficits, CN II-XII grossly intact, [**4-9**]
strength b/l in the upper and lower ext, sensation intact
unremarkable rapid/alternating and finger to nose.
Pertinent Results:
[**2109-8-27**] Barium esophagogram:
IMPRESSION: Normal esophagogram.
.
[**2109-8-23**] Bronchial washings cytology:
Clusters of atypical epithelial cells with enlarged nuclei and
conspicuous nucleoli, favor reactive pneumocytes.
.
[**2109-8-17**] CT chest without contrast:
IMPRESSION:
1. Interval worsening of multifocal consolidative and
ground-glass opacities throughout the lungs bilaterally, as
described above, consistent with progression of a multifocal
infectious process.
2. Unchanged prominent mediastinal nodes.
3. Stable small left pleural effusion.
.
[**2109-8-16**] Ankle xray:
FINDINGS: A frontal and lateral view (note that no mortise view
was
performed) of the right ankle were performed, without evidence
of fracture, effusion, or significant soft tissue abnormality.
Minimal degenerative changes seen at the talonavicular and
intertarsal joints. No significant interval change.
.
[**2109-8-16**] Lower extremity US:
IMPRESSION: No evidence of DVT bilaterally. Small amount of
fluid in the
right medial ankle joint.
.
[**2109-8-15**] Bone marrow cytogenetics:
FISH evaluation for a PML-RARA rearrangement was performed on
nuclei with the Vysis LSI PML/RARA Dual Color, Dual Fusion
Translocation Probe ([**Doctor Last Name 7594**]
Molecular) for PML at 15q22 and RARA at 17q21 and is interpreted
as ABNORMAL. Rearrangement was observed in 31/100 nuclei, which
exceeds the normal range (up to 1% dual rearrangement) for this
probe in our laboratory. A PML-RARA rearrangement is found in
most acute promyelocytic
leukemias (FAB M3).
.
[**2109-8-15**] BM biopsy:
DIAGNOSIS:
- HYPERCELLULAR MARROW FOR AGE WITH MATURING TRILINEAGE
HEMATOPOIESIS.
- DISORDERED MYELOID MATURATION IS PRESENT.
- NO DEFINITIVE MORPHOLOGIC EVIDENCE OF MYELOGENOUS LEUKEMIA
SEEN.
.
[**2109-8-14**] sputum:
Highly atypical squamous cells, suspicious for squamous cell
carcinoma
.
[**2109-8-13**] CT head:
IMPRESSION: Resolving small left occipital intraparenchymal
hemorrhage,
without evidence of new hemorrhage or other acute intracranial
abnormality.
.
[**2109-8-12**] CT chest
IMPRESSION:
1. Technically suboptimal study, nevertheless, with evidence of
bilateral
pulmonary emboli including probable right main pulmonary artery
embolus as
characterized above.
2. Ongoing progression of previously described pulmonary
findings,
characterized on [**7-27**] and [**8-1**]. In light of patient's
clinical
history, these findings may represent progression of infectious
process with some possible component of infarction.
.
[**2109-8-6**] colonic biopsy to eval diarrhea: no abnormalities. CMV
immunostains performed on parts A-D are negative with
satisfactory controls.
.
[**2109-8-1**] CT chest/abd/pelvis:
IMPRESSION:
1. Patchy ground-glass opacities throughout the left upper and
left lower
lobes as well as a few areas in the right lung, differential
includes atypical infectious process versus alveolar hemorrhage;
this appearance is largely unchanged from previous study.
2. No evidence for abscess or acute infectious process.
.
[**2109-7-27**] CT chest without contrast:
IMPRESSION:
1. Slight interval worsening of diffuse ground-glass opacities
in the left
lower lobe and right upper lobe with slight interval improvement
in the left upper lobe. While atypical infectious etiologies (ie
PCP) could have a similar appearance, given bronchoscopy
findings, this is most consistent with ongoing/recurrent diffuse
alveolar hemorrhage.
2. Interval development of multiple small nodular densities in
the bilateral lower lobes. This is not consistent with
hemorrhage, and most likely reflects a superimposed atypical
infectious process. In particular, fungal etiologies should be
considered, as well as a possibility of small septic emboli.
.
[**2109-7-26**] CT head without contrast:
IMPRESSION: Expected evolution of small left occipital
parenchymal hemorrhage without evidence of new hemorrhage or
other acute intracranial abnormality.
.
[**2109-7-19**] CT chest without contrast:
IMPRESSION:
1. Atypical pneumonia or hemorrhage, predominantly left lung.
2. Enlarged left paratracheal lymph node.
.
[**2109-7-15**] Echo:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly 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 structurally normal. Mild to
moderate ([**12-7**]+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2107-1-20**],
the severity of mitral regurgitation is slightly increased (at
least mild on review of the prior study). Biventricular systolic
function remains preserved. Trace aortic regurgitation is also
now present.
.
[**2109-7-13**] CT head: 6 mm left occipital intraparenchymal hemorrhage
with minimal amount of surrounding edema.
.
Labs on admission [**2109-7-13**]:
WBC-2.0*# RBC-2.93*# Hgb-9.6*# Hct-25.7*# MCV-88 MCH-33.0*
MCHC-37.5* RDW-17.1* Plt Ct-7*#
Neuts-35* Bands-0 Lymphs-36 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0
Myelos-0 NRBC-8* Other-29*
Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-2+
Spheroc-1+ Stipple-1+ Tear Dr[**Last Name (STitle) **]1+
PT-15.1* PTT-24.5 INR(PT)-1.3*
Fibrino-108*
FDP-[**Telephone/Fax (1) 14007**]*
Glucose-115* UreaN-18 Creat-1.2 Na-137 K-4.0 Cl-101 HCO3-26
AnGap-14
ALT-19 AST-27 LD(LDH)-403* AlkPhos-75 TotBili-0.7
Cholest-305*
UricAcd-7.1*
Calcium-8.9 Phos-3.4 Mg-2.1 UricAcd-6.4
VitB12-1404* Folate-13.4
Triglyc-627* HDL-46 CHOL/HD-6.6 LDLmeas-117
HIV Ab-NEGATIVE
Triglyc-627* HDL-46 CHOL/HD-6.6 LDLmeas-117
.
Micro:
[**2109-8-30**]:
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
Site: PENIS
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2:
positive for HSV2
.
[**2109-8-29**]: RPR non-reactive
.
[**8-23**], [**8-22**], [**8-20**], [**8-17**], [**8-16**], [**8-15**], [**8-14**], [**8-13**], [**8-12**], [**8-10**], [**8-8**],
[**8-6**], [**8-5**], [**7-26**], [**7-25**]: blood cx negative
[**8-23**], [**8-15**], [**8-8**]: urine cx negative
[**2109-8-23**]: CMV viral cx negative
[**2109-8-17**]: fungal cx positve for Aspergillus versicolor, negative
for Legionella, negative for acid fast bacilli
[**2109-8-16**]: No Antibody to B. BURGDORFERI DETECTED BY EIA
[**2109-8-7**]: no virus isolated from Respiratory Viral Screen &
Culture, Source: Nasopharyngeal swab
[**2109-8-5**]: stool viral cx negative
[**2109-8-2**]: CMV VL negative
[**8-1**], [**7-28**], [**7-27**], [**7-26**]: stool neg for Cdiff
[**2109-7-25**]: BRONCHOALVEOLAR LAVAGE negative for respiratory viral
Ag, no CMV
Brief Hospital Course:
57 y/o male who p/w bruising, increasing fatigue, night sweats,
and labs suggestive of low grade DIC, diagnosed with APML, s/p
7+4 induction with cytarabine and daunarubicin then ATRA, in
morphologic CR in bone marrow prior to discharge, with hospital
course complicated by fevers, multifocal pna, bilateral PE's,
?alveolar hemorrhage, atypical squamous cells in sputum, gout,
norovirus diarrhea, and genital HSV2.
.
# APML: given history, started on ATRA initially 50 mg [**Hospital1 **].
After bone marrow biopsy and flow cytometry confirmed suspicion
for APML, patient started 7+4 with daunorubicin and cytarabine.
Pt also started on dexamethasone 10 mg [**Hospital1 **] as prophylaxis
against ATRA syndrome, as on [**7-15**] the patient became short of
breath and CXR showed pulmonary congestion. He was enrolled in
the ECOG low to moderate risk APML protocol, and underwent
sternal bone biopsy. He was started on Cytarabine and
Daunarubicin 7+4 on [**7-17**]. His cell counts dropped subsequent to
this, and he was supported with PRBC and platelet transfusions.
His ATRA was continued until [**7-31**], when it was held due to
severe diarrhea that was thought to be possibly secondary to the
ATRA. ATRA re-started on [**2109-8-6**], when diarrhea was resolving and
noted to be norovirus, as seen by positive EIA. On [**2109-8-15**], BM
biopsy showing no morphologic evidence of myelogenous leukemia.
FISH for PML-RAR interpreted as abnormal, with re-arrangement
seen in 31/100 nuclei. On follow-up, plan to start Arsenic
consolidation.
.
# Intracerebral hemorrhage: pt noted to have 6x6 mm left
occipital intraparenchymal hemorrhage with minimal amount of
surrounding edema. Etiology felt to be plt count of 7 on
admission. No mass effect found. Neurosurgery was consulted,
and recommended keeping supporting platelet count through
transfusions, without other intervention. On repeat imaging
[**2109-8-13**], prior ICH noted to be "resolving small left occipital
intraparenchymal hemorrhage, without evidence of new hemorrhage
or other acute intracranial abnormality. Resolving left
occipital intraparenchymal hemorrhage, now measuring 5 x 2 mm.
No new hemorrhage detected."
.
# Fevers: DDX included elusive infection vs. drug reaction vs.
ATRA side effect. Patient had intermittent fevers throughout
hospitalization, most likely felt to be from multifocal pna vs.
side effect of ATRA, as his microbiology and bronchoscopy
work-up were largely negative. Antibiotics were largely guided
by ID consult, and at various times, included: aztreonam 2g IV
Q8, voriconazole 400mg IV Q12, vancomycin 1g IV Q8, levofloxacin
500mg PO Q24, daptomycin, micafungin, flagyl, bactrim, and
cefepime. Cefepime was later substituted with aztreonam on [**7-31**]
due to development of a drug rash. On discharge, patient had
completed at least a 14 day course of vancomycin and
levofloxacin for HAP. He was afebrile x 4-5 days.
.
# Multifocal pneumonia: imaging showing multifocal consolidative
and ground glass opacities throughout the lungs bilaterally,
consistent with multifocal infectious process, requiring [**Hospital Unit Name 153**]
transfer at one point (on 4-5L NC). Clinical picture worsened
while patient's counts were coming back. Suspected that as
patient's counts recover, he may be mounting more of an immune
response to underlying pulmonary infectious process. PCP was
less likely given only one side of the lungs was affected, but
he was started on bactrim therapy as well. While in the [**Hospital Unit Name 153**],
the patient was placed on now Day 4 Vanco/aztreonam/voriconazole
and Day 3 levaquin but cultures had been negative. He never
required intubation and was weaned off of O2 without difficulty.
Patient completed extensive antibiotic regimen (as noted above),
and completed at least 14 day course of vancomycin and
levofloxacin. Given his aspergillus versicolor positive fungal
culture on [**8-17**], patient will continue PO voriconazole 400 mg
Q12 for 11 more days on discharge.
.
# Atypical squamous cells in sputum: noted on [**2109-8-14**] sputum
sample. Evaluated by bronchoscopy, ENT, and barium swallow.
Bronchoscopy washings for cytology done [**2109-8-23**] showing
"clusters of atypical epithelial cells with enlarged nuclei and
conspicuous nucleoli, favor reactive pneumocytes." ENT
evaluation did not reveal any mucosal changes. Barium
esophagogram on [**2109-8-27**] normal. Patient declined evaluation with
EGD.
.
# Bilateral PE's: pt became hypoxic, and diagnosed with PE as
seen on [**2109-8-12**] imaging study. Pt started on heparin gtt, and
transitioned/discharged on lovenox. He was oxygenating well on
room air for several days prior to discharge.
.
# Gout: patient developed R ankle joint pain, mild erythema, and
warmth in RLE. LENI's negative. R ankle imaging showed no fx,
effusion, or soft tissue abnormality. Rheumatology was consulted
and performed joint tap, which was negative for septic
arthritis/infection and no crystals were noted. Initially
questioned hemarthroses. Patient subsequently developed L great
toe pain, with erythema and warmth, suggestive of podagra. He
was started on prednisone 40 mg, with taper, as treatment for
gout, with improvement. This taper will continue on discharge.
.
# Diarrhea: not felt to be Cdiff given three to four negative
Cdiff samples. Initially ATRA held from [**Date range (1) 14008**] (due to large
volume diarrhea >5L/day). ATRA re-started when patient's
diarrhea resolved. Of note, stool sample returned positive for
norovirus EIA. Repeat norovirus EIA several days later was
negative.
.
# Hemoptysis/alveolar hemorrhage: bronch [**7-25**] for hemoptysis
showed increasingly bloody return suggestive of ?alveolar
hemorrhage, although CT with predominant pathology in left lung
which would be unusual for DAH. Initially ATRA side effect
suspected, but this seems less likely given the unilateral
distribution. Initially started on IV steroids, and then
tapered, with clinical improvement and resolution of hemoptysis.
.
# Chronic back pain - continued home oxycodone and oxycontin
.
# Rash - the patient developed a diffuse morbilliform rash on
his buttocks, inguinal region and his back that was consistent
with a drug reaction. Cefepime was thought to be the most
likely cause, and was discontinued. The patient was given sarna
lotion which improved the pruritis.
.
# Genital HSV2: patient noted to have three lesions on the penis
concerning for HSV vs. syphilis. RPR negative. Dermatology
performed skin biopsy, and lesions were DFA positive for HSV2.
Patient started on valtrex 1 g [**Hospital1 **] until resolution of all
lesions. He is then to continue suppressive regimen of 500 mg
[**Hospital1 **] while immunosuppressed. Patient was counselled on
transmission and implications of HSV.
Medications on Admission:
**Narcotics agreement**
Doxycycline 100mg daily (for blepharitis)
HCTZ 25mg daily
Oxycodone 10mg daily
Oxycontin 10-20mg [**Hospital1 **]
Sertaline 100mg daily
Viagra 100mg prn
Blephamide(dose unknown)
Diovan 160mg daily
Ambien 5mg at bedtime
Discharge Medications:
1. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC,
non-heparin dependent: Flush with 10 mL Normal Saline daily and
PRN per lumen.
2. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg
Subcutaneous Q12H (every 12 hours) for 30 days: please dispense
pre-filled syringes.
3. Voriconazole 200 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 11 days.
Disp:*44 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for prn constipation.
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for acute gout.
Disp:*20 Tablet(s)* Refills:*0*
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia. Disp:*20 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*20 Tablet Sustained Release 12 hr(s)* Refills:*0*
10. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4 hours as
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
11. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
12. Prednisone 5 mg Tablet Sig: 4 tablets daily for 3 days, then
2 tablets daily for 3 days, then 1 tablet daily for 3 days, then
stop Tablets PO once a day. Disp:*21 Tablet(s)* Refills:*0*
13. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for anxiety, insomnia. Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
PRIMARY:
1. acute promyelocytic leukemia
.
SECONDARY:
1. multifocal pneumonia
2. gout
3. pulmonary embolus
4. genital herpes simplex virus type 2
Discharge Condition:
good, without shortness of breath, ambulating well, tolerating
food without difficulty, pain controlled
Discharge Instructions:
You were admitted to [**Hospital3 **] Hospital and diagnosed with
acute promyelocytic leukemia after bone marrow biopsy. You
completed a regimen called 7+4 with cytarabine and daunarubicin.
You also started and completed treatment with a medication
called ATRA. You will begin your next therapy with Arsenic with
Dr. [**Last Name (STitle) 410**] starting Monday, [**2109-9-2**]. Your hospital course was
complicated by multifocal pneumonia, for which you completed an
antibiotic course; gout, for which you will be placed on a
prednisone taper; atypical squamous cells in the sputum, which
will be re-evaluated by the pulmonary team; pulmonary embolus,
for which you will be on lovenox; and genital herpes simplex
virus, for which you will be on valtrex.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- stop hydrochlorothiazide
- stop sertraline
- stop sildenafil until genital lesions resolve
- stop valsartan
- increase oxycontin to 30 mg by mouth twice a day
- increase oxycodone to 5-10 mg by mouth every 4 hours as needed
for pain
- start valtrex 1000 mg by mouth twice a day until genital
herpes lesions are gone. then start 500 mg by mouth twice a day
until chemotherapy completed.
- start prednisone 20 mg by mouth for 3 days, then prednisone 10
mg by mouth for 3 days, then prednisone 5 mg by mouth for 3
days, then stop (treatment for acute gout)
- start ibuprofen 400 mg three times a day as need for gout pain
- start lovenox 100 mg subcutaneous injection twice a day
- start voriconazole 400 mg by mouth every 12 hours (end date
[**2109-9-10**])
- start protonix 40 mg by mouth daily
- start bactrim 1 tablet by mouth daily
- start senna 1 tablet by mouth twice a day as needed for
constipation
- start colace 1 tablet by mouth twice a day as needed for
constipation
- start ativan 0.5 mg tablet by mouth every 4-6 hours as needed
for anxiety, insomnia
Followup Instructions:
Please attend the following appointments below. In addition, you
have an appointment with Dr. [**First Name (STitle) **] (Dermatology) on [**2109-9-12**] at
10:45 AM. Please call [**Telephone/Fax (1) 1971**] if questions arise regarding
this appointment. You are to call [**Telephone/Fax (1) 457**] to arrange for an
appointment in 2 weeks with Dr. [**Last Name (STitle) 724**]. Finally, you will have a
pulmonary/lung appointment in [**2-6**] months time for repeat
bronchoscopy with non-contrast CT scan of chest. They will call
you and inform you of the appointment date and time. If you do
not hear from them in the next 48-72 hours, please call Dr. [**Name (NI) 14009**] office at [**Telephone/Fax (1) 3241**].
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2109-9-2**] 9:30
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2109-9-2**] 9:30
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2109-9-2**] 11:30
Completed by:[**2109-9-6**]
|
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"V70.7",
"284.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"45.25",
"81.91",
"41.31",
"38.93",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
19490, 19542
|
10515, 17306
|
329, 414
|
19732, 19838
|
3540, 5426
|
21744, 22963
|
2543, 2707
|
17599, 19467
|
19563, 19711
|
17332, 17576
|
19862, 20635
|
2722, 3521
|
20655, 21721
|
238, 291
|
442, 1996
|
8663, 10492
|
2018, 2283
|
2299, 2527
|
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