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Discharge summary
|
report
|
Admission Date: [**2179-7-28**] Discharge Date: [**2179-11-24**]
Date of Birth: [**2136-1-30**] Sex: F
Service: SURGERY
Allergies:
ATRIPLA / Morphine / Percocet
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
right-sided hepatic hydrothorax
Hepatitis C
HIV
Major Surgical or Invasive Procedure:
[**2179-8-17**]: liver transplant
[**2179-9-29**]: Combined liver and kidney ransplant
[**2179-10-6**]: transplant kidney biopsy
tunnelled HD line (now removed)
picc line
nasointestinal tube placement (multiple reinsertions)
Paracentesis
Thoracentesis
[**2179-11-4**]: percutaneous liver biopsy
ureteral stent removal [**2179-11-6**]
[**2179-11-18**]: Transjugular liver biopsy
History of Present Illness:
43 year old woman with hepatitis C cirrhosis (complicated by
ascites, encephalopathy, portal hypertensive gastropathy, grade
1 varices, hepatic hydrothorax, elevated AFP without focal liver
lesions) and HIV who presents with increased shortness of breath
.
She has recently experienced increasingly rapid reaccumulation
of her hepatic hydrothorax, requiring 3 weekly thoracenteses
since [**2179-5-23**]. She was admitted to [**Hospital 794**] Hospital
yesterday with SOB and increased O2 requirement. They did a 2
liter thoracentesis and admitted her because her Cr was up to
1.5 from 1.0, K 5.9 and her WBC is up to 20 from 7.8. She
received IVF and albumin for ARF but this continued to worsen
and her Cr was 1.9 prior to transfer. In term of her presumed
infection they are unsure of the source and unfortunately they
didnt send the fluid from the [**Female First Name (un) 576**] for cell count or culture
but did a paracentesis to evaluate for SBP. She was given
ciprofloxacin IV initially but this was later broadened to
cefotaxime and vancomycin.
.
On arrival to the floor, she states she is feeling well but is
still having baseline mild abdominal pain.
.
ROS: (+) baseline abdominal pain. Nausea, vomiting at OSH in the
setting of narcotic medications.
Denies fever, chills, headache, sore throat, cough, shortness of
breath, chest pain, dysuria, hematuria.
Past Medical History:
Hepatic hydrothorax
HIV: (CD4 303, VL ND [**2179-4-28**])
- diagnosed [**2157**], presumed from IVDU versus sexual transmission
from husband, who was long-term IV drug user
Hepatitis C cirrhosis
- diagnosed [**2176**]
- complicated by ascites, encephalopathy, portal hypertensive
gastropathy, grade 1 varices, hepatic hydrothorax, elevated AFP
without focal liver lesions
h/o necrotizing fascitis [**2163**] (complication of dog bite)
Pulmonary nodule, noted [**3-/2178**], 0.7cm
PSH:
- Liver transplant [**2179-8-17**]
- Liver/kidney transplant [**2179-9-29**].
- [**2179-10-7**] Exploratory retroperitoneal exploration
and revision ureteral anastomosis, evacuation of hematoma,
removal of packing.
Social History:
The patient lives with her mother and does not work due to
disability. She has a 20 year old daughter. She very
occasionally used to smoke tobacco and last smoked two years
ago. The patient reported that she stopped consuming alcohol ~3
years ago. History of other substance use includes IVDU (stopped
[**2156**]), cocaine and mushrooms, no current use.
Family History:
Mother alive & well but suffers from high blood pressure and
hyperlipidemia. Father died in [**2173**] from Parkinson's disease and
had h/o MI.
Physical Exam:
VS - Temp 97.9F, BP 108/66, HR 88, R 18, O2-sat 100% RA
GENERAL - Well-appearing woman in NAD, comfortable, appropriate,
AO x3
HEENT - EOMI, sclerae mildly icteric, MMM, OP clear
NECK - Soft, supple, LAD
LUNGS - CTA on left, decreased BS [**11-21**] of the way up on right, no
wheezing/rales, respirations unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, TTP RUQ, mild ascites with palpable fluid
wave, no masses, no rebound/guarding
EXTREMITIES - WWP, 2+ edema up to knees bilaterally, +DP/PT
pulses,
SKIN - no rashes or lesions, spider angiomas across upper chest
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength
grossly intact, no asterixis
.
Pertinent Results:
On Admission: [**2179-7-28**]
WBC-13.9*# RBC-2.29* Hgb-8.2* Hct-26.1* MCV-114* MCH-35.6*
MCHC-31.3 RDW-18.1* Plt Ct-55*
PT-22.8* PTT-48.0* INR(PT)-2.1*
Glucose-85 UreaN-42* Creat-1.6* Na-126* K-4.0 Cl-99 HCO3-20*
AnGap-11
ALT-69* AST-125* LD(LDH)-268* AlkPhos-154* TotBili-9.1*
Albumin-2.7* Calcium-7.6* Phos-3.0 Mg-2.3
At time of liver transplant: [**2179-8-17**]
PT-31.4* PTT-76.1* INR(PT)-3.4*
Glucose-318* UreaN-39* Creat-1.9*# Na-143 K-3.9 Cl-103 HCO3-19*
AnGap-25*
ALT-463* AST-896* CK(CPK)-217* AlkPhos-44 Amylase-59
TotBili-5.4*
DirBili-2.1* IndBili-3.3
At time of combined liver/kidney transplant [**2179-9-29**]
Glucose-75 UreaN-43* Creat-1.5* Na-136 K-4.8 Cl-99 HCO3-26
AnGap-16
ALT-162* AST-268* AlkPhos-1156* TotBili-20.9*
HBsAg-NEGATIVE HBcAb-NEGATIVE HBsAb-POSITIVE
At time of discharge to rehab: [**2179-11-24**]
WBC-4.7 RBC-3.73*# Hgb-11.1*# Hct-33.5*# MCV-90# MCH-29.8
MCHC-33.2 RDW-26.4* Plt Ct-338
PT-15.0* PTT-42.8* INR(PT)-1.3*
Glucose-114* UreaN-47* Creat-0.9 Na-133 K-3.9 Cl-99 HCO3-23
AnGap-15
ALT-34 AST-77* AlkPhos-1104* TotBili-17.2*
Albumin-2.3* Calcium-7.9* Phos-4.6* Mg-1.8
Cyclspr-214
Brief Hospital Course:
43F with history of Hep C cirrhosis (complicated by ascites,
encephalopathy, portal hypertensive gastropathy, grade 1
varices, hepatic hydrothorax, elevated AFP) and HIV (CD4 303 in
early [**2179-4-20**])who transferred from [**Hospital 794**] Hospital with SOB
[**12-22**] recurrent hepatic hydrothorax, ARF, and leukocytosis [**12-22**] to
now known SBP. She requiring weekly or biweekly thoracenteses
since [**Month (only) 205**]. MELD score in 40s-50s and awaiting transplant.
She was admitted to the medicine service s/p thoracentesis at
the OSH, and was not in respiratory distress on arrival.
Diagnostic paracentesis was done and showed SBP, requiring 5-day
treatment course with Ceftriaxone. Due to increasing
respiratory distress, a thoracentesis was done for 3.3L on [**7-29**],
transudative fluid on analysis. Her post-[**Female First Name (un) 576**] course was
complicated by re-expansion pulmonary edema and tachypnea,
requiring transfer to the SICU for a day. Repeat CXRs from that
point showed only bilateral effusions without recurrence of the
hydrothorax. There was a question of new consolidation on the
post-ICU CXR and an 8-day treatment for hospital-acquired
pneumonia was started with Cefepime/Flagyl/Vancomycin. As her
liver function began to decline precipitously, the decision was
made to leave her antibiotics on-board to prevent any infections
that may prevent her from undergoing surgery while waiting for a
transplant to arrive.
She experienced ARF likely secondary to hepatorenal syndrome.
MELD steadily increased, to a peak of >50. HAART was
discontinued due to worsening renal function. Dialysis was
started. Nutritional status was poor. Anemia was treated with
transfusions every few days.
On [**2179-8-16**] an ECD liver donor was available and she underwent
liver transplant with Roux-en-Y hepaticojejunostomy. Intra-op
course was complicated by hypothermia ([**12-22**] to CVVH), persistent
coagulopathy, prolonged time to HA reperfusion (90 min), delayed
graft function. Over the first 24 hours post-op, she continued
to be coagulopathic with a falling hematocrit along with rising
LFTs (1550/[**2168**], TB 10.9). Liver duplex was normal.
On [**2179-8-18**] she required exploration, hematoma evacuation. Liver
appeared hyperemic but viable with good pulse in the hepatic
artery. Hepaticojej was intact. LFTs continued to rise
(2800/3000, TB 17) and lactate remained elevated. She was
relisted for primary graft non-function on postop day 2.
By POD 6 she was extubated. LFTs were steadily improving
(ALT/AST 170/664, TB13.5) therefore she was delisted from the
transplant list. TBili began to rise from POD 7 reaching 60.8 by
POD 12. Liver duplex demonstrated parvus tardus arterial
waveforms which later resolved.
WBC rose to 17. Blood cultures were sent. On [**8-24**], blood
cultures were positive for enterococcus faecalis vanco
sensitive. Daptomycin and Zosyn were started and continued for
16 days. Rectal swab also isolated VRE. Zosyn was stopped after
~ 6 days subsequent blood cultures were negative.
On POD [**8-30**]: hematocrit and platelets fell precipitously. This
was thought to be passenger leukocyte syndrome, treated with
transfusion of ABO-O PRBCs and ABO-B plasma, platelets,
Rituxamab,and switch to cyclosporin from prograf for possible
HUS.
Liver bx (POD 12)showed prominent ballooning degeneration with
moderate to severe cholestasis, cholangiolar proliferation and
associated mixed inflammation most suggestive of a severe
preservation/reperfusion injury. At this time, she was
relisted for liver transplant (MELD 52) as well as a kidney
transplant.
She experienced an UGIB on POD 20 secondary to bleeding ulcer at
J-J anastomosis. This was clipped endoscopically and 6 units of
PRBCs were given over the next 2 days. She rebled on POD 25. The
ulcer was unable to be re-clipped endoscopically. Only 1U of
PRBCs was needed.
She steadily improved and was transferred out of the SICU after
29 days. T bili decreased slowly and plateaued at 20. She
remained relatively stable while awaiting re-transplant while
dialysis dependent.
On [**2179-9-29**], liver/kidney donor became available. She underwent
standard criteria liver transplant with RNY hepaticojejunostomy
with iliac artery supraceliac conduit to the donor common
hepatic artery ?????? uneventful intra-op course. She also received a
cadaveric renal transplant. Of note, pre-transplant, T and
B-cell crossmatches were positive. After the liver was
re-perfused for approximately 1 hour. Repeat crossmatch
demonstrated a negative T-cell crossmatch and a positive B-cell
crossmatch
Post-operatively, liver began functioning immediately but the
kidney wasn't functioning. The crossmatch was repeated, and
initially unclear, but ultimately determined to be negative. No
ATG was given as she was felt to be too sick at baseline. She
was extubated on [**9-30**] and continued on CVVH. She transferred
out of the SICU.
On [**10-4**], she seized and transferred back to the SICU. Head CT
showed new bifrontal white matter hypodensities with no
significant mass effect. Neurology was consulted and Keppra
started. Recs were to obtain a head MRI. This was done
demonstrating multiple subcortical white matter lesions in both
cerebral hemispheres showing fast diffusion. Differentials
considered were post-transplant lymphoproliferative disorder,
infection, and posterior reversible encephalopathy syndrome.
On [**10-5**], HCT dropped from 30 to 22 after renal bx for delayed
graft function (DGF).
She developed R flank pain with increasing abdominal distension.
CT of abdomen showed massive 28 x 17 x 15-cm right
retroperitoneal heterogeneous hematoma, extending from the right
liver tip inferiorly to the right pelvis; appeared to surround
the transplanted right kidney and displaces the native right
kidney medially. She was taken emergently to the OR by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] who performed retroperitoneal exploration and evacuation
of hematoma. Upon entering the retroperitoneum, a massive amount
of old and fresh blood was encountered. The kidney looked
marginally viable and dusky and soft. The retroperitoneum was
packed with laparotomy sponges and she was temporarily closured.
She transferred to the SICU for correction of the coagulopathy
with 8U PRBCs overnight along with appropriate factors.
On [**10-6**], she returned to the OR for retroperitoneal exploration
with revision of ureteral anastamosis. A massive amount of
fresh blood & clot was evacuated. Upon exposure of the operative
field, the ureter was noted to be dilated. Ureterotomy was made
and with difficulty, a ureteral stent was advanced across the UV
anastomosis; ureterotomy closed. Ureter detached from it??????s
anastomosis to the peritoneum and was then anastomosed to the
bladder over a double-J stent. Retroperitoneum was packed and
hemostasis achieved. Drains were placed and retroperitoneum
closed.
She was extubated 2 days later. Urine output was brisk.
Creatinine decreased. Dialysis was stopped.
Remainder of hospital course by systems:
Neuro:
??????Extensive work-up negative including CSF for JCV, HSV, EBV,
Cryptococcal Ag, HIV VL, bacterial/viral/fungal cx, cytology
??????Negative serum Aspergillus Ag, Cryptococal Ag, Toxo, RPR
??????Ultrasensitive JCV PCR (Dr. [**Last Name (STitle) 2340**]??????s lab) negative
??????Ddx: PML vs CI-related leukoencepholpathy
??????Fk switched to [**Last Name (un) **] and MMF lowered to 250 daily 2 days after
seizure
??????Repeat MRI [**2179-10-16**] (11 days after seizure): decrease in the R
frontal lesion; resolution of the hyperintense signal in the
previously noted lesions
??????No further seizures; maintained on Keppra
??????Brain bx put on hold given improvement brain lesions.
??????Repeatimaging held given ARF
??????Non-con MRI [**2179-11-11**] (POD 43): continued improvement in frontal
lesion; all others resolved (c/w PRES)
GI:
??????AP/TB steadily rose to 450/19 by POD 15
??????Duplex ([**10-11**]): dramatic change in echotexture with radiating
echogenic bands distributed along portal pathways concerning for
vascular compromise
??????CTA ([**10-11**]): short segment HA stricture
??????Angio ([**10-12**], POD 16): focal narrowing in the HA just distal to
the GDA stump; successful stenting
??????AP (1500) continued to rise despite ursodiol, TB fell
??????Bx ([**10-17**], POD 21): Mild portal mixed inflammation with occ
lobular apoptotic hepatocytes c/w early recurrent Hep C without
increased fibrosis, foci of bile duct damage
??????Tube cholangiogram: patent anastomosis but failed to visualize
the L ducts
??????MRCP ([**11-1**], POD 26): no biliary dilatation
??????Liver bx ([**11-3**], POD 28) ?????? AP/TB 1700/7: scattered lobular
apoptotic hepatocytes and associated minimal lobular mononuclear
inflammation c/w with recurrent Hep C; no increase in fibrosis;
interval resolution of portal inflammation and bile duct damage
??????Duplex ([**11-13**], POD 47): Parvus tardus wave forms
??????Tube Cholangiogram ([**11-14**], POD 48): patent but attenuated
intrahepatic ducts
??????Angio ([**11-15**], POD 49):patent stent.
.Continued ASA/plavix
GU:
??????Following revision of ureteral anastomosis, kidney began
working and HD was held
??????Foley was ultimately removed and I/O??????s NR [**12-22**] to incontinence;
followed weights
??????[**2179-10-24**] (POD 25/18): Cr rose to 1.6 (from baseline 0.9-1)
??????Vanco 30, [**Last Name (un) 1380**] 20
??????Foley placed, oliguric
??????Cr 2.0 on POD 27/20
??????HD [**10-28**] - [**11-6**] intermittent
??????Renal bx [**2179-10-28**] (POD 29/22): widespread interstitial edema and
mild diffuse interstitial fibrosis and tubular atrophy; ATN
??????Kidney function improved over the following 3 weeks and HD was
held
-Ureteral stent found to be out of position and in bladder,
removed by urology
ID:
??????[**10-11**] Bactermia: VSE
??????[**10-11**] UTI: Enterobacter ([**Last Name (un) **] Amikacin, Cefepime, [**Last Name (un) **],
Nitrofurantoin)
??????[**10-27**] RP Swab (from re-exploration): VSE
??????[**11-8**] UTI: Resistant Enterobacter ([**Last Name (un) **] to only Amikacin &
[**Last Name (un) **])
-Last day of antibiotics [**2179-11-22**]
Medications on Admission:
Ciprofloxacin 250mg qday (SBP ppx)
Lactulose 30ml tid
Raltegravir 400mg [**Hospital1 **]
Clotrimazole 10mg qid
Ascorbic Acid 1000mg qhs
Spironolactone 100mg daily
Furosemide 40mg daily
Tolvaptan 30mg daily
Emtricitabine-Tenofovir 200-300 mg daily
Caltrate-600 Plus Vitamin D3 600-400 mg-unit [**Hospital1 **]
Discharge Medications:
1. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. epoetin alfa 4,000 unit/mL Solution Sig: One (1) ml Injection
MWF (Monday-Wednesday-Friday).
3. benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed for tooth pain.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: no more than 2 grams per day.
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO QHS (once a day (at bedtime)) as needed for anxiety.
9. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): check TSH in 5 weeks.
10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): frontal brain lesion.
12. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for sbp <110 or HR <60.
14. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO Q72H (every 72 hours): last [**2179-11-22**].
15. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
17. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): see taper schedule.
18. cyclosporine modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours): (Neoral)
trough level every Monday and Thursday am.
19. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hepatic artery stent.
20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): hepatic artery stent.
21. hydromorphone 2 mg Tablet Sig: 0.25-0.5 Tablet PO Q6H (every
6 hours) as needed for pain.
22. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) ml
Injection Q8H (every 8 hours) as needed for nausea.
23. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
24. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-21**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
25. insulin lispro 100 unit/mL Solution Sig: follow printed
sliding scale Subcutaneous ASDIR (AS DIRECTED).
26. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
27. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
28. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
HIV
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Recurrent hepatic hydrothorax
Liver transplant, failure with re-transplant of Liver with roux
en y HJ/kidney
recurrent Hepatitis C cirrhosis
hematoma
ureteral anastomosis breakdown
UTI, enterobacter cloacae
malnutrition
hypothyroid
depression
incision wound
brain lesions, likely calcineurin inhibitor effect vs PML
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Fall risk
Discharge Instructions:
You will transfer to [**Hospital 100**] Rehab
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you experience
any of the following: fever, chills, nausea, vomiting, inability
to take any of your medications, feeding tube clogs, increased
jaundice, increased abdominal distension, incision redness/wound
drainage, decreased urine output, weight gain of 3 pounds in a
day
You will have labs drawn every Monday and Thursday with results
to [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 673**]
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] MD, [**Telephone/Fax (1) 673**], [**Hospital **] Medical Office Building [**First Name8 (NamePattern2) 10357**] [**Location (un) 86**]; Date/Time Monday [**2179-11-29**] @ 9:30 AM.
Completed by:[**2179-11-24**]
|
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"112.0",
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"403.91",
"999.89",
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"511.89",
"456.21",
"041.85",
"E878.0",
"286.7",
"599.0",
"263.9",
"571.5",
"293.0",
"279.51",
"997.5",
"789.59",
"070.41",
"572.3",
"038.40",
"585.6",
"996.81",
"799.4",
"782.4",
"E879.8",
"486",
"584.5",
"V08",
"570",
"780.39",
"518.4",
"998.12",
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"55.24",
"50.11",
"54.12",
"45.34",
"34.91",
"54.91",
"87.77",
"88.47",
"87.54",
"38.95",
"39.95",
"56.74",
"50.59",
"55.01",
"39.50",
"55.69",
"50.51",
"50.13"
] |
icd9pcs
|
[
[
[]
]
] |
18840, 18906
|
5218, 12298
|
338, 717
|
19325, 19325
|
4077, 4077
|
20054, 20336
|
3227, 3372
|
15835, 18817
|
18927, 19304
|
15502, 15812
|
19511, 20031
|
12326, 15476
|
3387, 4058
|
251, 300
|
745, 2114
|
4091, 5195
|
19340, 19487
|
2136, 2839
|
2855, 3211
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,338
| 103,685
|
47938
|
Discharge summary
|
report
|
Admission Date: [**2183-3-2**] Discharge Date: [**2183-3-5**]
Service: MEDICINE
Allergies:
Codeine / Sulfonamides / Penicillins / Vicodin / Quinine Sulfate
/ Nsaids / Ephedrine / Ambien / Trazodone / Remeron
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
painful foot
Major Surgical or Invasive Procedure:
peripheral catheterization x 2
History of Present Illness:
[**Age over 90 **] year old female with severe PVD s/p multiple interventions,
CKD and DM presents to ED with bilateral leg pain worse on left.
Patient states the onset was acute on the day of admission. In
the ED, her left lower extremity was noted to be cold and
pulseless for whcih she was started on Heparin gtt.
As per [**Hospital Unit Name 196**] admission note: Pt last admited 3 months prior for
similar symptoms; she was taken urgently to cath lab where she
was found to have TO of proximal LSFA. Thrombectomy of LSFA
without restoration of flow so TPT and peroneal were
subsequently stented. However, several days later she
complained of episodes of worsened left leg and foot pain.
Intervention at that time included angioplasty to TPT plaque and
thrombectomy of the SFA. Final angiography demonstrated
improved flow, with 10-20% residual stenosis in the SFA and
TPT. The patient was asymptomatic at the time of discharge with
good blood flow to her LLE evident on exam.
.
As documented in our prior admit note, pt has been doing well
since discharge. Morning of admission while standing doing
chores had abrupt unset bilateral LE pain up to her knees. It
lasted several hours and slowly resolved on its own. Has not
had pain like this in the past. Denied any chest pain,
palpitations or dyspnea. Believes her left foot might be a bit
colder then normal. States that her son looked at her legs a few
days prior and said they looked good. Denies any parathesia or
anesthesia. At baseline, able to ambulate around the apt without
much difficulty. Denies classic caludication symptoms but states
that her legs get tired with walking and then get better with
rest. Able to lie flat at night without SOB or leg pain. Pt
denies any ankle edema, palpitations, syncope or presyncope.
.
On review of symptoms, she denied any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She did have extensive echymosis with her last
infuison of heparin. She denies recent fevers, chills or
rigors. All of the other review of systems were negative as not
mentioned above.
.
Admitted to [**Wardname 5010**] Service and underwent LE angiography in AM
which showed Left lower extremity - CFA was normal. The SFA
(left) occluded at the level of stents. The distal vessel has a
PA and distal PT at the foot. The AT was occluded. The distal
vessel was crossed into the PA and baloon angioplasty of the PA
was done. The flow in the PA was improved with the SFA still
ocludded with noted thormbus.
Past Medical History:
# Peripheral Vascular Disease-
[**4-/2181**] occluded stents in the LSFA, occluded trifurcation. The
LSFA stented. PTCA was performed on the L PT and the L lateral
tarsal at that time.
[**1-28**] occluded left SFA + occluded [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 101149**], pt underwent
successful PTCA/PCI of L SFA.
[**9-27**]: LSFA stenting of instent restenosis
[**10-28**]: RSFA stenting
[**11-27**]: thrombectomy of LSFA without restoration of flow. TPT and
peroneal stented. Repeat angiography with angioplasty to TPT
plaque and thrombectomy of the SFA. Final angiography
demonstrated improved flow, with 10-20% residual stenosis in the
SFA and TPT.
# Atrial Fibrillation: s/p AVJ ablation and pacemaker placement
#
# Chronic Kidney Disease: baseline Cr 2.5-3.0
# CHF: followed by [**Doctor Last Name **], mostly LE edema but sometimes also
gets pl effusions and pulm edema, EF [[**2179**]] was 70%; mild LVH,
mild AR, MR and mild pulm HTN, Goal wt around 125
# Diabetes Mellitus: diet controlled
# Glaucoma
# h/o lung nodules unclear Hx not being w/u
# h/o falls: lumbar and cervical spinal stenosis, poor vision
# h/o voice hoarseness
Social History:
Social History:
Patient lives by herself. Daughter is a nurse and one son is a
physician (radiologist). Quit tobacco 45 years ago. No EtOH or
other drug use. Has VNA 5 days per week and help with cleaning
for 3 hours once per week.
Family History:
Family History:
Heart disease, diabetes in her mother and 2 female siblings.
Physical Exam:
VS: BP 137/46 HR 74 T 94.9 RR 14 Sats 94%
.
GENERAL: thin and elderly but comfortable in NAD.
HEENT: Pupiles equal and reactive to light. No JVD appreciated.
CHEST: clear to ausculation anteriorly
CARDIAC: Nondispalced PMI. regular rate and rhythm, [**1-28**]
holosistolic murmur best heard There was a [**1-28**] holosystolic
murmur best at the apex
ABD: BS+, soft, non tender non distended. No hepatomegaly
appreciated.
EXT: Right groin line present. Mild oozing.
Left leg cool, decreased sensation medial aspect of the sole
bilaterally.
Cyanosis and delayed cap refill evident LLE.
.
Pulses:
Right: Carotid 2+ Femoral 1+ Popliteal non DP non PT non
Left: Carotid 2+ Femoral 1+ Popliteal dop DP non PT non
Pertinent Results:
[**2183-3-2**] 12:10PM PT-12.3 PTT-28.0 INR(PT)-1.1
[**2183-3-2**] 12:10PM PLT COUNT-295
[**2183-3-2**] 12:10PM ANISOCYT-1+ MICROCYT-1+
[**2183-3-2**] 12:10PM NEUTS-80.9* LYMPHS-11.8* MONOS-5.1 EOS-1.5
BASOS-0.6
[**2183-3-2**] 12:10PM WBC-9.6 RBC-4.66 HGB-13.4 HCT-39.6 MCV-85
MCH-28.7 MCHC-33.8 RDW-17.2*
[**2183-3-2**] 12:10PM CALCIUM-10.1 PHOSPHATE-4.6* MAGNESIUM-2.5
[**2183-3-2**] 12:10PM estGFR-Using this
[**2183-3-2**] 12:10PM GLUCOSE-137* UREA N-63* CREAT-2.9* SODIUM-142
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-20* ANION GAP-19
[**2183-3-2**] 08:55PM PT-13.1 PTT-133.2* INR(PT)-1.1
.
[**3-3**] CT Head
IMPRESSION: No evidence of acute intracranial pathology,
including no intracranial hemorrhage
.
[**3-3**] Cath
FINAL DIAGNOSIS:
1. Occluded LSFA stents
2. Diffuse below knee disease
3. Likely large thrombotic burden.
4. LLE thromobolysis using TPA
.
[**3-3**] Cath
FINAL DIAGNOSIS:
1. Significant restoration of flow after thrombolysis
2. diffuse, critical LSFA and below knee disease.
3. Successful PTA of the L PT (distal and proximal)
4. Successful stenting of the mid LSFA instent restenosis
5. Successful stenting of the proximal LSFA lesion
6. Successful PTA of the L popliteal
.
[**3-4**] CT Abd/Pelvis
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Large right groin hematoma extending into the medial aspect
of the right thigh.
3. Large right-sided pleural effusion. Moderate left pleural
effusion. These measure relatively high attenuation, and
hemorrhage cannot be excluded. Associated atelectasis, with near
complete collapse of the right lower lobe noted.
4. Nodular opacities are seen at the lung bases. Followup
imaging recommended to document resolution or stability.
5. Single posterior mid-right renal lesion does not meet CT
criteria for simple cyst.
.
[**3-4**]
IMPRESSION: Moderate to large right pleural effusion, possibly
representing hemothorax given history, although moderate
effusion has been present since [**2182-11-22**] CT. Pulmonary
edema.
.
Brief Hospital Course:
The patient was admitted with an ischemic left foot and was
brought to the cath lab for intervention. She underwent
angioplasty and received tPA and stenting with transient
improvement in flow. However, her foot again became pulseless
and ischemic, and she became hypotensive requiring pressers.
Her family (daughter and son) wanted the patient made
comfortable, and expressed that the patient would not wish to
live without her foot. Subsequently the patient's goal of care
was changed to comfort and she was started on a Morphine drip.
She died shortly after this.
Medications on Admission:
Aspirin 325 mg per day
Plavix 75 mg perday.
Toprol 50
Vitamin B12 1000 mcg IM monthly
Lasix 20 mg p.o. daily
multivitamin one tab daily
pilocarpine eyedrops
timolol eyedrops
Trusopt eyedrops
Protonix 40 mg p.o. every morning
Prevacid 15 mg p.o. nightly
Tylenol 500 mg two tabs as needed for pain.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"440.22",
"427.31",
"585.9",
"511.9",
"250.00",
"458.29",
"799.02",
"V45.01",
"440.21",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"99.10",
"00.40",
"00.43",
"00.46",
"00.42",
"88.48",
"38.93",
"39.50",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8271, 8280
|
7325, 7896
|
335, 367
|
8327, 8332
|
5283, 6021
|
8384, 8390
|
4473, 4536
|
8243, 8248
|
8301, 8306
|
7922, 8220
|
6192, 7302
|
8356, 8361
|
4551, 5264
|
283, 297
|
395, 3005
|
3027, 4191
|
4223, 4441
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,043
| 138,040
|
30287+57689
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-11-4**] Discharge Date: [**2111-11-12**]
Date of Birth: [**2079-3-29**] Sex: M
Service: SURGERY
Allergies:
Chantix
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Zollinger-[**Doctor Last Name 9480**] syndrome (gastrinoma in setting of MEN-1
syndrome)
Major Surgical or Invasive Procedure:
[**2111-11-4**]:
1. Classical Whipple resection
2. Open cholecystectomy
3. Intraoperative ultrasound
4. Extended portal lymphadenectomy
History of Present Illness:
This 32-year-old gentleman is well-known to me over the last
year-and-a-half as I have followed him for Zollinger-[**Doctor Last Name 9480**]
syndrome in the setting of MEN-1. When I first met him his
parathyroid and pituitary issues were not yet under control and
he required operations for these in the last few months. These
went successfully and he is under control and now ready to
attack his pancreas-
related disease. Interestingly, when I first met him a
year-and-a-half ago he had no obvious pancreatic neoplastic
disease. However, over the course of this year he has developed
obvious lesions. His gastrin level has been controlled with
Prilosec but he has symptoms when he skips his doses. His
gastrin level has decreased on therapy but has not normalized.
He has manifested with evidence of a 2.5-cm lesion in the head
of the pancreas area as well as multiple other smaller lesions
found on endoscopic ultrasound. A small lesion was seen in the
head of the pancreas less than 1 cm as well as 1
in the body and 1 in the tail. The main large lesion was
octreotide positive and there is also a patent blush of
octreotide activity in the porta hepatis as well.
I had a long discussion with [**Known firstname 3228**] and his wife about his
disease process and the rationale for proceeding with an
operative intervention at this point. The goal would not be
necessarily to achieve eugastronemia, but rather to control
the potential for metastatic spread of his gastrinoma. We
discussed this fact in great depth and I told him that the
burden of disease in the head of pancreas was significant and
would likely require a Whipple's resection but that local
excisional therapy may be possible instead. We also talked about
the distal lesion and I indicated that it was potential that I
might be able to enucleate these at the same setting. However,
we talked in great depth about the possibility of a total
pancreatectomy in order to control all this disease and despite
the fact that he realized these to be neoplastic tumors he was
not willing to consent to a total pancreatectomy at this point
in time. Therefore we intended to do a Whipple's resection with
potential for distal gland enucleation if technically feasible.
Past Medical History:
4 gland parathyroidectomy w/reimplantation of parathyroid tissue
[**7-11**], hypoparathyroidism, transphenoidal pituitary surgery
[**2111-2-11**], hypogonadism, DM, HTN, Hyperlipidemia, Dyslipidemia
Social History:
Married
Plumber
EtOH: rare social occasion
Tobacco: Quit [**2110-4-8**]
Family History:
Mother 53 yrs old: MEN 1 w/ hyperparathyroidism, Zollinger
[**Doctor Last Name 9480**], DM post pancreatectomy, Bipolar depression.
Maternal GF: MEN 1
Maternal Uncle: MEN 1
Paternal GM: DM
Physical Exam:
Pre-op exam:
VS: T 98, HR 60, BP 139/84, RR 20, SpO2 96RA
Gen: NAD, comfortable
CV: S1, S2, no murmurs
Resp: CTAB
Abd: Soft, NT, ND
Ext: No edema
Pertinent Results:
[**2111-11-9**] 05:35AM BLOOD WBC-17.3* RBC-3.43* Hgb-9.9* Hct-28.6*
MCV-84 MCH-28.9 MCHC-34.7 RDW-14.3 Plt Ct-330#
[**2111-11-7**] 06:10AM BLOOD WBC-14.5* RBC-3.52* Hgb-10.1* Hct-29.7*
MCV-84 MCH-28.6 MCHC-34.0 RDW-14.3 Plt Ct-219
[**2111-11-6**] 06:05AM BLOOD WBC-17.2* RBC-3.83* Hgb-10.8* Hct-32.4*
MCV-85 MCH-28.3 MCHC-33.5 RDW-14.5 Plt Ct-199
[**2111-11-5**] 03:04AM BLOOD WBC-11.6* RBC-4.60 Hgb-13.3* Hct-38.0*
MCV-83 MCH-28.8 MCHC-34.9 RDW-14.6 Plt Ct-339
[**2111-11-4**] 07:24PM BLOOD WBC-15.9*# RBC-4.58* Hgb-13.1* Hct-37.2*
MCV-81* MCH-28.6 MCHC-35.3* RDW-14.4 Plt Ct-409
[**2111-11-12**] 09:10AM BLOOD Glucose-135* UreaN-6 Creat-0.6 Na-141
K-3.8 Cl-101 HCO3-32 AnGap-12
[**2111-11-10**] 06:15AM BLOOD Glucose-113* UreaN-7 Creat-0.7 Na-143
K-3.5 Cl-99 HCO3-31 AnGap-17
[**2111-11-9**] 05:35AM BLOOD Glucose-106* UreaN-10 Creat-0.6 Na-140
K-3.5 Cl-100 HCO3-29 AnGap-15
[**2111-11-7**] 06:10AM BLOOD Glucose-139* UreaN-19 Creat-0.8 Na-143
K-4.0 Cl-105 HCO3-29 AnGap-13
[**2111-11-6**] 06:05AM BLOOD Glucose-160* UreaN-24* Creat-0.9 Na-140
K-4.3 Cl-105 HCO3-27 AnGap-12
[**2111-11-5**] 03:04AM BLOOD Glucose-212* UreaN-18 Creat-1.1 Na-137
K-4.1 Cl-101 HCO3-22 AnGap-18
[**2111-11-4**] 07:24PM BLOOD Glucose-153* UreaN-17 Creat-1.1 Na-139
K-4.8 Cl-103 HCO3-22 AnGap-19
[**2111-11-12**] 09:10AM BLOOD Calcium-7.9* Phos-5.0* Mg-1.7
[**2111-11-11**] 05:50AM BLOOD Calcium-7.4* Phos-4.3 Mg-1.9
[**2111-11-10**] 06:15AM BLOOD Calcium-6.9* Phos-5.7* Mg-1.7
[**2111-11-9**] 05:35AM BLOOD Calcium-7.8* Phos-4.6*# Mg-1.7
[**2111-11-8**] 08:05PM BLOOD Calcium-7.0*
[**2111-11-8**] 10:50AM BLOOD Calcium-6.5*
[**2111-11-8**] 06:15AM BLOOD Calcium-6.3* Phos-2.7
[**2111-11-7**] 06:10AM BLOOD Calcium-6.5* Phos-2.0* Mg-2.0
[**2111-11-6**] 06:05AM BLOOD Calcium-7.0* Phos-2.0*# Mg-2.1
[**2111-11-5**] 03:04AM BLOOD Albumin-3.4 Calcium-7.7* Phos-7.6*#
Mg-2.1
[**2111-11-4**] 07:24PM BLOOD Phos-6.0* Mg-1.7
Brief Hospital Course:
This is a 32 year old male with Zollinger-[**Doctor Last Name 9480**] syndrome and
gastrinoma in setting of MEN-1 syndrome. He was admitted to the
West 2A general surgery service and taken to the OR on [**2111-11-4**]
for a classical Whipple resection, open cholecystectomy,
intraoperative ultrasound, and extended portal lymphadenectomy.
Intraoperatively, he had hypertension and desaturations, and so
was kept intubated postoperatively and transferred to the SICU.
On POD#1, he was extubated, then transferred to the floor. He
did well post-operatively and followed the "Whipple" pathway.
Pain: Postoperatively, PCA Dilaudid was started per APS with
good pain control. He was transitioned to oral pain medications
once tolerating a diet.
GI/GU: Postoperatively, he was NPO/IVF with a NGT. On POD#3, the
NGT was removed and his diet was slowly advanced over the next
few days with return of bowel function according to the Whipple
pathway. On POD#4, foley was removed with good UOP. By POD#5, he
was tolerating clears liquids. On POD#6, JP amylase was measured
from both JP drains (drain #1: 65; drain #2: 2241); both drains
were kept in.
His abdomen was soft, nondistended and the incision with staples
was C/D/I. The staples were removed prior to discharge and steri
strips placed. He was tolerating regular food and reported
+flatus and +BM prior to discharge.
Post-op Hyperglycemia: Postoperatively, the patient discontinued
his metformin and was ordered for q4h fingersticks with insulin
according to a sliding scale. His blood sugars were
well-controlled during his hospital stay.
Post-op Hypocalcemia: Postoperatively, the patient's
electrolytes were closely monitored. Calcium was repleted as
necessary, and the patient was restarted on his calcitriol that
was slowly increased during his hospital stay. He was also
started on calcium carbonate 1g TID. By the time of his
discharge, his corrected calcium was normalized on oral calcium.
At the time of discharge on POD#8, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Cabergoline 0.5 (1 tab qMon, 0.5 tab qWed), calcitriol 0.5 mcg
[**Hospital1 **], metformin 1000'', lopressor 50 [**Hospital1 **], omeprazole 40 [**Hospital1 **],
testosterone 200 mg/mL IM q2wks, vit D2
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
3. Cabergoline 0.5 mg Tablet Sig: 1.5 Tablets PO on Sunday ().
Tablet(s)
4. Cabergoline 0.5 mg Tablet Sig: 0.5 Tablet PO qWednesday ().
5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day) as needed for
hypocalcemia.
Disp:*100 Tablet, Chewable(s)* Refills:*2*
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. testosterone
200 mg/mL IM q2wks
11. Vitamin D Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Zollinger-[**Doctor Last Name 9480**] syndrome (gastrinoma in setting of MEN-1
syndrome)
Discharge Condition:
Good
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* VNA nursing services will help you with your JP drain care.
* If you are feeling hypocalcemic (with symptoms such as
numbness, tingling, spasms, twitching, etc.), take your calcium
supplements and contact your endocrinologist.
* Do not continue your metformin. Record your blood sugars
3x/day (fasting in AM, supper, and bedtime). Then bring this
information to your endocrinologist at your follow-up
appointment.
Followup Instructions:
1. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks. Call
his office at ([**Telephone/Fax (1) 2363**] to schedule an appointment.
2. Please follow-up with your endocrinologist Dr. [**First Name (STitle) **]
[**Name (STitle) 10759**] on [**2111-11-20**] at 11:20am. Call her office at
[**Telephone/Fax (1) 1803**] to confirm your appointment.
3. Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to update him
on your recent surgery and adjust your home medications as
necessary. Call his office at [**Telephone/Fax (1) 42666**] to schedule an
appointment.
Completed by:[**2111-11-12**] Name: [**Known lastname 12061**],[**Known firstname **] C. Unit No: [**Numeric Identifier 12062**]
Admission Date: [**2111-11-4**] Discharge Date: [**2111-11-12**]
Date of Birth: [**2079-3-29**] Sex: M
Service: SURGERY
Allergies:
Chantix
Attending:[**First Name3 (LF) 2083**]
Addendum:
After discussion with the patient's endocrinologist Dr. [**First Name (STitle) 12063**]
[**Name (STitle) **], discharge medications were adjusted to the
following per her recommendations: calcium carbonate switched
to calcium citrate 1040mg tabs, 2-3 tabs PO daily for
hypocalcemia.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1066**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2111-11-12**]
|
[
"401.9",
"272.4",
"275.41",
"251.5",
"258.01",
"157.4",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.7",
"40.3",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
11593, 11802
|
5378, 7524
|
357, 495
|
8969, 8976
|
3457, 5355
|
10223, 11570
|
3085, 3276
|
7776, 8763
|
8857, 8948
|
7550, 7753
|
9000, 10200
|
3291, 3438
|
228, 319
|
523, 2757
|
2779, 2979
|
2995, 3069
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,957
| 120,325
|
50673+59275
|
Discharge summary
|
report+addendum
|
Admission Date: [**2134-4-26**] Discharge Date: [**2134-5-5**]
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
R great toe ulcer
Major Surgical or Invasive Procedure:
Right superficial femoral artery to above-knee
popliteal bypass with polytetrafluoroethylene and a composite
right saphenous vein jump graft to the peroneal artery.
History of Present Illness:
Mr. [**Known lastname 105255**] is an 87M w/DM2, CAD who presents with a
nonhealing right great toe ulcer. He is s/p L fem to AK [**Doctor Last Name **]
bypass with PTFE, and jump graft from PTFE graft to left
peroneal
artery using reverse left basilic vein in [**12-14**], and s/p RLE
angiogram and vein mapping [**2134-4-22**]. Patient has had this
nonhealing ulcer for 5 weeks and is followed by Dr. [**Last Name (STitle) 1391**] in
clinic. He denies claudication. He denies fevers, chills,
sweats, SOB, chest pain, abdominal pain, or change in
urinary/bowl habits. Patient would like to proceed with a RLE
bypass procedure.
Past Medical History:
-CAD: Severe 3 vessel disease s/p 3v CABG [**2108**](SVG=>D1=>LAD,
SVG=>OM1=>OM3, SVG= >AM). SVG=>D1=>LAD was stented [**2128**]. Repeat
cath [**7-12**] showed inoperable disease. During admit [**10-12**], had CP
a/w some dynamic ST segment depressions in anterior leads,
medically managed with aspirin, plavix, ACE, imdur, and
betablocker. LVEF >55% on Echo done [**12/2131**]
-Incarcerated paraesophageal hernia s/p laparoscopic repair with
fundoplication in [**10-12**]; associated gastric outlet obstruction
resolved with surgical repair
-Lower gastrointestinal bleed secondary to hemorrhoids and
colonic polyps, admit [**2129-11-20**]
-Hypertension with mild symmetric LVH
-Afib, first noted post-op during [**10-12**] admission post op after
paraesophageal hernia repair, converted to NSR on 11/[**2131**]. Off
coumadin [**2-8**] significant bleeding issues.
-Hyperlipidemia
-Diabetes type II
-By MRI/MRA: left posterior parietal infarct, chronic
periventricular microvascular ischemic changes, moderate disease
resulting in 60-70% stenosis of the right precavernous and
cavernous ICA
-s/p bilateral carotid endarterectomy
-Peripheral vascular disease status post left toe amputation,
followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 105256**] of prostate cancer status post radiation therapy
-Cataracts
Social History:
No history of tobacco, no illicit drugs, no EtOH use. Walks
without a walker at home. Lives with his wife [**Name (NI) 1446**] and son
[**Name (NI) **] who is active in his care. Retired physical therapist,
musician and barber. Independent of ADLs except for showering.
Wife does the bills. He does his own medications and his son
supervises. 3 children, 3 grandchildren and 7 great
grandchildren. Last fell [**10-18**] and was admitted to [**Hospital 2940**]
Family History:
History of MI in mother (death 89), father (death 67).
Physical Exam:
Upon Discharge:
T: 97.9, 57, 132/56, 14, 95 RA
Gen: Comfortable, NAD
Chest: CTAB
Cor: Ireg Ireg, no murmurs, normal S1S2
Abd: Soft, NT/ND
Ext: Long medial thigh incision is C/D/I with staples in place.
There are several blisters paraincisionally that have been
incised and are draining serous fluid. Right big toe superficial
ulcer without exposed bone, erythema
or drainage; well-healed left 1st/2nd toe amps. RLE 1+
nonpitting edema. SILT bilat.
Pulses:
fem [**Doctor Last Name **] DP PT
R - - dop dop
L palp palp dop dop
Pertinent Results:
[**2134-4-26**] 04:20PM BLOOD WBC-4.7 RBC-3.27* Hgb-9.7* Hct-29.9*
MCV-92 MCH-29.6 MCHC-32.3 RDW-13.8 Plt Ct-194
[**2134-4-27**] 07:00PM BLOOD WBC-5.6 RBC-2.52* Hgb-7.4* Hct-21.2*#
MCV-84# MCH-29.5 MCHC-35.0 RDW-16.0* Plt Ct-89*#
[**2134-4-27**] 09:12PM BLOOD Hct-27.4*# Plt Ct-145*#
[**2134-4-27**] 11:35PM BLOOD Hgb-8.6* Hct-24.4*
[**2134-4-28**] 02:41AM BLOOD WBC-4.8 RBC-3.53*# Hgb-10.5* Hct-29.2*
MCV-83 MCH-29.6 MCHC-35.8* RDW-15.7* Plt Ct-115*
[**2134-4-29**] 02:21AM BLOOD WBC-7.0 RBC-3.20* Hgb-9.5* Hct-27.0*
MCV-84 MCH-29.6 MCHC-35.1* RDW-16.0* Plt Ct-115*
[**2134-4-30**] 02:49AM BLOOD WBC-5.9 RBC-2.78* Hgb-8.0* Hct-23.3*
MCV-84 MCH-28.8 MCHC-34.4 RDW-15.6* Plt Ct-115*
[**2134-5-1**] 03:15AM BLOOD WBC-4.5 RBC-2.84* Hgb-8.4* Hct-24.3*
MCV-85 MCH-29.5 MCHC-34.6 RDW-16.4* Plt Ct-123*
[**2134-5-1**] 09:11PM BLOOD Hct-29.1*
[**2134-5-2**] 04:15AM BLOOD WBC-4.9 RBC-3.52* Hgb-10.2* Hct-29.6*
MCV-84 MCH-28.9 MCHC-34.4 RDW-15.9* Plt Ct-139*
[**2134-5-3**] 04:00AM BLOOD WBC-5.5 RBC-3.29* Hgb-9.9* Hct-28.4*
MCV-86 MCH-30.0 MCHC-34.8 RDW-15.8* Plt Ct-166
[**2134-5-5**] 05:13AM BLOOD Hct-28.8*
[**2134-4-26**] 04:20PM BLOOD PT-13.8* PTT-26.1 INR(PT)-1.2*
[**2134-4-27**] 04:15PM BLOOD PT-17.5* PTT-135.3* INR(PT)-1.6*
[**2134-4-27**] 07:00PM BLOOD PT-18.3* PTT-46.4* INR(PT)-1.7*
[**2134-4-28**] 02:41AM BLOOD PT-16.3* PTT-38.7* INR(PT)-1.5*
[**2134-4-27**] 04:15PM BLOOD Fibrino-287#
[**2134-4-26**] 04:20PM BLOOD Glucose-145* UreaN-40* Creat-1.2 Na-139
K-4.1 Cl-104 HCO3-22 AnGap-17
[**2134-4-27**] 07:00PM BLOOD Glucose-183* UreaN-30* Creat-0.8 Na-139
K-3.8 Cl-114* HCO3-20* AnGap-9
[**2134-4-28**] 02:41AM BLOOD Glucose-163* UreaN-26* Creat-0.9 Na-138
K-4.4 Cl-112* HCO3-20* AnGap-10
[**2134-4-29**] 06:35PM BLOOD K-3.9
[**2134-4-30**] 02:49AM BLOOD Glucose-131* UreaN-21* Creat-1.0 Na-138
K-3.7 Cl-104 HCO3-26 AnGap-12
[**2134-4-30**] 01:40PM BLOOD K-4.4
[**2134-5-1**] 03:15AM BLOOD Glucose-105 UreaN-22* Creat-1.1 Na-137
K-4.0 Cl-103 HCO3-29 AnGap-9
[**2134-5-2**] 04:15AM BLOOD Glucose-119* UreaN-25* Creat-1.2 Na-136
K-3.8 Cl-100 HCO3-30 AnGap-10
[**2134-5-3**] 04:00AM BLOOD Glucose-124* UreaN-26* Creat-1.1 Na-138
K-3.9 Cl-102 HCO3-29 AnGap-11
[**2134-5-4**] 04:14AM BLOOD Creat-1.0 K-3.5
[**2134-5-4**] 11:48AM BLOOD Glucose-228* UreaN-24* Creat-1.1 Na-136
K-3.9 Cl-99 HCO3-29 AnGap-12
[**2134-5-5**] 05:13AM BLOOD Glucose-159* UreaN-24* Creat-1.0 Na-136
K-4.0 Cl-103 HCO3-27 AnGap-10
[**2134-4-27**] 09:12PM BLOOD CK(CPK)-120
[**2134-4-28**] 02:41AM BLOOD CK(CPK)-195*
[**2134-4-28**] 05:05PM BLOOD CK(CPK)-186*
[**2134-4-29**] 02:21AM BLOOD CK(CPK)-184*
[**2134-5-1**] 09:11PM BLOOD ALT-16 AST-21 AlkPhos-127* TotBili-0.9
[**2134-4-27**] 09:12PM BLOOD CK-MB-7 cTropnT-0.03*
[**2134-4-28**] 02:41AM BLOOD CK-MB-10 MB Indx-5.1 cTropnT-0.33*
[**2134-4-28**] 05:05PM BLOOD CK-MB-9 cTropnT-0.26*
[**2134-4-29**] 02:21AM BLOOD CK-MB-8 cTropnT-0.18*
[**2134-5-4**] 11:48AM BLOOD CK-MB-3 cTropnT-0.09*
[**2134-5-4**] 06:45PM BLOOD cTropnT-0.06*
[**2134-4-26**] 04:20PM BLOOD Calcium-9.8 Phos-4.4 Mg-2.3
[**2134-4-27**] 07:00PM BLOOD Calcium-7.5* Phos-4.4 Mg-1.4*
[**2134-4-29**] 02:21AM BLOOD Calcium-8.1* Phos-3.9 Mg-1.7
[**2134-5-1**] 03:15AM BLOOD Calcium-7.6* Phos-2.6* Mg-2.0
[**2134-5-3**] 04:00AM BLOOD Calcium-7.6* Phos-2.3* Mg-1.8
[**2134-5-4**] 11:48AM BLOOD Calcium-7.6* Phos-2.0* Mg-3.4*
[**2134-5-5**] 05:13AM BLOOD Calcium-7.8* Phos-2.3* Mg-2.4
Brief Hospital Course:
[**2134-4-26**] Pt was admitted in pre-op antibiotics.
[**2134-4-27**] Day of surgery: right [**Name (NI) 105435**] (Ptfe),Rt.
AKpop-peroneal ( composite vein ) BPG. transfused
intraoopertively six uits packed red blood cell., three FFp and
1 unit platlets.Transfered to ICU intubated. serial
hematocrics. Labile B/p overnight.
[**2134-4-28**] no overnight events. Wean to extubate. Remained in
ICU.Neo gtt wean.
[**2134-4-29**] Transfered to VICU for continued ppostoperative care
when bed avaible. Diuresis continued. diet advanced as
tolerated.
[**2134-4-30**] Cordis changed to triple lumen catheter. Transfered to
VICU.Transfused for Hct. 26.9 Bowel regment.
[**2134-5-1**] pain controlled. tolerating po's. home meds started.
Evaluated by physical thearphy.Will require rehab when
discharged.
04/26-27/09 ambulated to chair today.continued to be followed by
physical thearphy.
[**2134-5-4**] awaiting rehab screening.
[**2134-5-5**] D/C to rehab-stable
Medications on Admission:
plavix 75', [**Month/Day/Year **] 325', metoprolol XL 50', Januvia 50', lisinopril
40', folic acid 1', aspirin 81', MVI, calcium/vit D',
pravastatin
80', folate 1', hydrochlorthiazide 25', norvasc 5', isosorbide
mononitrate ER 30mg'
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: One (1) inj
Subcutaneous ASDIR (AS DIRECTED).
2. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
R great toe ulcer, RLE ischemia
Discharge Worksheet-Discharge Diagnosis-Finalized:[**Last Name (LF) **],[**First Name3 (LF) **],
PA on [**2134-5-5**] @ 1252
R great toe ulcer, RLE ischemia
histroy of hypertensiomn
histroy of dyslipdemia
history of DM2, oral agents
h9istroy of prostate cancers/p chemotx
history of UTI,treated
histroy of hiatal hernia
history of GI bleed [**2-8**] polyps/hemrroids
history of carotid disease s /p bilateral carotid endartectomies
history of coronary artery disease s/p CABG"s [**2108**],s/p PCI
stenting
history of paraesohgeal hernial s/p laperscopic fundoplication
history of perpheral vascular disease,s/p left fem-akpop w PTFE,
jump graft to left peroneal, toe amps
postoperative acute blood loss anemia, transfused
postop respiratory insuffiency , vent supported, extubated
posotoperative hypotension requiring neo gtt, resolved
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-9**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
please follow-up with Dr. [**Last Name (STitle) 1391**] in 3 weeks. Call [**Telephone/Fax (1) 1393**]
to make that appointment
Completed by:[**2134-5-5**] Name: [**Known lastname 17172**],[**Known firstname 1080**] J Unit No: [**Numeric Identifier 17173**]
Admission Date: [**2134-4-26**] Discharge Date: [**2134-5-5**]
Date of Birth: [**2046-11-1**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 231**]
Addendum:
It is important to note that Mr. [**Known lastname **] had a bradycardic
episode on [**2134-5-4**] in which his HR dropped into the 38-40 range
for several hours. This happened soon after he received 25 mg of
lopressor PO. An EKG was recorded at that time, which was
unchanged compared to previous EKGs. His HR returned to his
normal 50-60 range. At this point, his lopressor was
discontintued. He had beeing taking 25mg [**Hospital1 **]. His home dose is
normally 50 mg Toprol XL.
He should be re-evaluated for use of lopressor in the future.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] of [**Location (un) 729**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2134-5-5**]
|
[
"V58.66",
"427.31",
"V10.46",
"V58.67",
"438.89",
"428.0",
"458.29",
"V45.81",
"E942.6",
"414.00",
"427.89",
"V58.69",
"250.00",
"428.32",
"518.5",
"285.1",
"401.9",
"440.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"39.56"
] |
icd9pcs
|
[
[
[]
]
] |
14138, 14364
|
6939, 7907
|
235, 402
|
10219, 10228
|
3541, 6916
|
13070, 14115
|
2900, 2956
|
8191, 9211
|
9327, 10198
|
7933, 8168
|
10252, 12637
|
12663, 13047
|
2971, 2971
|
178, 197
|
2987, 3522
|
430, 1064
|
1086, 2407
|
2423, 2884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,375
| 163,862
|
34843
|
Discharge summary
|
report
|
Admission Date: [**2157-11-6**] Discharge Date: [**2157-11-10**]
Date of Birth: [**2109-9-7**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Loss of lower leg function & urinary retention
Major Surgical or Invasive Procedure:
Lumbar decompression & fusion
History of Present Illness:
48 y RHM former steel worker with history of renal cell
carcinoma. On [**2157-11-4**] Mr. [**Known lastname **] fell , he hurt his right leg and
left arm. A month prior to the cyberknife treatments he had an
episode where by he was "bear hugged" by a stranger, and ever
since then his back has been getting progressively worse. He was
admitted to [**Hospital1 18**] after MRI showed Progressive collapse of the
L2 vertebral body with retropulsed bone and soft tissue
producing severe cauda equina compression.
Past Medical History:
Renal cell carcinoma
GERD
A fib
HTN
Social History:
N/A
Family History:
N/A
Physical Exam:
On Admission:
A+Ox3, NAD
Cardiac: RRR, No M/R/G
Lungs: CTA/B
Abd: soft, non-tender
Lower extremity: [**2-1**] IP, 1-2/5 quads, hamstrings. He was weak
at baseline, but has worsened.
On Discharge:
Bilateral lower extremity: IP 3+/5, Quads 3+/5, [**Last Name (un) 938**] [**4-2**] &
gastroc [**5-2**].
Pertinent Results:
MRI L spine [**2157-11-6**]
CONCLUSION: Progressive collapse of the L2 vertebral body with
retropulsed
bone and soft tissue producing severe cauda equina compression.
Progressive growth of the L3 vertebral metastasis with
enlargement of the left pedicle.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] for bilateral lower extremity
weakness and parasthesias. After MRI of his lumbar spine showed
L2 compression fracture with retropulsion resulting in
compression of cauda equina. He was brought emergently to the
OR for lumbar decompression and fusion. He tolerated the
procedure and was left intubated overnight in the TSICU. Once
extubated, Mr. [**Known lastname **] stable and brought to the general floor.
His pain was controlled with medication and he was started on
lovenox for DVT prophylaxis. He strength began to improve
quickly. Mr. [**Known lastname **] worked with phycial therapy who cleared him
for discharge to rehab facility.
Medications on Admission:
carvedilol 3.125 daily
methadone 7.5mg q4hrs
simvistatin 10mg daily
omeprazole 20mg daily
digoxin 250ug daily
colace 100mg daily
bideprion 150mg daily
prochlorperazine 10 q hs
vicodin 5/325 q6hrs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO daily ().
5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Methadone 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for HR > 90.
11. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Metastatic renal cell carcinoma with metastatic pathologic
fracture of L2 with spinal cord compression and injury.
2. Metastatic renal cell carcinoma.
Discharge Condition:
Stable
Discharge Instructions:
Please keep incision clean and dry. You may shower in 48 hours,
but please do not soak the incision. Change the dressing daily
with clean dry gauze. If you notice drainage or redness around
the incision, or if you have a fever greater than 100.5, please
call the office at [**Telephone/Fax (1) **]. Please resume all home
mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **]
have been given additional medication to control pain. Please
allow 72 hours for refills of this medication. Please plan
accordingly. You can either have this prescription mailed to
your home or you may pick this up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in prescriptions for
narcotics to the pharmacy. If you have questions concerning
activity, please refer to the activity sheet.
Followup Instructions:
Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3648**] PA-C. You have an
appointment scheduled on [**2157-11-29**] at 2.00pm. If you have any
questions, please call [**Telephone/Fax (1) **].
|
[
"427.31",
"733.13",
"197.0",
"189.0",
"530.81",
"401.9",
"344.61",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"77.49",
"77.79",
"81.63",
"03.53",
"81.05",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
3810, 3880
|
1658, 2366
|
366, 398
|
4078, 4087
|
1378, 1635
|
4974, 5207
|
1036, 1041
|
2613, 3787
|
3901, 4057
|
2392, 2590
|
4111, 4951
|
1056, 1056
|
1254, 1359
|
280, 328
|
426, 939
|
1070, 1240
|
961, 998
|
1014, 1020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
36
| 122,659
|
7413
|
Discharge summary
|
report
|
Admission Date: [**2131-5-12**] Discharge Date: [**2131-5-25**]
Date of Birth: [**2061-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Sternal click
Major Surgical or Invasive Procedure:
[**2131-5-15**] Sternal Debridement with Re-wiring
[**2131-5-17**] Emergency resternotomy for cardiac tamponade
[**2131-5-18**] Mediastinal washout/sternal plating/bil. pectoralis
flaps
[**2131-5-24**] PICC line placement
History of Present Illness:
Mr. [**Known lastname 27218**] is a 69 year old male who recently [**Known lastname 1834**] CABG
on [**2131-5-4**] by Dr. [**Last Name (STitle) 914**]. His postoperative course was
relatively uneventful. Since discharge, he has been concerned
about his chest incision. Patient stated he felt a "click" when
he coughed. He also noted a small amount of erythema and serous
drainage. His temperature at home has been at most, 100 F. He
has been short of breath with increasing fatigue and unable to
do his daily chores. Given the above complaints, he presented to
the ED and was subsequently admitted for further evaluation and
treatment.
Past Medical History:
Coronary Artery Disease - s/p recent CABG on [**2131-5-4**]
Chronic Obstructive Pulmonary Disease
Hypertension
History of Syncope
Depression
Benign Prostatic hypertrophy
GERD
Anxiety
Chronic Back Issues
History of Bladder Cancer - s/p Excision and BCG treatment
Social History:
Married, lives with his wife, 5 children. He is a retired truck
driver and currently helps out in his son??????s restaurant.
+tobacco 1ppd x 55 years. Occasional ETOH.
Family History:
Noncontributory
Physical Exam:
Vitals: T 98.3, BP 128/74, HR 94, RR 22, SAT 97 on 3L
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: bibasilar crackles noted
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, 1+ edema,
Pulses: palpable distally
Neuro: nonfocal
Sternum: positive click, no drainage, minimal erythema
Pertinent Results:
[**2131-5-13**] Chest CT Scan: Sternal dehiscence with an extensive
fluid collection extending along the entire length of the
sternum. While this measures simple fluid density, infection
cannot be excluded. Bilateral pleural effusions measuring simple
fluid density.
[**2131-5-17**] Echo: There is a moderate sized pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
[**2131-5-18**] LE U/S: 1. RIGHT LOWER EXTREMITY: Extensive thrombosis
of the right femoral vein along its entire length and no
significant internal flow. 2. LEFT LOWER EXTREMITY: No evidence
for DVT.
[**2131-5-18**] Echo: The right atrium is moderately dilated. A
mass/thrombus associated with a catheter/pacing wire is seen in
the right atrium and/or right ventricle. This mass disappeared
later in the exam. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. The left ventricular cavity is unusually small and
hyperdynamic. There is mild LVH. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. Right ventricular systolic function is
borderline normal. There are simple atheroma in the aortic arch
and the descending thoracic aorta. 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. Moderate to severe
[3+] tricuspid regurgitation is seen. All findings discussed
with surgeons at the time of the exam.
[**2131-5-24**] UE U/S: Persistent areas of intraluminal thrombus in the
left IJ, and within the superficial veins of the left and right
cephalic veins, and new thrombus in the superficial left basilic
vein.
[**2131-5-12**] 05:45PM BLOOD WBC-12.8*# RBC-3.59* Hgb-10.4* Hct-30.1*
MCV-84 MCH-28.9 MCHC-34.5 RDW-15.5 Plt Ct-578*#
[**2131-5-17**] 01:06AM BLOOD WBC-20.1* RBC-2.50* Hgb-7.1* Hct-20.6*
MCV-83 MCH-28.6 MCHC-34.7 RDW-16.0* Plt Ct-601*
[**2131-5-19**] 03:02AM BLOOD WBC-30.5* RBC-3.08* Hgb-9.6* Hct-27.8*
MCV-90 MCH-31.2 MCHC-34.6 RDW-16.2* Plt Ct-188
[**2131-5-25**] 05:18AM BLOOD WBC-11.5* RBC-2.97* Hgb-8.8* Hct-26.3*
MCV-89 MCH-29.5 MCHC-33.3 RDW-15.6* Plt Ct-446*
[**2131-5-12**] 05:45PM BLOOD PT-12.3 PTT-30.4 INR(PT)-1.1
[**2131-5-18**] 10:56PM BLOOD PT-28.1* PTT-80.3* INR(PT)-2.9*
[**2131-5-25**] 05:18AM BLOOD PT-25.2* PTT-30.9 INR(PT)-2.5*
[**2131-5-12**] 05:45PM BLOOD Glucose-102 UreaN-23* Creat-1.5* Na-133
K-4.9 Cl-99 HCO3-26 AnGap-13
[**2131-5-20**] 03:20AM BLOOD Glucose-115* UreaN-21* Creat-1.4* Na-136
K-4.0 Cl-106 HCO3-22 AnGap-12
[**2131-5-25**] 05:18AM BLOOD Glucose-103 UreaN-23* Creat-1.3* Na-136
K-3.5 Cl-99 HCO3-28 AnGap-13
[**2131-5-18**] 06:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES-Negative
Brief Hospital Course:
Mr. [**Known lastname 27218**] was admitted [**5-12**] with sternal instability and
[**Month/Day (1) 1834**] chest CT scan which confirmed sternal dehiscence. It
was also notable for an extensive fluid collection extending
along the entire length of the sternum. He was empirically
started on antibiotics and taken to the operating room on [**5-15**]
for sternal re-wiring. There was no evidence of sternal wound
infection. Postoperatively, he was maintained on antibiotics and
wound irrigation. On [**5-17**] in the early AM, he became acutely
hypotensive and increased his chest tube drainage. Transferred
to the CSRU, Swan placed, and transfused one unit. Emergent Echo
revealed a moderate sized pericardial effusion that appeared
circumferential. His chest was ultimately opened emergently in
the unit for washout, and returned to the OR for complete
washout and a hole in the vein graft was sutured closed. Please
see op reports for surgical details. Following surgery he was
transferred to the with open chest and plastic surgery was
consulted regarding sternal plating. The following day he was
brought back to the operating room for chest closure. Echo done
at that time revealed an acute Pulmonary Embolism/Thrombus in
the RA/RV. This mass/thrombus disappeared later on exam. He then
[**Month/Year (2) 1834**] sternal plating closure/bil. pectoralis flaps done by
plastic surgery. Following surgery he was again transferred back
to the CSRU for invasive monitoring. Argatroban started for
presumed HIT (eventually came back negative) and Hematology
consulted. On [**5-21**] he was weaned from sedation, awoke
neurologically intact and extubated. Following extubation a
bedside swallow study was done, which he initially failed, but
repeated [**5-23**] with improvement. Also on [**5-23**] he was transferred
to the SDU for further care. Extremity U/S revealed thrombus in
his right femoral vein, left IJ, superficial veins of the left
and right cephalic veins, and in the superficial left basilic
vein. On [**5-24**] a PICC line was placed. Although operative wound
cultures were eventually negative, per ID, he will receive 4
weeks of vancomycin for high risk of sternal contamination. He
continued to improve and worked with physical therapy during his
post-op course for strength and mobility. On [**5-25**] he was
discharged to rehab facility with the appropriate follow-up
appointments. Of note, he will remain on Coumadin for DVT/PE for
minimum of 6 months.
Medications on Admission:
lasix 20 [**Hospital1 **]
aspirin 81 qd
plavix 75 qd
lipitor 20 qd
lisinopril 5 qd
lopressor 25 [**Hospital1 **]
detrol 4 qd
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
15. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q12H (every 12 hours) for 1 months: via PICC line.
18. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
21. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please adjust for an INR [**2-10**] (for DVT/PE).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Sternal Instability/Dehiscence - s/p Sternal Re-wiring
Pulmonary Embolism
DVTs of LIJ, Right superficial femoral
PMH: Coronary Artery Disease - s/p recent CABG on [**2131-5-4**],
Chronic Obstructive Pulmonary Disease, Hypertension,
Gastroesophageal Reflux Disease, Anxiety, History of Bladder
Cancer - s/p Excision and BCG treatment
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. PLEASE SHOWER DAILY. No creams,
lotions or ointments to incisions. No driving for at least one
month. No lifting more than 10 lbs for at least 10 weeks from
the date of surgery. Monitor wounds for signs of infection.
Please call with any concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in [**4-12**] weeks, call for appt [**Social Security Number 27220**]
Dr. [**Last Name (un) **] in [**2-10**] weeks, call for appt
Dr. [**First Name (STitle) **] in [**7-17**] days, call for appt [**Telephone/Fax (1) 1416**]
Completed by:[**2131-5-25**]
|
[
"998.11",
"401.9",
"414.01",
"415.11",
"996.72",
"V45.81",
"530.81",
"600.00",
"496",
"V10.51",
"998.31",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.51",
"34.03",
"86.74",
"34.79",
"39.32",
"99.04",
"38.93",
"77.61"
] |
icd9pcs
|
[
[
[]
]
] |
9599, 9671
|
5079, 7553
|
334, 557
|
10048, 10054
|
2167, 5056
|
10393, 10681
|
1710, 1727
|
7728, 9576
|
9692, 10027
|
7579, 7705
|
10078, 10370
|
1742, 2148
|
281, 296
|
585, 1222
|
1244, 1507
|
1523, 1694
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,908
| 108,258
|
43382
|
Discharge summary
|
report
|
Admission Date: [**2111-11-27**] Discharge Date: [**2111-11-29**]
Date of Birth: [**2043-8-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Erythromycin Base / Levaquin / Neurontin / Keflex / Avelox /
Penicillins / Bactrim
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
s/p mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68 year old male who was walking along the side walk when he
tripped and fell over a raised portion of it. He denies LOC at
that time and then went to his car and drove himself to [**Hospital6 4874**]. While there he had imaging done of his
cervical spine, shoulder, right wrist, and left knee which were
all negative. He also had a Head CT which showed a left frontal
SDH measuring 4mm in diameter. he was placed [**Female First Name (un) **] cervical
collar and transferred to [**Hospital1 18**] for further evaluation. Once
here his films were reviewed and a question of a left patellar
fracutre was raised. He complains of left knee and right wrist
pain as well as headache. He denies dizziness, nausea,
vomiting,
difficulty ambulating, changes in bowel or bladder habits that
are new(has a urinary incontinence issue beign followed by Dr.
[**Last Name (STitle) **].
Past Medical History:
Uveitis, Otosclerosis, Urinary Incontinence at times
consisent with urge incontinence, herniated lumbar discs, GERD
Social History:
unknown
Family History:
NC
Physical Exam:
O: T:98 BP: 140/90 HR:92 R:18 O2Sats:98% RA
Gen: WD/WN, comfortable, NAD. laceration above right eye closed
with steri strips
HEENT: Pupils: PERRL bilaterally EOMs full without
nystagmus
Neck: Cervical Collar in place
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-13**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On discharge: Neurologically intact
Pertinent Results:
CT C-SPINE W/O CONTRAST [**2111-11-27**]
No acute fracture or malalignment. Multi-level degenerative
changes.
CT HEAD W/O CONTRAST [**2111-11-27**]
Small acute left subdural hematoma with effacement of adjacent
sulci but no shift of normally midline structures or evidence of
herniation.
CT HEAD W/O CONTRAST [**2111-11-28**]
1. Stable small left frontal subdural hemorrhage. No new focus
of
hemorrhage.
2. Trace left maxillary sinus disease
Brief Hospital Course:
68 y/o M s/o fall presents with L SDH. He was admitted to
neurosurgery for medical observation. Repeat head CT on [**11-28**]
showed a stable L SDH and CT c-spine negative for any fractures.
Patient reported pain in neck when trying to clear c-spine, so
flexion and extension films were ordered.
On [**11-29**] he was stable on the floor ambulating safely with
nursing. A discharge and follow up plan was discussed with the
patient and he will be going home.
Medications on Admission:
Lansoprazole 30mg daily,
Methotrexate every friday, Prednisolone 1gtt each eye [**Hospital1 **], Folic
Acid 1mg daily, Oxybutin ER, Clonazepam
Discharge Medications:
1. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
2. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every
4-6 hours as needed for pain: Do not exceed 4gm of tylenol
daily.
Disp:*40 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:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
L frontal SDH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge 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.
?????? you have been prescribed Dilantin (Phenytoin) for
anti-seizure. You will continue to take this medication for one
week and then stop.
- Refrain from driving for one month. you may resume driving
after you are seen in our clinic with a follow up head CT.
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.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2111-11-29**]
|
[
"E885.9",
"719.46",
"873.42",
"E001.0",
"873.43",
"719.43",
"364.3",
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"854.01",
"E849.5",
"722.10",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4496, 4502
|
3299, 3760
|
370, 377
|
4560, 4560
|
2830, 3276
|
5788, 6248
|
1466, 1470
|
3954, 4473
|
4523, 4539
|
3786, 3931
|
4711, 5765
|
1485, 1729
|
2787, 2811
|
310, 332
|
405, 1285
|
1981, 2773
|
4575, 4687
|
1307, 1425
|
1441, 1450
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,648
| 146,254
|
45027
|
Discharge summary
|
report
|
Admission Date: [**2180-8-5**] Discharge Date: [**2180-8-14**]
Date of Birth: [**2123-3-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57M with HTN, DM Type II, CAD s/p MI in [**2175**], ESRD (baseline Cr
of 6.6) not on HD currently being screened for transplant, who
presented to the ED [**2180-8-4**] complaining of SOB over a few hours,
followed by chest discomfort, nausea, and vomiting. He denied
fevers or chills. He had taken two sublingual NTG tabs at home,
and reported some substernal 8/10 chest pain in the ED. An
initial CXR in the ED showed clear lung fields, however a repeat
demonstrated flash pulmonary edema. BiPAP was tried, however he
did not tolerate it and ended up vomiting. As he didn't tolerate
BiPAP, he was intubated. His BP, 180s SBP in the ED, was
initially controlled with NTG and propofol drips. At the time of
transfer to the CCU, he was changed to fentanyl and midazolam
drips, which made the pt normotensive and comfortable. While in
the ED, he was also treated with morphine 2mg IV, lasix 40 IV x1
and put out 370mL urine over 3 hours. An ASA was given with
EMS. The patient was home alone the night he presented, so it is
possible he did not take his evening BP meds without his
girlfriend around to remind him. Tox screen was negative.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Hypertension
2. CARDIAC HISTORY:
- MI by report in [**2175**]
3. OTHER PAST MEDICAL HISTORY:
- Diabetes Type 2, diagnosed age 40, now on insulin
- CKD with AV fistula placed for potential HD in [**4-18**] but not
yet on HD, creatinine 6.6 mg/dL in [**4-/2180**]
- HTN
Social History:
current smoker
Family History:
Sister: breast cancer age 51
Brother: obesity, [**Name (NI) 21418**]
Father: [**Name (NI) 21418**], died of cancer
Physical Exam:
Initial ED vitals: T 98.1, HR 83, BP 185/95, RR 25, 99% on 3L by
NC
Gen: sedated, comfortable
HEENT: NCAT
Pulm: Coarse breath sounds noted bilaterally
CV: RR, nl S1, S2, +S4, no M/R appreciated
Abd: Soft, hypoactive BS
Ext: 2 + pulses, no cyanosis or edema, +clubbing
Pertinent Results:
[**2180-8-5**] 01:55AM CK-MB-3 cTropnT-0.06* proBNP-[**Numeric Identifier **]*
[**2180-8-5**] 01:55AM CK(CPK)-52
[**2180-8-5**] 01:55AM WBC-13.2* RBC-3.58* HGB-10.0* HCT-28.5*
MCV-80* MCH-28.1 MCHC-35.2* RDW-14.4
[**2180-8-5**] 01:55AM PLT COUNT-197
[**2180-8-5**] 02:10AM GLUCOSE-186* LACTATE-1.1 NA+-141 K+-4.1
CL--100 TCO2-23
[**2180-8-5**] 01:55AM UREA N-63* CREAT-4.8*#
[**2180-8-5**] 01:55AM LIPASE-135*
[**2180-8-5**] 08:32AM TRIGLYCER-166* HDL CHOL-25 CHOL/HDL-3.6
LDL(CALC)-31
[**2180-8-5**] 01:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CXR 2AM [**8-5**] Findings consistent with mild CHF
CXR 4AM [**8-5**] Interval development of pulmonary edema with fluid
overload with upper lobe venous congestion, and fluid in the
minor fissure.
Echo [**8-5**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the basal inferior septum
and basal inferior wall. The remaining segments contract
normally (LVEF = 45-50 %). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild concentric left ventricular hypertrophy.
Regional systolic dysfunction c/w CAD. Mild mitral
regurgitation. Moderate pulmonary hypertension.
ECG [**8-4**] 2AM: normal sinus rhythm with prolonged QT at 422msec.
No ST segment abnormalities noted. Repeat study at 3:30AM showed
a normal QT.
Brief Hospital Course:
57M with DM-II, HTN, CAD s/p MI in [**2175**], and ESRD not on HD who
presented with SOB and CP and had flash pulmonary edema in the
setting of hypertensive urgency in the ED.
.
# CORONARIES: Known CAD s/p MI in [**2175**]. As the pat is new to our
system, his anatomy is unknown to us. During this
hospitalization, pt recieved ASA 325mg PO daily instead of his
usual home 81mg. No acute ECG changes were found during
hospitalization. Cardiac enzymes were followed and ruled out MI.
Lipid panel showed an LDL of 31 and a slightly elevated total
cholesterol of 166, so no statin was started.
.
# PUMP: Pt clinically presented with flash pulmonary edema. Echo
showed EF 45-55%, mild concentric left ventricular hypertrophy,
regional systolic dysfunction c/w CAD, mild mitral
regurgitation, and moderate pulmonary hypertension. Patient was
able to be weaned off the ventilator and successfully extuibated
day 2 of hospitalization. Pt has vigorous response to IV Lasix
initially and was euvolemic for the rest of the admission.
.
# RHYTHM: Patient was in NSR until day 2 of admission when rates
of 140s-150s were seen on tele. ECG showed A Fib. Patient had no
known diagnosis of A Fib. Given his HTN and cardiac disease, it
was felt that the patient likely had undiagnosed paroxysmal A
Fib. He was already on a BBlocker for rate control, and coumadin
was started. INRs were follwed by CCU team and pharmacy. Pt's
PCP made aware of new Dx of A Fib and anti-coagulation. Pt given
a prescription to have INR checked in dialysys the day after
discharge with results to be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital 2082**].
.
# HTN / Hypertensive urgency: Blood pressures were difficult to
control. Clonidine was switched to a patch to prevent rebound
from missing a dose, but ultimately d/c as made pt sommulent.
Able to decrease home dose of hydralazine from 100mg [**Hospital1 **] to 50mg
TID by adding amlodipine 10mg daily. Patient had been titrated
up to max BBlocker dose prior to the initiation of HD, but with
HD the dose was lowered to metoprolol 75mg [**Hospital1 **]. Pt got his home
dose of Lasix as requested by renal, 40mg daily. Renal US showed
no revidence of renal vascular disease as a cause of refractory
HTN.
.
# ESRD: Renal follow the patient throughout admission. Cr rose
from 4.8 to 5.7 ultimately before the initiation of dialysis. Pt
began HD [**8-8**]. Nephrocaps were continues throught admission, and
calcium acetate was started per renal recs. He had three days of
a row of uneventful diaysis, but did experience hypertension
follwing the third HD treatment. During his 4th HD treatment on
[**8-12**], he had an episode of tacycardia into the 120s that resolved
with his usual AM dose of metoprolol. pt is on an afternoon
outpatient dialysys schedule, so will have morning meds on board
prior to dialysis to prevent HTN and tachycardia during HD.
Patient is scheduled for regular Tuesday, Thursday, and Saturday
dialysis at [**Location (un) **] - [**Location (un) 86**] Dialysis Center.
.
# Nausea: Intermittent complaint throughout admission. Normal
ECG and cardiac enzymes during episodes of nausea, so unlikely
an anginal equivalent. Episodes oftern required anti-emetics and
anxiolytics to resolve. The afternoon after the third course of
HD, the patient began to feel nauseated and have shaking chills.
SBP was 190s as he had not recieved his BP meds prior to
dialysis. Pan cultures were negative. Symptoms were managed with
hydralazine, NTG, and Ativan. CT was done to rule out an
intraabdominal infection or process; it showed 2 enlarged
mesenteric lymph nodes, likely reactive. No evidence of
mesenteric ischemia or infection. Patient should have f/u CT in
3 months to re-evalute lymph nodes. No nausea was reported on
day of discharge.
.
# Diabetes: The patient's home dose of Lantus was given during
admission. Elevated blood sugars were covered with sliding scale
humolog. His glucoses were well-controlled throughout admission.
.
# Hepatitis: Hepatitis panels were sent as part of routine
pre-dialysis labs. Hepatitis C antibody was positive. Hep C
viral load was 8,670,000 IU/mL. patietn was instucted to call
[**Hospital1 18**] Liver Clinic to make an appointment for follow up.
Medications on Admission:
toprol XL 300 mg QD, hydralazine 100 mg TID, clonidine 0.2 mg
TID, ASA 81, calcitriol 0.25 mg QG, phoslo 667 TID with meals,
nephrocaps, aranesp monthly, lasix 40 mg QD, hydroxizine 25 mg
TID PRN, chantix, vit D [**Numeric Identifier 1871**] weekly, viagra PRN
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take half ([**2-12**]) a pill on Monday [**8-14**], and then take a
whole pill daily after that.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Physical Therapy
Please evaluate and treat patient for any difficultly in
ambulating independently.
Medical Dx: ESRD on dialysis, hypertension
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertension
Hepatitis C
ESRD on dialysis
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:
Thank you for coming to [**Hospital1 69**]. We
diagnosed a new condition this admission, Hepatitis C. Please
make an appointment to see a liver doctor. You started dialysis
this admission. We discontinued your clonidine; please stop
taking it. We changed your doses of metoprolol (Toprol) and
hydralazine. Please fill the new prescriptions and discard the
old ones. We started 3 new medicines. Amlodipine is for your
blood pressure. Calcium acetate helps your kidney balance the
salts in your body. Coumadin (warfarin) was started because of
an abnormal heart rhythm. It helps prevent blood clots from
forming. It is very important to keep your appointments with
your doctor while on this medicine.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Dialysis tomorrow (Tuesday)
Department: Internal Medicine
Name: Dr. [**First Name (STitle) **] [**Doctor Last Name **]
When: Wednesday [**2180-8-17**] at 1: 15 PM
Address: [**Apartment Address(1) 96275**], [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 54873**]
Department: Cardiology
Name: Dr. [**First Name8 (NamePattern2) **] [**Doctor Last Name 313**]
When: Wednesday [**2180-8-30**] at 11:00
Location: [**Hospital6 **]
Address: [**Location (un) **] 4TH FL, [**Location (un) **],[**Numeric Identifier 13108**]
Phone: [**Telephone/Fax (1) 47675**]
(Reminder that patient has an appointment with Neurology on the
same day at 2:30 PM)
Physical therapy has recommended you go to an outpatient
physical therapist near you. Please call to make an apointment.
You will need to bring the prescription we give you to that
appointment.
It is important that you call the liver clinic to make an
apointment at ([**Telephone/Fax (1) 451**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
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"V58.67",
"305.1",
"518.4",
"414.01",
"583.81",
"412",
"362.01",
"428.33",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
10214, 10220
|
4292, 8562
|
334, 340
|
10305, 10305
|
2319, 4269
|
11300, 12400
|
1893, 2009
|
8874, 10191
|
10241, 10284
|
8588, 8851
|
10487, 11277
|
2024, 2300
|
1609, 1638
|
275, 296
|
368, 1515
|
10320, 10463
|
1669, 1845
|
1537, 1589
|
1861, 1877
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,784
| 190,601
|
37590
|
Discharge summary
|
report
|
Admission Date: [**2112-12-10**] Discharge Date: [**2112-12-20**]
Date of Birth: [**2085-12-3**] Sex: M
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture
Placement of right subclavian central venous line
History of Present Illness:
27M prisoner with history of oxycodone and heroin abuse,
presenting to ED after found altered in his prison cell.
Reports note that for 3 days he has been in the medical unit -
altered with slurred speech, fecal and urinary incontinence.
Also with other abnormal behaviors (talking on a pretend cell
phone). Was noted that since 3 days prior to that (~[**12-4**]) he
has not left his cell. Very little if any food intake x days.
Yesterday evening continued drooling, playing with his feces and
incontinent of urine. Brought to [**Hospital3 4107**] where he was
found to have massive pneumomediastinum (seems to have been
noted on head CT before R subclavian line placement). Also
noted to have leukocytosis to 20K. Received 2gm ceftriaxone,
1gm vanco, and 700mg acyclovir. Head CT normal. LP performed
and showed 10 RBCs and 3 WBCs on tube 4. Tox screen negative.
Flu negative. He was transferred to [**Hospital1 18**] for further
management.
.
In the ED, initial vs were: 98.5 P80 138/65 R30 98% RA. Patient
was given lorazepam (for shaking behaviors), unasyn, and then
zosyn, also getting fluconazole. 3L NS given. Thoracics
consulted. CXR showed subclavian CVL crossing midline, line
then pulled back. Barium swallow showing no evidence of leak
(but anterior wall not fully evaluated). Thoracics not
suspicious of line or esophagus as cause, think more likely to
be related to ?lingular bleb seen on CT. Thoracics recommended
high flow O2, zosyn and fluconazole. Also recommend CT
esophagram with Optiray contrast once barium has passed below
diaphragm.
.
On the floor, patient denies pain or specific complaints.
Tremulous. Does endorse shortness of breath when asked. Denies
headache or neck stiffness or chest pain.
Past Medical History:
- Polysubstance abuse - endorses recent (10 days ago) oxycodone
use - snorting. Endorses history of IVDU - heroin. Endorses
rare marijuana use and cigarette smoking. Denies EtOH use.
- Bipolar disorder
- Anxiety/panic attacks treated with benzos
- Girlfriend reports patient abuses heroin, oxycodone, cocaine,
marijuana, and that he takes up to 50mg Xanax per day.
Social History:
- Tobacco: Occasional smoker.
- Alcohol: Rare per patient
- Illicits: As above.
- Arrested and incarcerated 10 days ago. Prior was living with
his fiancee [**Doctor First Name **] and his 2 year old son.
Family History:
Depression in mother and grandfather
Physical Exam:
On admission:
General: Tremulous, eyes mostly closed. Slightly tachypneic.
Speech slowed though not appreciably slurred.
HEENT: Sclera anicteric, pupils large (6->3) bilaterally, opens
eyes on own but difficulty keeping open when exposed to light.
O2 mask on. Opens mouth only slightly - cannot open past 1-2 cm
despite best efforts. Visualized portions of OP clear.
Neck: JVD not elevated, no LAD, able to bend chin to chest.
able to palpate crepitus above clavicles bilaterally.
Lungs: Clear to auscultation bilaterally, but very poor effort.
Can also hear rub ?crepitus at LLSB with respiratory efforts.
CV: Regular rate and rhythm, normal S1 + S2, soft SM at LLSB.
Abdomen: soft, thin, non-distended, bowel sounds present, mild
diffuse tenderness to palpation. no rebound tenderness or
guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses. R lateral leg with rash
from hip to lower shin on lateral side only - erythematous with
some areas of scabbing, seem most c/w friction/scrape injury.
Neuro: Lethargic but easily arousable. Keeps eyes open only
slightly then closes. Speech slowed, ?slurred, does not open
mouth wide as above. Oriented to 26th, hospital. Knows 1.75 is
7 quarters. Tremulous at rest and more with motions ?spasticity
vs. true rigidity . Strength 5/5 in uppers and lower
extremities, though fatigues very easily with dorsiflexion, less
so with plantarflexion. Sensory grossly intact but poor
participation. 2+ DTRs at [**Name2 (NI) 84351**] and patellae.
Pertinent Results:
Labs at [**Hospital3 3583**]:
CSF tube 4: 10 RBCs, 3 WBCs.
CSF tube 1: 3498 RBCs, 5 WBCs.
CSF tube 2: 77 glucose, 30 protein.
serum WBCs 20.1 (75N 2B, 14L 9M)
Serum: albumin 4.3, AST 61, ALT 25, AP 69, bili total 2.2, CK
[**2102**]
Serum: neg TCAs, neg [**Last Name (LF) **], [**First Name3 (LF) **], EtOH
Urine: 2-5 WBCs, [**2-17**] RBCs, 3+ acetone, 1+ bili, 2+ albumin, SG
1.043
negative for amphetamines, barbs, BZs, cocaine, opiates,
cannabanoids.
Microbiology Data:
Flu negative (OSH)
Admission Labs at [**Hospital1 18**]:
[**2112-12-10**] 08:30AM WBC-18.0* RBC-4.79 HGB-13.7* HCT-39.6* MCV-83
MCH-28.6 MCHC-34.5 RDW-12.9
[**2112-12-10**] 08:30AM PLT COUNT-354
[**2112-12-10**] 08:30AM [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2112-12-10**] 08:30AM FREE T4-1.9*
[**2112-12-10**] 08:30AM TSH-0.95
[**2112-12-10**] 08:30AM OSMOLAL-287
[**2112-12-10**] 08:30AM TOT PROT-6.6 ALBUMIN-4.0 GLOBULIN-2.6
CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-1.9
[**2112-12-10**] 08:30AM ALT(SGPT)-22 AST(SGOT)-55* LD(LDH)-240
CK(CPK)-1386* ALK PHOS-76 TOT BILI-0.8 DIR BILI-0.3 INDIR
BIL-0.5
[**2112-12-10**] 08:30AM GLUCOSE-99 UREA N-21* CREAT-0.8 SODIUM-139
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
[**2112-12-10**] 08:39AM LACTATE-1.3
[**2112-12-10**] 08:30AM cTropnT-<0.01
[**2112-12-10**] 08:30AM CK-MB-30* MB INDX-2.2
[**2112-12-10**] 08:19PM CK(CPK)-967*
C Difficile toxin negative x 3
Imaging:
CT head at OSH: no bleed, hydrocephalus, or mass effect. Tiny
hypodense foci consistent with infarcts, some old and some age
indeterminate due to small size. Subcutaneous emphysema in
visualized pharynx.
CT chest at OSH: Subcutaneous emphysema from skull base to
mediastinum. Some foci between the mediastinum and medial
pleura. One focus posterior to the sternum and anteromedial to
the pleura bilaterally. Otherwise no pneumothorax. No
mediastinal shift. Lungs clear.
CXR at OSH: right subclavian line crosses midline to terminate
in LEFT brachicephalic vein. Pneumomediastinum and subcutaneous
air.
Imaging at [**Hospital1 18**]:
EKG: sinus tach at 96, NANI, QRS 80, QTc 455. No ST changes.
[**2112-12-10**]: Esophagram: No evidence of contrast leakage.
Technically limited study due to suboptimal positioning given
patient's mental status.
[**2112-12-10**] CT Chest:
1. Extensive pneumomediastinum extending into the neck and
abdomen.
2. There is NO extraluminal contrast from the upper GI performed
earlier
today. Small amount of intraluminal contrast is identified.
3. No mediastinal hematoma. Right paratracheal fluid and gas
accounts for
the medial right apical pulmonary opacity identified on chest
radiographs.
[**2112-12-11**] EEG:
This is a mildly abnormal routine EEG in the waking and drowsy
states due to a mildly slow and disorganized background
consisting mostly of theta frequencies. This may be secondary to
a marked drowsiness or encephalopathy or may be suggestive of a
meningitic process. There were no epileptiform features or focal
or lateralized abnormalities.
[**2112-12-11**] CT Head: No acute intracranial pathology.
[**2112-12-11**] CT Chest:
1. No evidence of esophageal injury.
2. Extensive pneumomediastinum, not significantly changed from
prior.
[**2112-12-14**] ECG: Sinus rhythm. Low inferior lead T wave amplitude
is non-specific and tracing may be within normal limits.
Unstable baseline makes assessment difficult. Since the
previous tracing of [**2112-12-10**] there is probably no significant
change but unstable baseline on both tracings makes comparison
difficult.
[**2112-12-14**] CT Abdomen and Pelvis: 1. Normal appendix. 2. Bilateral
symmetric perinephric fluid is unusual in a patient of this age
and of unclear etiology and clinical significance. 3.
Pneumomediastinum, partially imaged.
[**2112-12-14**] CXR: In comparison with the study of [**12-10**], the
extensive gas within the mediastinum, subcutaneous regions, has
cleared. There is no evidence of pneumonia or other acute
cardiopulmonary disease at this time.
[**2112-12-14**] KUB: No evidence of obstruction.
Brief Hospital Course:
27 year old male prisoner with history of polysubstance abuse
who presented with altered mental status, pneumomediastinum, and
leukocytosis.
#. Acute Encephalopathy: He was initially admitted with altered
mental status for 3 days while in prison. Prior to transfer
here from [**Hospital3 3583**], he underwent a lumbar puncture that
was not consistent with meningitis. After admission, he was
started on Acyclovir for HSV treatment before his HSV PCR came
back negative. He underwent head CT that was negative for acute
intracranial process. EEG showed no epileptiform features.
Serum osmolality was normal. Ultimately it was felt that the
most likely diagnosis was medication withdrawal vs ingestion, as
he had been taking very large doses of Xanax and multiple
illegal drugs prior to incarceration. NMS and serotonin excess
were considered less likely given his lack of fever and
hyperadrenergic symptoms, although he did have some muscle
rigidity. He was followed by both the psychiatry and neurology
services, and was started on benztropine for possible dystonic
reaction and clonidine for possible opioid withdrawal.
Benztropine was stopped prior to discharge and clonidine was
weaned. He continued to have some confusion and some myoclonic
jerks, but overall his mental status improved throughout
admission and he was alert and oriented x 3 on discharge. He
was also started on a multivitamin and thiamine.
#. Pneumomediastinum: He was found to have a pneumomediastinum
at the OSH and was evaluated by thoracic surgery after transfer.
It was not clear what the etiology of his pneumomediastinum
was, but his body type is consistent with spontaneous idiopathic
pneumomediastinum. CT esophagram was done and showed no
evidence of esophageal perforation. He was initially started on
Zosyn and fluconazaole for possible esophageal perforation and
to treat a possible mediastinal infection but these were
discontinued as this was considered less likely. He remained
hemodynamically stable and did not require oxygen
supplementation. The thoracic surgery team felt that his
pneumomediastinum would likely be self-limited and follow-up
chest xray showed significant clearing of his pneumomediastinum.
#. Diarrhea: He developed watery diarrhea and stool incontinence
approximately 5 days into hospitalization. It was accompanied
by a new leukocytosis and he was initially empirically treated
for C Diff with oral vancomycin. His lab results came back C
Diff negative x 3 and his antibiotics were discontinued.
Ultimately it was thought that his diarrhea may also be a result
of a withdrawal syndrome.
#. Hypertension: He had significant hypertension during his
hospitalization with SBP in the 160's to 170's. Due to the
combination of this and possible opioid withdrawal, he was
started on low-dose clonidine twice daily. This medication was
tapered to daily and should be eventually discontinued.
#. Leukocytosis: He had a leukocytosis on admission that
resolved with his resolving mental status. Blood cultures and
urine cultures were done which show no growth. His CSF culture
from [**Hospital3 3583**] was negative. He had a recurrent
leukocytosis accompanied by significant watery diarrhea as
above.
#. Acute Renal Failure: He developed acute renal failure with a
creatinine increase from 0.7 to 2.9. The renal service was
consulted and it was felt most likely related to either
Acyclovir administration or contrast-induced. He was given IV
fluids, acyclovir was stopped, and his creatinine trended back
down.
#. Proteinuria and Ketonuria: He had ketonuria on admission that
was felt to be related to low oral intake (starvation ketosis).
He also had proteinuria that improved somewhat with hydration,
but should be followed up as an outpatient.
#. Elevated CK: He had elevated CK on admission that downtrended
to normal range by the time of discharge. It was felt to be
related to the underlying cause of his mental status, with NMS
being considered but felt less likely.
# Code: He was full code during this hospitalization.
Medications on Admission:
- Xanax, per girlfriend he was taking very large doses ("50mg a
day")
- ?doxepin per patient
- ?risperdal per OSH notes, patient denies. Per prison, was
likely taking Restoril
- per prison, prescribed paxil x1 on the 17th but refused; did
receive librium last night.
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day:
This medication should be continued for 2-3 days and then
discontinued if the patient remains normotensive.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
Altered Mental Status
Pneumomediastinum
Acute Renal Failure
Secondary Diagnosis:
Polysubstance Abuse
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory but with some balance difficulty
Discharge Instructions:
You were admitted to the hospital with altered mental status.
This was felt to be due to medication withdrawal from some of
the medications you were taking prior to being in prison such as
Xanax. You also were found to have air in some tissue in your
chest (pneumomediastinum) and were seen by thoracic surgery who
felt that this would get better over time. You had a lumbar
puncture done at [**Hospital3 3583**] which showed you did not have
meningitis. You also had kidney failure in the hospital, but
your kidney function improved prior to discharge.
Changes to your medications:
STOPPED Xanax, Restoril, and other anxiety medications
ADDED multivitamin and thiamine
ADDED clonidine 0.1mg by mouth daily. This medication should be
discontinued after 2-3 days if you remain normotensive.
Followup Instructions:
You are being discharged back to the correctional facility and
you should be seen by a physician while you are there.
You have the following appointment scheduled for follow-up:
Department: Neurology
Location: [**Hospital Ward Name 23**] Building, Floor 8, [**Hospital1 18**]-[**Location (un) 86**] [**Hospital Ward Name 516**]
Phone: [**Telephone/Fax (1) 1844**]
Date/Time: [**2113-1-5**] at 1:00pm
|
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"791.0",
"292.0",
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icd9cm
|
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,387
| 122,561
|
36724
|
Discharge summary
|
report
|
Admission Date: [**2160-3-25**] Discharge Date: [**2160-4-4**]
Date of Birth: [**2104-1-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 yo M with history of HIV, ESRD on HD presents with dyspnea
and hypoxemia after recent travel to [**State 108**]. Denies any sick
contacts there. [**Name2 (NI) **] was in airport on evening prior to
presentation and had sudden onset of dyspnea prior to boarding
the plan. Was told he had a low oxygen sat and was put on
supplemental oxygen on the plane. Was not feeling well last
night and thus stayed at his sister's house. He slept well
overnight, but awoke in the morning with dyspnea. Went to
dialysis today they took off an extra 1.5 kg of volume. Denies
feeling fevers, though having intermittent dry cough.
.
Upon arrival to the ED vitals were: T 99, HR 106, BP 136/98, RR
18, O2Sat 96% 6L. Was noted to be hypoxemic at presentation to
ED. Had CXR with bilateral infiltrates. Received levofloxacin.
Obtained CTA chest to rule out pulmonary embolism and no PE was
noted, but CT preliminarily read as multiple ground glass
opacities consistent with infection. Patient given 3 Bactrim DS
tablets for empiric cdiff treatment. Vitals prior to transfer to
the MICU were: T 99.6, HR 110, BP 121/81, RR 20, O2Sat 93% 10L
FM.
.
REVIEW OF SYSTEMS:
(+)ve: dry cough, dyspnea
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, sputum production, hemoptysis, nausea, vomiting,
diarrhea, constipation, hematochezia, melena, dysuria, urinary
frequency, urinary urgency, focal numbness, focal weakness,
myalgias, arthralgias
Past Medical History:
1) HIV (recent CD4 235 in [**12/2159**])
- dx [**2143**] with Pneumocystis pneumonia
- started on ARVs approximately [**2156**]; unknown CD4 nadir
2) ESRD related to HIV nephropathy on dialysis (TuThSa at [**Location (un) **]
[**Location (un) **])
- HD starting [**10/2158**]
- prior left chest tunneled HD cathter
- currently using right upper extremity A-V fistula placed [**2159**]
3) Hypertension
4) Possible MGUS
Social History:
Patient lives alone and does not require assistance with ADLs.
TOBACCO: Denies
ETOH: Denies
ILLLICTS: Denies
Family History:
Denies family history of cancer. ? father with diabetes
Physical Exam:
VS: T 99.3, HR 110, BP 144/72, RR 21, O2Sat 95% 4L NC
GEN: NAD
HEENT: PERRL, EOMI,
NECK: Supple, no JVP elevation
PULM: Bilateral basilar crackles without wheezing
CARD: RR, nl S1, nl S2, II/VI murmur at RUSB
ABD: BS+, soft, NT, ND
EXT: No C/C/E
SKIN: No rashes
NEURO: Alert and oriented x 3, CN II-XII intact, strength 5/5 in
all extremities
PSYCH: Mood and affect appropriate to clinical situation
Pertinent Results:
Admission Labs:
[**2160-3-25**] 11:30AM BLOOD WBC-12.6* RBC-4.31* Hgb-12.9* Hct-38.4*
MCV-89 MCH-29.9 MCHC-33.6 RDW-17.5* Plt Ct-353
[**2160-3-25**] 09:29PM BLOOD WBC-12.6* RBC-3.69* Hgb-11.1* Hct-32.9*
MCV-89 MCH-30.2 MCHC-33.8 RDW-17.4* Plt Ct-296
[**2160-3-25**] 09:29PM BLOOD PT-15.3* PTT-29.6 INR(PT)-1.3*
[**2160-3-25**] 11:30AM BLOOD Glucose-137* UreaN-35* Creat-5.1* Na-141
K-4.9 Cl-99 HCO3-29 AnGap-18
[**2160-3-25**] 09:29PM BLOOD Glucose-148* UreaN-44* Creat-6.4*# Na-139
K-4.4 Cl-100 HCO3-25 AnGap-18
[**2160-3-25**] 11:30AM BLOOD cTropnT-0.10*
[**2160-3-25**] 12:02PM BLOOD Lactate-2.4* K-4.3
.
CTA Chest ([**2160-3-25**]):
1. No evidence of pulmonary embolus or acute aortic pathology.
2. Diffuse bilateral ground-glass opacities, right greater than
left with multiple nodular opacities. These findings are most
compatible with an infectious etiology.
3. Moderate hiatal hernia with fluid in the esophagus.
.
AXR, Portable ([**2160-3-31**]):
Air is seen in non-dilated loops of small bowel. No
free air is seen. The structures are grossly unremarkable. There
is a
moderate-to-large volume of urine in the bladder. IMPRESSION: No
free air.
.
Portable CXR ([**2160-3-31**]):
1. Increased pulmonary edema. Underlying infectious process is
not well
evaluated in the setting of this edema.
2. Tracheal deviation to the right. Evaluation with PA
radiograph is
recommended if patient is clincally able.
.
CT Head ([**2160-3-31**]):
1. Extensive white matter hypodensities could be related to
chronic small
vessel ischemic disease if the patient has the appropriate risk
factors,
specifically hypertension and/or diabetes. Otherwise, given the
patient's
history of HIV, these white matter hypodensities could be
explained by HIV
encephalopathy or another immunocompromise related to infectious
process.
Recommend clinical correlation.
2. Lacune in the posterior limb of the left internal capsule.
3. Global cerebral atrophy.
.
EEG ([**2160-4-1**]):
Abnormal routine EEG due to the presence of a
disorganized [**7-1**] Hz theta rhythm background seen during the most
awake
portions of the tracing with frequent generalized suppressive
burst
activity. This is consistent with a mild to moderate diffuse
encephalopathy. In addition, there are occaisonal sharp and slow
wave discharges occuring mostly over the right frontocentral
region, and
occasionally in a generalized distribution with a left sided
predominance, suggestive of a focal and a generalized cortical
irritability. However, there were no electrographic seizures
seen.
.
MR [**Name13 (STitle) 430**] Without Contrast ([**2160-4-1**]):
1. No evidence of acute intracranial abnormality.
2. There is extensive periventricular and subcortical white
matter FLAIR
hyperintensities likely representing the sequela of chronic
small vessel
ischemic disease. No evidence of intracranial hemorrhage or
infarction.
3. Bilateral mastoid sinus fluid/mucosal thickening, right
greater than left.
.
CXR ([**2160-4-2**]):
The patient has been extubated and the nasogastric tube has been
removed. No focal parenchymal opacities have newly occurred.
There are no major pleural effusions. Unchanged moderate
cardiomegaly without evidence of pulmonary edema. Mild
tortuosity of the thoracic aorta. A remnant opacity in the right
upper lobe that has decreased in size since the previous
examination needs attention at future followups.
.
Microbiology Results:
.
CRYPTOCOCCAL ANTIGEN (Final [**2160-4-4**]): ANTIGEN NOT DETECTED.
Performed by latex agglutination.
.
[**2160-4-1**] Rapid Respiratory Viral Screen & Culture:
Respiratory Viral Culture: Negative
Respiratory Viral Antigen Screen (Final [**2160-4-2**]): Negative
Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza
A, B,
and RSV by immunofluorescence.
.
[**2160-4-1**] BRONCHOALVEOLAR LAVAGE:
1. GS: 1+ PMNs, no microorganisms
2. Respiratory Culture: (10K-100K microorganisms), commensal
respiratory flora
3. Legionella Culture: negative
4. PCJ IF: negative
5. Fungal Culture: negative
6. AFB Smear/Culture: no AFBs seen, none isolated on culture
.
[**2160-3-31**] Toxoplasma: negative by PCR
[**2160-3-31**] [**Male First Name (un) 2326**] Virus: negative by PCR
[**2160-3-31**] HSV (CSF): negative by PCR
[**2160-4-4**] Histoplasma Urinary Antigen: > 100 (+)
.
[**3-31**] CSF:
GRAM STAIN (Final [**2160-3-31**]): No PMNs, No microorganisms,
Cryptococcal antigen negative
FLUID CULTURE: negative
FUNGAL CULTURE: negative
ACID FAST CULTUR: negative
VIRAL CULTURE: negative
.
[**3-30**], [**3-31**] Stool C. diff negative
.
[**3-31**] Urine cultures: negative
.
[**3-31**] Blood cultures: negative
.
[**3-29**] Urine legionella antigen negative
.
[**3-28**] Sputum GRAM STAIN (Final [**2160-3-28**]): <10 PMNs and >10
epithelial cells/100X field. Immunoflourescent test for
Pneumocystis jirovecii (carinii) (Final [**2160-3-28**]): NEGATIVE for
Pneumocystis jirovecii (carinii).
.
[**3-27**] HIV-1 Viral Load/Ultrasensitive (Final [**2160-3-28**]): HIV-1 RNA
is not detected.
.
Discharge Labs:
[**2160-4-4**] 06:05AM BLOOD WBC-11.1* RBC-3.58* Hgb-10.9* Hct-31.9*
MCV-89 MCH-30.4 MCHC-34.1 RDW-16.7* Plt Ct-334
[**2160-4-4**] 06:05AM BLOOD Glucose-90 UreaN-52* Creat-6.8*# Na-141
K-4.6 Cl-101 HCO3-24 AnGap-21*
[**2160-4-4**] 06:05AM BLOOD Calcium-8.6 Phos-6.3*# Mg-2.2
Brief Hospital Course:
56 y/o male with history of HIV, ESRD on HD presents with
dyspnea and hypoxemia.
.
#. Hypoxemia/Dyspnea: Patient presented with a non-productive
cough and was noted to desaturate with relatively little
exertion. Patient had history of pneumocystis jirovecci
pneumonia in [**2143**]. Pulmonary embolism ruled out with CTA chest.
Patient had sputum culture and gram stain with PCP smear sent
that was negative for Pneumocystis jirovecii. Patient received
empiric coverage of bacterial pneumonia with Ceftriaxone and
Azithromycin (which was eventually switched to Levofloxacin),
Bactrim and Prednisone for PCP pneumonia and [**Name9 (PRE) 83043**] for
influenza. Oseltamivir was stopped when respiratory viral
culture was negative. A BAL was performed in the ICU while the
patient was intubated which was again negative for PCP, [**Name10 (NameIs) 3**] well
as other viruses and bacteria. Patient received a 10-day course
of Levofloxacin and was discharged to complete a 21-day course
of Bactrim and Prednisone. Other studies were sent at discharge.
Histoplasma urinary antigen came back positive following
discharge. The patient's primary ID physician was [**Name (NI) 653**] with
the result.
.
#. Altered Mental Status: On [**2160-3-31**] patient felt to be altered
from baseline mental status. In setting vomiting, NGT placement
attempted, though patient had desat to high 80s requiring NRB
with return of sats to 100%. However, given AMS and increased
O2 requirement, was transferred to MICU for further monitoring.
Was intubated given concern for airway protection, and had LP
given acute change in mental status. LP not concerning for
acute meningitis, and multiple studies sent. Patient started
empirically on acyclovir until CSF HSV PCR came back negative.
Patient had CT head which demonstrated hypodense lesions that
could represent chronic ischemic changes vs. infection given
known HIV. MRI obtained revealed no evidence of acute
intracranial abnormality, but did reveal extensive
periventricular and subcortical white matter FLAIR
hyperintensities likely representing the sequela of chronic
small vessel ischemic disease. Patient's mental status
significantly improved, and he was extubated the following day.
Patient did have an EEG, which demonstrated mild to moderate
diffuse encephalopathy, with occasional sharp and slow wave
discharges occuring mostly over the right frontocentral region,
and occasionally in a generalized distribution with a left sided
predominance. Neurology was consulted and felt that the
underlying process was likely multifactorial in the setting of
infection and hypoxia and not due to an underlying seizure
disorder. No seizure prophylaxis was recommended.
.
#. GI Bleed: On morning of [**3-31**], patient vomited for unclear
reasons. The emesis was reportedly "coffee grounds," HCT checked
and was stable. Patient started on IV protonix. GI consulted,
and felt that since patient was not actively bleeding, HCT
remained stable, and patient hemodynamically stable. Patient
subsequently underwent an EGD that revealed white plaques
consistent with [**Female First Name (un) 564**] but was otherwising unrevealing. Patient
was restarted on Fluconazole prior to discharge.
.
#. HIV: Patient's last known CD4 was 265 on [**2161-1-6**]. Reports
compliance with all HIV meds and prophylaxis. Continued him on
home Stavudine, Darunavir, Ritonavir, Lamivudine. Patient
received Fluconazole as above.
.
#. ESRD on HD: Patient on HD (TuThSa at [**Location (un) **] [**Location (un) **]) for
HIV nephropathy. Patient received dialysis per his schedule
throughout admission. Patient was instructed to take Bactrim and
Fluconazole following his dialysis sessions. Patient was also
started on Calcium acetate for his elevated phosphorus prior to
discharge.
.
#. Hiccoughs: Patient with chronic hiccoughs controlled with
Gabapentin and Baclofen. These meds were initially held as
possible contributors to his mental status. They were restarted
prior to discharge with a dose reduction in his Gabapentin for
his decreased renal function.
Medications on Admission:
MEDICATIONS: Confirmed with patient's outpatient pharmacy CVS
[**Location (un) **]
1) Nifedepine ER 30 once daily
2) Renocaps softgels once daily
3) Gabapentin 600 mg AM, 600 mg noon, 700 mg QHS
4) Fluconazole 100 mg once at 6PM on dialysis days
5) Stavudine 20 mg daily at 6PM on dialysis days
6) Baclofen 10 mg [**Hospital1 **]
7) Darunavir 800 mg once daily
8) Ritonavir 100 mg daily
9) Bactrim DS MWF
10) Lamivudine 10 mg/mL take 2.5 mL daily
11) Omeprazole 20 mg [**Hospital1 **]
12) Furosemide 40 mg QOD
13) Timolol 0.5% gel one drop each eye daily
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Candidal Esophagitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **]:
You were admitted to the hospital with shortness of breath that
is most likely due to a pneumonia (an infection in your lung).
You were treated for this infection. You will need to take
antibiotics after discharge.
.
The following changes were made to your medications:
1. START taking Calcium acetate. Take three capsules by mouth
three times a day with meals (total of nine capsules each day).
This medication helps to lower the amount of phosphorus in your
blood.
2. START taking Bactrim. Take 120 mL by mouth three times a week
after dialysis (Tu,Th,Sa): Take 120 mL on [**4-25**], [**4-10**],
[**4-12**], and [**4-15**].
3. Resume taking your Bactrim prophylaxis on [**4-16**]. DO NOT take
your Bactrim tablets until you have finished your course of
liquid Bactrim as above for your pneumonia. Take one double
strength tablet by mouth on Mondays, Wednesdays and Fridays.
4. START taking Prednisone 20 mg by mouth daily. Take one tablet
daily starting on [**4-5**]. Take one tablet daily through [**4-15**].
5. Your Gabapentin dose has been changed because of your kidney
function. You were taking 600 mg in the morning, 600 mg at noon
and 700 mg at night. You should now START taking 300 mg by mouth
once a day. Your outpatient physician may make further
adjustments in your dosing.
6. Your Fluconazole dose has been changed. Take 200 mg by mouth
after dialysis. Take only on dialysis days.
.
No other changes have been made to your medications. Please
continue taking all other medications as prescribed.
Followup Instructions:
Please keep all follow-up appointments as below:
.
Name: [**Last Name (un) **],IOANA I.
Location: [**Hospital6 **]
Address: [**Location (un) 11452**], [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 42773**]
** Please follow up with Dr. [**Last Name (STitle) **] or a nurse within one week.
Dr.[**Name (NI) 83044**] office should contact you directly. If you have not
heard from them by Monday, [**4-7**], please call [**Telephone/Fax (1) 42773**] to
schedule an appointment. **
Completed by:[**2160-4-14**]
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
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12855, 12861
|
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|
310, 316
|
12936, 12936
|
2867, 2867
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14649, 15190
|
2374, 2431
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1491, 1788
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263, 272
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344, 1472
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2883, 7862
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12951, 13063
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1810, 2231
|
2247, 2358
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,550
| 134,988
|
19288
|
Discharge summary
|
report
|
Admission Date: [**2173-12-24**] Discharge Date: [**2173-12-28**]
Date of Birth: [**2113-8-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization x 2
BMS to SVG-OM
History of Present Illness:
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5936**] [**Telephone/Fax (1) 52542**] OSH; Primary Cardiologist, Dr.
[**Last Name (STitle) 5310**]
CC:[**CC Contact Info 52543**].
The patient is a 60 year old male transferred from [**Hospital1 3325**] with NSTEMI. His past medical history is significant
for CAD s/p MI at age 30 s/p CABG in [**2164**] at [**Hospital1 756**] (LIMA->LAD,
SVG->L-PDA, SVG->OM2) with Cypher to SVG->OM2 in [**2170**], DMII,CHF
(EF unknown) and HTN who presented to [**Hospital3 3583**] on Friday
after 1 week of increasing chest pain in intensity and
frequency.
The patient states he had been chest pain free after his most
recent cardiac cath in [**11/2170**] until 6 months ago when he started
to notice SSCP with minimal exertion that would last 1-2 minutes
and resolve spontaneously 2x/month. Over the past few months,
his chest CP increased to 2-3 times a day and resolved with 2-3
sublingual nitroglycerins.
He informed his cardiologist at this time who recommended a
repeat catheterization months ago but the patient failed to do
so due to insurance reasons. He states, however, that he has
been compliant with all his medications, especially Plavix, and
his diet.
In addition, the patient notes increasing shortness of breath
with minimal exertion. At baseline, he can climb 12 steps in his
house without difficulty. Now, after 12 steps, has to sit down
secondary to shortness of breath. He can barely shop for
groceries secondary to angina and shortness of breath. Admits to
orthopnea over past 1 week, no [**Location (un) **], no PND.
On Sunday, the patient awoke from his sleep with 12/10
substernal chest pain that radiated to his midscapular region,
across his back (anginal equivalent to MI) and jaw associated
with SOB, nausea,diaphoresis. The patient took 2 SL nitros and
the pain resolved within 20 minutes. He did not call 911.
From Monday to Thursday, the patient noted increasing episodes
of CP while at rest and worsening SOB with minimal activity. He
saw his cardiologist on Tuesday who recommended elective cath on
Thursday. However, an elevated Cr was detected and the cath was
delayed.
Then, Thursday night, the chest pain worsened and he spoke to
his cardiologist on Friday who referred him to the ED. He drove
himself and a friend to the ER at [**Hospital3 3583**].
At [**Hospital3 3583**], his EKG showed :
Sinus tachycardia at 100 bpm,, NL axis and QT. LVH. Peaked T
waves V1-V3. 2-[**Street Address(2) 2051**] depressions with TWI I,II,III,AVF,V4-V6.
1-2 mm STE in V1-V2.
His labs were significant for a K of 5.1, Cr 1.7, WBC of 9, Hct
34, CK 178, Troponin I 2.57.
His CXR at [**Hospital3 3583**] showed a RML pneumonia.
He was given ASA and started on a heparin drip and transferred
to [**Hospital1 18**].
In the ED, the patient was chest pain free. He was continued on
a Hep gtt, given a Plavix load of 600mg x1, Nitro gtt,
Metoprolol 5mg IVx1, Metoprolol 25mg PO x1. Cardiology evaluated
the patient and recommended adding integrillin.
His EKG at [**Hospital1 18**] showed:
NSR 94 bpm, NL axis, 1-2 mm STE V1-V2, deep S qaves V1-V3. [**Street Address(2) 52544**] depressions in V5-V6, I, AVL, III, III, and AVF with
TWI.
His troponin-T was 0.62, MBI 9.8, CK 153, MB 15. Cr 1.7, K 4.2.
Hct 32.
He was admitted for NSTEMI.
Last cardiac cath [**2170-12-4**]:
Left-dominant,LMCA patent,ostial LAD 80-90% stenosis, totally
occluded after S1.LCX with 70% lesion after OM1. Grafted OM2
occluded proximally.OM3 80% stenosis. LPDA occluded. RCA
occluded proximally with collaterals from LCX. Stump occlusion
of SVG->PDA.SVG->OM2 with 90% proximal stenosis, LIMA to LAD
patent. Markedly elevated LV filling pressures (LV 141/26 mmHg),
moderate pulmonary arterial hypertension (52/25 mmHg). Cypher
SVG-OM2.
No echo here.
ROS: Positive nonproductive cough with recent RUL pneumonia
treated with antibiotics that caused watery diarrhea - last
episode 4 days prior. No fevers/chills. No bloody stools.
Occasional palpitations with shortness of breath. + bilateral
calf pain with exertion - relieved at rest.
Past Medical History:
CAD s/p several MIs (1st at 30), s/p CABG in [**2164**], most
recentCypher [**11/2170**] SVG-OM2 Patent LIMA-LAD. Occluded SVG-PDA.
Stenosed SVG-OM2. Moderate-severe left ventricular diastolic
heart failure. Mild-moderate right ventricular diastolic
dysfunction]
- Right femoral artery pseudoaneurysm s/p cath at [**Hospital1 756**] in
[**2164**] -> surgical repair
-CHF, EF unknown
-HTN
-Hyperlipidemia
-Depression
-NIDDM x 10 years
- no known renal insufficiency
-GERD with gastric ulcers
-s/p CCY
- h/o remote ETOH abuse
- OA in back, hips bilaterally
Social History:
Lives in [**Location 52545**], divorced, 2 kids.
-Quit TOB 11years ago, smoked 4ppd x 40 years; No ETOH use at
present, however, formerly drank 2 6 packs of beer/day + whiskey
with frequent "blackouts" but no history of DTs.
Family History:
-F: several MIs (1st at 40), died at 74
-M: died at 45yo from Uterine/Ovarian CA
-Brother died of Pancreatic Cancer
Physical Exam:
Tc=97.6 P=87 BP=112/60 RR=16 97% on 2 Liters O2
Gen- NAD, AOX3
HEENT - 8 cm [**Last Name (LF) 22116**], [**First Name3 (LF) 13775**], EOMI
Heart - Regular rate and rhythm, no murmurs/rubs/gallops
Lungs - Bibasilar crackles
Abdomen - Soft, NT, ND + BS
Ext - Right femoral artery with palpable bulge s/p surgical
repair of pseudoaneurysm with bruit, left femoral artery with +2
pulses, +1 d. pedis left, +1 d. pedis right, no edema
Neuro - Grossly intact
Rectal (in ED) - declined
Pertinent Results:
CHEST (PORTABLE AP) [**2173-12-24**] 9:33 PM
IMPRESSION: Moderate CHF.
See HPI for EKG findings.
ECHO Study Date of [**2173-12-25**]
EF 20%.
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The right ventricle is not well
seen but there may be right ventricular chamber enlargement.
Right ventricular function is difficult to assess. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis with slightly better contraction in the
inferior wall. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen.
There is
moderate pulmonary artery systolic hypertension. There is no
pericardial
effusion.
C.CATH Study Date of [**2173-12-27**]
FINAL DIAGNOSIS:
1. Multivessel native coronary artery disease.
2. Severe systolic and diastolic ventricular dysfunction.
3. Markedly reduced cardiac index.
4. Moderate to severe pulmonary hypertension
5. In-stent restenosis of the SVG to OM
6. Bilateral iliac disease.
7. Left iliac perforation treated with a covered stent.
8. Successful bare metal stent placement in the SVG to OM.
9. Post-procedure the patient denied chest pain, dyspnea or
nausea and
was hemodynamically stable.
Brief Hospital Course:
The patient is a 60 yo male with CAD s/p several MIs s/p CABG in
[**2164**] (LIMA-LAD, SVG-L-PDA, OM2) and Cypher to OM2 in [**2170**], DMII,
and CHF (EF 20%) who presented with acute NSTEMI on [**2173-12-24**].
.
#CAD-Significant CAD hx now w/NSTEMI.
--Continue to cycle CE until peak
--The patient was continued on a Hep gtt, Integrillin gtt
(renally dosed)x 18 hours, and Nitro gtt prior to cath.
--He was continued on ASA, Plavix, Lopressor 12.5 mg [**Hospital1 **], Plavix
75 mg, Lipitor 80 mg.
-- No ACE given acute renal failure
-- The patient underwent the planned cath on Monday [**2173-12-27**].
During the cath, it was found that his SVG-OM had a 99% stenosis
from his prior stent. A bare metal stent was placed as a result.
The cath was complicated by a left iliac dissection and
perforation which was treated with a covered stent on the left
and bare metal stent to the right. Pre and post-cath, the
patient complained of lumbar back pain that he stated was
secondary to his history of sacroiliitis and lumbar disc
degeneration.
Shortly after arriving on the floor in the evening, the
patient's groins were evaluated and found to have no hematoma
bilaterally, bilateral femoral bruits (present pre-cath) with +1
d. pedis bilaterally that were dopplerable. The patient was
pain or discomfort. Shortly thereafter around 10:30 or 10:45 pm,
the [**Name8 (MD) 228**] RN found him sitting up in bed and asked the
patient to lie supine as he was to remain supine for a certain
number of hours post-procedure. However, the patient appeared
nauseous and vomited. He then vomited ([**Name8 (MD) **] RN report) a second
time nonbloody, clear liquid in a projectile fashion and fell
forward to the floor, losing consciousness.
the patient lay on the floor, unresponsive, pale, not breathing
and without a pulse. An ambu bag was used to ventilate the
patient as CPR was initiated. The external defibrillator showed
ventricular tachycardia and the patient received a 200 J shock.
He remained in VT and was shocked again at 360 J. Meanwhile, CPR
was resumed between each shock. He went into PEA arrest and was
given 3 mg of epinephrine total. He returned to VT and required
multiple shocks. He was given another dose of epinephrine and
loaded with amiodarone 300 mg IV followed by a drip infusion.
Meanwhile, the patient was intubated by anesthesia. A pulse was
palpable by multiple physicians participating in the code and a
wide complex, regular rhythm at a rate of 60-70? was visible.
The patient was given fluids and a gas was checked during this
time. The cardiology attending of record was notified during the
code who recommended calling the fellow and activating the cath
lab. The cardiology fellow was called and stated he was on his
way to evaluate the patient.
The patient's initial gas was 7.42/57/320. His lactate was 12.
He was started on pressors and transferred to the MICU as there
were no available beds in the CCU. Vascular surgery was called
as the patient's Hct returned as 24 (down from 30) pre-cath and
the concern was for an RP bleed given the known cath
complication earlier that day. The vascular consultants
evaluated the patient in the MICU and felt there was no
indication for the OR at this time. His care was assumed by the
MICU attending and his team. He returned to ventricular
tachycardia and required DCCV in the MICU on levophed. The
levophed was stopped and neo was resumed and the patient was
transfused with blood and given fluids after a central line was
placed.
The cath lab was activated by the cardiology fellow to evaluate
the patient for in-stent thrombosis and iliac arteries with
concern for an RP bleed. The patient was deemed too unstable for
evaluation by CT imaging during this time.
In the cath lab, the stent that was placed on [**2173-12-27**] appeared
to be patent. Vascular surgery was called once more as the
patient's Hct was found to be 18. The vascular resident were
requested to notify the chief vascular resident on call as well
as the attending vascular surgeon. The patient received
continuous CPR while in the cath lab as he repeated went into
ventricular tachycardia and was losing his arterial pressure.
Wide open pressors were in place as were wide open fluids, blood
transfusions.
Vascular surgery felt there was no role for surgical correction
at the patient proceeded to decline.
CPR was discontinued and the patient was declared dead at 1:28
am.
The patient's attending cardiologist was notified. Multiple
attempts were made to find a contact number for family which was
not located in the chart's admission information -only the name
of his daughter, [**Name (NI) **] [**Name (NI) 6105**]. 411 was called and search
attempts were made through the internet to located his daughter
but her number was not listed.
The patient's PCP's office was notified and the information was
shared with the covering physician. [**Name10 (NameIs) **] medical examiner's
office was called and the person answering the phone "[**Doctor Last Name **]"
case was declined for post-mortem.
The patient's floor nurse was able to find a number in a nursing
note for [**First Name4 (NamePattern1) **] [**Known lastname 6105**] and multiple attempts were made to
contact her nearly roughly 3 am. A message was left for her to
[**Name6 (MD) 138**] the MD. She returned the phone call later that morning
between 7 and 7:30 and was informed of her father's death. She
was provided details of the events preceding his death and asked
to come in with her family to discuss the case with her father's
team of doctors and [**Name5 (PTitle) **] [**Name5 (PTitle) 691**] questions as well as to view the
body.
.
#PUMP:
Echo on [**12-25**] with EF 20%, global HK with dilated CM. Mod MR,
TR.
Given 20 mg IV lasix during presentation with fluid overload
with caution with ARF. Cr remained stable and his breathing
improved.
.
#. Acute renal failure-- Unclear etiology. The patient did have
diarrhea 4 days prior to presentation to suggest possibilty of
pre-renal azotemia. However, on exam, he appears overloaded.
.
#. CODE: FULL
Medications on Admission:
Prilosec
-Metoprolol 50mg [**Hospital1 **]
-Plavix 75mg daily
-Metformin 850mg [**Hospital1 **]
-Glyburide 10mg [**Hospital1 **]
-Zoloft 100mg daily
-Aspirin 81 mg daily
-fish oil
** NOT ON STATIN secondary to myalgias.
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
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58,247
| 159,012
|
13498
|
Discharge summary
|
report
|
Admission Date: [**2158-10-23**] Discharge Date: [**2158-11-27**]
Date of Birth: [**2087-2-2**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet / Darvon
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Ultrasound guided paracentesis
History of Present Illness:
71F with AIH/cryptogenic cirrhosis and portal hypertension c/b
fluid retention, hyponatremia, hepatic encephalopathy and HCC
s/p RFA [**2158-10-11**] (solitary 2.0 cm segment III liver lesion),
moderate AS, here with increasing abdominal pain for the past 4
days. She denies fevers, chills, sob, cp, diarrhea,
constipation, or pain in other locations beside abdomen. She
denies new weakness or fatigue. Given h/o prior SBP, she sent
to ED from liver clinic for evalation of SBP and etiology of
worsening abdominal pain. She denies altered mental status
Initial VS in the ED: 96.6 122/58 87 18 98% on RA. Exam notable
for tender abdomen, but no nausea/vomiting, fevers, chills. Labs
notable for asymptomatic hyponatremia to 119. A dx tap was
perform demonstrating only 72 WBC, but 9150 RBC's. Urine lytes
demonstrates NA <10, OSM 344. UA was significant for 26 epi's,
mod bacteria, and 33 hyalian cast, but patient was asymptomatic.
Patient was given hydromorphone for pain. VS prior to transfer:
98 84 14 107/60 [**2-17**] pain
Past Medical History:
1. Cirrhosis with portal hypertension
2. Hypertension.
3. Hyperlipidemia (monitored only.)
4. Reported history of UC diagnosed 3 years ago on colonoscopy,
but she is asymptomatic is not on pharmacologic therapy.
5. Left knee arthroscopy.
6. Left shoulder and elbow fracture with pins (unable to
undergo
MRs.)
7. Left total hip replacement in [**2148**].
8. Total hysterectomy in the [**2116**].
9. Appendectomy at age 30.
10. Tonsillectomy.
11. Cholecystectomy in the [**2126**].
12. Osteoporosis.
13. Systolic heart murmur.
14. Reported history of PE/DVT, on Coumadin in the [**2116**].
Social History:
She lives alone. No history of alcohol excess. Lifelong
nonsmoker. Competent of all ADLS IADLS. Previously worked as a
jewelry maker and [**Hospital Ward Name **].
Family History:
No liver disease in family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 116/69 86 18 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 [**3-14**] mid to late peaking
systolic murmur with quite S2
Abdomen: obese with somewhat tense, tender, distended, bowel
sounds present, no rebound tenderness or guarding,
Ext: Warm, well perfused, 2+ pulses, 4+ edema throughout lower
extremities, no asterixis
Neuro: non-focal exam except AxOx3, able to perform serial days
of the week accurate, and serial months backward accurately
except for skipping may and [**Month (only) **].
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 104/61 84 18 95%RA, I:740mL O:Inc BMx3
General: Alert, oriented x3, in no acute distress
HEENT: NC/AT, Sclerae icteric, PER, EOMI
Neck: supple
Lungs: normal respiratory effort, no accessory muscle use, clear
to auscultation bilaterally, bibasilar rales, no wheezes or
rhonchi
CV: Regular rate and rhythm, normal S1, [**3-14**] mid to late peaking
systolic murmur with quiet S2, loudest at RUSB
Abdomen: Obese, non-tender, ND, +BS, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, LE edema
Neuro: no focal neurologic deficits
Pertinent Results:
ADMISSION LABS:
[**2158-10-23**] 01:45PM BLOOD WBC-7.0 RBC-3.62* Hgb-12.5 Hct-36.0
MCV-100* MCH-34.6* MCHC-34.8 RDW-14.6 Plt Ct-UNABLE TO
[**2158-10-23**] 03:47PM BLOOD PT-18.3* PTT-38.6* INR(PT)-1.7*
[**2158-10-23**] 01:45PM BLOOD Glucose-115* UreaN-15 Creat-1.0 Na-119*
K-3.9 Cl-82* HCO3-29 AnGap-12
[**2158-10-23**] 01:45PM BLOOD ALT-24 AST-102* AlkPhos-189* TotBili-5.0*
[**2158-10-23**] 11:35PM BLOOD Osmolal-259*
Studies:
RUQ US ([**2158-10-24**]):
1. Patent hepatic veins with normal pulsatility and without
evidence for
Budd-Chiari.
2. Moderate amount of ascites, relatively unchanged from prior
CT.
3. Cirrhosis without focal lesions.
TTE ([**2158-10-24**]): The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Severe calcific aortic stenosis. Symmetric LVH with
hyperdynamic systolic function. Mild mitral regurgitation.
RUQ US ([**2158-10-31**]):
1. Cirrhotic liver. Splenomegaly. Moderate amount of ascites.
2. Doppler assessment of the main portal vein shows patency and
appropriate directionality of flow.
DISCHARGE LABS:
[**2158-11-26**] 07:30AM BLOOD WBC-5.2 RBC-2.82* Hgb-9.4* Hct-28.3*
MCV-100* MCH-33.3* MCHC-33.2 RDW-17.9* Plt Ct-UNABLE TO
[**2158-11-26**] 07:30AM BLOOD Glucose-79 UreaN-27* Creat-2.6* Na-130*
K-4.0 Cl-94* HCO3-27 AnGap-13
[**2158-11-24**] 05:10AM BLOOD ALT-24 AST-69* AlkPhos-192* TotBili-9.8*
[**2158-11-26**] 07:30AM BLOOD Albumin-2.0* Calcium-8.4 Phos-5.1* Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname 25699**] is a 71 yo female with a PMH of AIH/cryptogenic
cirrhosis and portal hypertension complicated by fluid
retention, hyponatremia, hepatic encephalopathy and HCC s/p RFA
[**2158-10-11**] (solitary 2.0 cm segment III liver lesion), severe AS,
who presented with increasing abdominal pain for 4 days.
# Abdominal Pain: Upon admission the pt reported 4 days of
worsening abdominal pain and distention. This was thought to be
due to post-procedural pain from her recent RFA of an HCC 1.5
weeks prior to admission, as well as distention from ascites
secondary to her cryptogenic cirrhosis. She had a diagnostic
paracentesis performed in the ED which showed no evidence of
SBP. She had a RUQ ultrasound performed which showed patency of
the hepatic vessels, as well as moderate ascites relatively
unchanged from her prior CT scan on [**2158-10-11**]. She was given
oxycodone 5mg Q4H PRN, which adequately controlled her pain. On
[**2158-10-26**] a therapeutic paracentesis was performed with
ultrasound guidance. This markedly improved her pain and
distention. At time of discharge she did not have any abdominal
pain.
# Hypervolemic Hyponatremia: Upon admission the patient's Na was
119, down from a baseline of 125 during her last admission. This
was thought to be due to hypervolemic hyponatremia secondary to
her cirrhosis. She was asymptomatic with regards to the
hyponatremia with no mental status changes. She was initially
maintained on 1L of daily fluid restriction, and her home Lasix
and spironolactone were held in order to preserve sodium.
However, over the course of 2 days this did not result in
appreciable increase in her sodium, which ranged from 116-119
from [**Date range (3) 40847**]. As such she was started on Tolvaptan
15mg on [**2158-10-25**], and her fluid restriction was liberalized. Her
Tolvaptan was increased to 30mg daily on [**2158-10-25**] due to no
increase in her sodium on the 15mg dose. She continued to have
poor response to this so it was stopped and she was ultimately
started on CVVH for removal of fluid with resolution of her
hyponatremia. Due to [**Last Name (un) **] (see below) she was continued on
hemodialysis and her diuretics were stopped.
# Acute Kidney Injury: Patient developed progressive volume
overload that was refractory to diuresis. She was initially
started on octreotide and midodrine out of concern for HRS but
ultimately transitioned to CVVH for removal of approximately
30kg of fluid. Etiology of renal failure was thought to be
predominantly due to cardiorenal syndrome with small component
of HRS. Patient was successfully transitioned to hemodialysis.
She was continued on midodrine and hydrocortisone to support her
blood pressures during dialysis given episodes of hypotension.
Eventually her SBP stabilized in 100-110's and hydrocortisone
was stopped. She was discharged on midodrine 10mg TID. A
tunneled HD line was placed for outpatient HD which she will
have on a M/W/F basis.
# Hypoxic Respiratory Distress: Patient developed increasing
oxygen requirement in the ICU initially requiring BiPAP and then
mechanical ventilation. The cause of her distress was felt to be
related to volume overload and improved with CVVH. She was
successfully extubated and on nasal cannula at the time of
transfer. She failed speech/swallow evaluation after extubation
but per family wishes, her diet was advanced for comfort with
the understanding that she remains at high risk for aspiration.
# Severe AS: The patient had a history of AS with an estimated
valve area of 1.0-1.2cm from her prior echo in 5/[**2158**]. Upon
admission cardiology was consulted to assess whether or not her
AS might be leading to her fluid overload state. A repeat echo
was obtained which revealed an aortic valve area of 0.9
consistent with severe aortic stenosis. Cardiology was consulted
who felt valvoplasty was not indicated in this patient given her
multiple medical conditions and her high risk of morbidity with
a surgical intervention. Pt has follow up with Dr. [**Last Name (STitle) **].
# AIH/cryptogenic cirrhosis: Pt presented with worsening MELD
scores due to renal failure. Patient is not a transplant
candidate given her severe aortic stenosis. She was maintained
on supportive treatment for her liver disease including
lactulose for her hepatic encephalopathy and tube feeds for her
poor nutrition. Tube feeds were stopped on patient and families
request because they felt she was able to take in adequate
nutrition on her own. She was discharged on lactulose 15 mL PO
TID and neomycin Sulfate 500 mg PO Q8H for prevention of hepatic
encephalopathy. She was also discharged on Ciprofloxacin HCl 250
mg PO Q24H for SBP prophylaxis.
# Goals of Care: Team meeting was held with liver, renal, and
palliative care to discuss goals of care now that patient is
dialysis-dependent. We reviewed her overall poor prognosis given
the extent and incurable nature of her underlying liver disease.
The renal team discussed the importance of continued
hemodialysis and emphasized the fact that no fluid had yet been
taken off during her hemodialysis sessions and that this would
likely be required in the future. The decision of the meeting
was to continue hemodialysis on the floor and see how she
tolerates it. Pt and her family decided that she would do best
going home with hemodialysis. Pt was provided with prescription
for [**Doctor Last Name 2598**] lift, wheel chair, and hospital bed which patient
received and had set up in home prior to discharge.
TRANSITIONAL ISSUES: None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 250 mg PO Q24H
2. Acetaminophen 650 mg PO Q8H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Lactulose 30 mL PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Spironolactone 100 mg PO DAILY
Discharge Medications:
1. Hospital bed
Semi-electric hospital bed. Patient requires this for severe
debility; she is bedbound and requires maximal assistance for
repositioning. Wt 83.1 kg, Ht. 66 in.
2. Wheelchair
Standard wheelchair with elevating leg rests. Patient requires
this for severe debility. Wt 83.1 kg, Ht. 66 in.
3. Alternating pressure pad
Patient requires this as she is completely bedbound, with
multiple pressure ulcers.
4. [**Doctor Last Name 2598**] Lift
Please provide home [**Doctor Last Name 2598**] Lift.
Medically necessary because patient has significantly limited
functional mobility and is dependent for sit to stand transfer.
5. Acetaminophen 650 mg PO Q8H:PRN pain
6. Aspirin 81 mg PO DAILY
7. Lactulose 15 mL PO TID
8. Ascorbic Acid 500 mg PO BID
RX *ascorbic acid 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
10. Miconazole Powder 2% 1 Appl TP QID rash
RX *miconazole nitrate [Anti-Fungal] 2 % Apply to fungal rash
four times a day Disp #*1 Bottle Refills:*0
11. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
TID W/MEALS Disp #*90 Tablet Refills:*0
13. Vitamin B Complex 1 CAP PO DAILY
RX *B complex vitamins [B-Complex] 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
14. Ciprofloxacin HCl 250 mg PO Q24H
15. TraMADOL (Ultram) 25 mg PO HS:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*15 Tablet Refills:*0
16. Neomycin Sulfate 500 mg PO Q8H
RX *neomycin 500 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Cirrhosis
Hypervolemic hyponatremia
Hypotension
Volume overload
End stage renal failure
Severe Aortic Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 25699**],
You were recently hospitalized for abdominal pain and
distention. These symptoms were thought to be due both pain from
your recent radiofrequency ablation of your hepatocellular
carcinoma, as well as fluid in your belly, known as ascites,
secondary to your cirrhosis. Your ascites was drained under
ultrasound guidance. You also developed hypotension, volume
overload, and failure of your kidneys which requires
hemodialysis. We also found that you have worsening of your
aortic stenosis; you were evaluated by cardiology who determined
that the risks outweighed the benefits of surgery. You will be
discharged home and continue dialysis as an outpatient.
Followup Instructions:
[**Location (un) **] [**Location (un) **] Dialysis Center
[**Location 8262**], [**Numeric Identifier 1415**]
Phone: [**Telephone/Fax (1) 5972**]
Nephrologist: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]
Scheduled: Monday, Wednesday, Friday-
**Tuesday, [**11-28**] at 6:00pm and Friday, [**12-1**] at
6:00pm- Dr. [**First Name (STitle) 805**] will follow up with you at your next
dialysis for your hospitalization.
**Special schedule due to the upcoming [**Holiday 1451**] Holiday**
Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] T.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appointment: Tuesday [**2158-12-5**] 1:00pm
Department: CARDIAC SERVICES
When: MONDAY [**2158-12-11**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2158-12-18**] at 9:40 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"38.95",
"96.72",
"54.91",
"96.6",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
13428, 13485
|
5733, 11264
|
305, 337
|
13640, 13640
|
3567, 3567
|
14534, 15982
|
2211, 2241
|
11621, 13405
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13506, 13619
|
11317, 11598
|
13816, 14511
|
5339, 5710
|
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11285, 11291
|
251, 267
|
365, 1401
|
3583, 5322
|
13655, 13792
|
1423, 2013
|
2029, 2195
|
2997, 3548
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,881
| 172,088
|
42925
|
Discharge summary
|
report
|
Admission Date: [**2175-4-6**] Discharge Date: [**2175-4-8**]
Date of Birth: [**2126-6-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
ESLD, hypotension
Major Surgical or Invasive Procedure:
EGD s/p variceal banding
intubation
central line placement
History of Present Illness:
The patient is a 48-yo man with chronic EtOH abuse and
depression, who was BIBA after being found by neighbors living
in squalor and confused. He had not been seen in several weeks,
and was found in this state by his neighbors when they were
doing a wellness check. The patient is a poor historian, but he
denies any prior medical issues or h/o liver disease. He states
that he does this occasionally, going without food or drink for
several days at a time. Per the patient, he has not had any food
or drink in 3 days, and no EtOH in about 6 days, although he
usually drinks 4 beers daily. Since he stopped drinking EtOH he
has been drinking lots of water instead, although he has not had
any water either in the last 3 days, and currently feels very
thirsty. He also complains of difficulty getting up out of bed
due to weakness. He denies any pain. He also denies any recent
fevers, chills, abdominal pain, nausea, vomiting, diarrhea,
constipation, melena, hematochezia, hematemesis,
lightheadedness, chest pain, or shortness of breath. He usually
seeks care at [**Hospital1 2177**], last seen there a few months ago. He has had
abdominal distention for many months, coming-and-going, and has
previously had a paracentesis done at [**Hospital1 2177**] months ago. He also
notes a h/o hematemesis, but denies any recently. He also denies
any h/o EtOH withdrawal symptoms, including DTs or seizures.
.
In the ED: VS - Temp 97.8F, HR 118, BP 86/45, R 18, SaO2 94% RA.
Physical exam showed many stigmata of chronic liver disease,
including obvious ascites, but no clear trauma or infection.
Guaiac + brown stool on rectal. He received a banana bag and 3L
NS IVF, with improvement of his SBP to the 90s and in his mental
status. ECG showed sinus tachycardia. CXR showed no pneumonia,
possible small right pleural effusion. NCHCT showed atrophy out
of proportion for age, no acute hemmorhage, extensive right max
sinus dz. CT-Abdomen/Pelvis showed extensive ascites, shrunken
liver, diffuse colonic wall thickening sparing sigmoid-
concerning for infectious, inflammatory and less likely ischemic
causes. He was T&Cx2, Blood Cx were sent x2. He received Zofran,
Protonix, and Cipro IV, and was ordered for Flagyl as well. GI
was consulted, who will follow along for his colitis. Liver was
not consulted in the ED. He was not transfused for his Hct of
22. He did not receive any Benzodiazepines. He is admitted to
the MICU for further care.
.
ROS: See HPI. +Diplopia x few days. Denies fevers, chills,
shakes, headaches, lightheadedness, dizziness, chest pain,
shortness of breath, palpitations, abdominal pain, nausea,
vomiting, diarrhea, constipation, melena, hematochezia,
hematemesis, dysuria, hematuria.
Past Medical History:
Chronic ETOH abuse.
Social History:
Lives at the [**Location (un) 1833**] Inn (?halfway house). Drinks EtOH daily,
usually 4 beers daily, but has not had any EtOH in ~6 days.
Smokes tobacco: [**12-16**] PPD. Denies other drugs or illicits.
Family History:
Father died of lymphoma. Mother and 2 brothers alive. Unable to
obtain further family history. Denies liver or other GI disease.
Physical Exam:
VS - Temp 96.4F, HR 120s, BP 82/49, R 13-19, SaO2 99% RA.
General - cachectic, frail, chronically ill appearing man in
NAD, comfortable; +fetor hepaticus
HEENT - NC/AT, PERRL/EOMI, +amblyopia, +scleral icterus, dry MM,
poor dentition
Neck - supple, no thyromegaly or JVD
Lungs - CTA bilat, no r/rh/wh
Heart - tachycardic, nl S1-S2, no MRG
Abdomen - NABS, soft/NT, no rebound / guarding; +distended with
flank distention, shifting dullness, fluid wave; unable to
palpate HSM
Extrem - WWP, no c/c/e, 2+ PDs
Skin - no jaundice, +spider angiomata and stigmata of chronic
liver disease
Neuro - awake, A&Ox2 (self, hospital: [**Hospital1 18**] vs. [**Hospital1 2177**]), CNs
grossly intact, muscle strength 4+/5 throughout, sensation
grossly intact throughout, +asterixis, gait not assessed
Pertinent Results:
ECG - sinus tachycardia @ 115bpm, NA/NI, no acute ischemic
changes.
.
CXR - Given the technique, the cardiac silhouette is likely
within normal limits. There are low lung volumes. There is no
definite consolidation. Minimal blunting of the right
costophrenic angle may represent a tiny pleural effusion.
Dedicated PA and lateral could be performed. There is no
evidence of pneumothorax or focal consolidation. Healing right
rib fracture is identified.
.
NCHCT - (prelim / wet read) atrophy out of proportion for age.
no acute hemmorhage. extensive right max sinus dz.
.
CT-Abdomen/Pelvis w/ Contrast - (prelim / wet read) extensive
ascites, shrunken liver. diffuse colonic wall thickening sparing
sigmoid- concerning for infectious, inflammatory and less likely
ischemic causes
Brief Hospital Course:
48-yo man with chronic EtOH abuse and depression who presents
after being found by his neighbors in squalor, with confusion
and hypotension, also with ascites, colitis, anemia, and
hyponatremia. Following admission, he developed hypotension
likely secondary to sepsis and acute GIB bleed unimproved with
transfusions, persistant unresponsiveness despite being off
sedation, persistant respiratory failure and intubation,
multiorgan failure, hypotension requiring pressors. In light of
his critical illness, family was called and after discussion
with mother, patient was made comfort measures only. Family was
present at bedside when patient expired peacefully at 7:20 PM,
[**2175-4-8**].
.
A brief sumary of most acute hospital issues are as follows:
#. Hypotension: Initially felt to be [**1-16**] poor nutrition and PO
intake, but then he was found to have SBP. Over hospital course,
he developed a pressor requirement for levophed and was felt to
be in septic physiology. Furthermore, he developed a large
variceal bleed which also contributed to his hypovolemia.
.
# SBP: He was found on paracentesis to have SBP and was treated
with Vanc/Zosyn. He had a 3L paracentesis on hospital day 2. He
received albumin.
.
# Respiratory failure: He developed increased O2 requirement and
was found to have bilateral pulmonary infiltrates on CXR. He was
intubated on ARDSnet protocol. he continued to have difficulties
with oxygenation over hospital course.
.
#. GIB/Anemia: Patient developed a large variceal bleed and
required 16 units PRBC. Liver was consulted and he underwent
banding of varices. he remained on octreotide/PPI drip. On the
second hospital day, he developed an acute Hct drop to 14 from
28, with source unclear. [**Name2 (NI) **] received FFP, platelets, pRBCs.
Abdomen was noted to be increasingly distended and an
intraabdominal source was most likely. Surgery and liver were
followed, but felt patient not a surgical candidate given
extremely poor prognosis and critical illness.
.
#. Hyponatremia - Likely [**1-16**] hypovolemia as intravascularly dry
on exam, but also with contribution of drinking lots of free
water.
.
#. Cirrhosis - Pt with long chronic daily EtOH use, physical
exam findings of chronic liver disease and portal hypertension,
and CT showing nodular liver and ascites. Labs also c/w
cirrhosis, w/ elevated INR and low albumin. MELD 22, DF 77.
.
#. EtOH abuse - Pt w/ chronic daily EtOH abuse, although none in
the last few days. No h/o DTs or withdrawal seizures.
.
#. ?Colitis: initially noted on CT but was ultimately felt to be
related to hypoalbuminemia and bowel edema and not an infectious
colitis.
Medications on Admission:
none.
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
|
[
"571.2",
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"285.1",
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"788.5",
"995.92",
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"572.3",
"348.39",
"567.23",
"507.0",
"038.9",
"518.81",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"45.13",
"42.33",
"54.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7899, 7908
|
5158, 7803
|
330, 390
|
7967, 7985
|
4355, 5135
|
3403, 3534
|
7859, 7876
|
7929, 7946
|
7829, 7836
|
3549, 4336
|
273, 292
|
418, 3123
|
3145, 3166
|
3182, 3387
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,275
| 144,176
|
43676
|
Discharge summary
|
report
|
Admission Date: [**2137-4-16**] Discharge Date: [**2137-4-26**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
Mental Status changes
s/p Fall
Labile HTN
RLE cellulitis/ecchoymoses
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 yo M with a h/o ESRD on HD, sz disorder, labile HTN
presenting to ED with mental status changes. Given confusion,
history largely obtained through chart. Per pt's son, on [**Name (NI) 2974**]
of last week, pt had a fall while stepping off bus and injured
RLE. Pt was given vanc at HD for cellulitis. On Sunday night pt
had sz activity and was possibly given ativan. Since that time
patient has been confused. Pt dialyzed today and brought from HD
by son. [**Name (NI) **] pt's family, he has not been compliant with his
medication. Of note pt was recently hospitalized [**2-17**] was mental
status changes and hypertensivve urgency. During the
hospitalization his mental status improved with. His BP was
controlled with a labetalol drip that was rapidly tapered off in
the setting of HD.
In the [**Name (NI) **], pt's vitals: 99, 73, 196/80, 16, 95% on ? O2. CXR
with evidence of [**Name (NI) 1106**] congestion, but no effusion or
consolidation. ekG: nsr @84 bpm LAD, lvh, 1 mm STE v1-3, std
v5-6 (all new), TWi in L (old). CEs pending at time of transfer
to MICU. Pt was given vanc 500 mg IV x2, lamictal 250 mg ivX1,
keppra 375 mg iv X1, nortyptiline 10 mg X1, sensipar 30 mg ivx1.
Pt with sbps that reached 260s. Given HTN, pt given clonidine
0.1 mg po x1, lopressor 10 mg ivx1, hydral 10 mg ivx1. Given
poor response pt was started on nitro gtt with some improvement
to sbps 180s. Pt with increased oxygen requirement to 4L by NC,
increased rr to 30s, started on BIPAP. Renal consulted with
plans for urgent dialysis. Pt transferred to MICU for further
management.
In the ICU....
CV: In the MICU the patient had persistent HTN with BP in
150-212/70-103 and he was managed in the MICU with labetalol
gtt, metoprolol 200mg QD, lisinopril 20mg QD, nifedipine 120mg
PO, and clonidine 0.1 [**Hospital1 **], ST to 115. He also had elevated
troponins, and EKG abnormalities attributed to ESRD and stable
LVH respectively. He was eventually titrated off of labetalol
gtt and transitioned to his home regimen for HTN management.
Renal: Seen by Nephrology, and HD was initiated.
Resp: O2 was d/c'd as patient's respiratory status improved and
with O2sats were 97% RA.
GI/GU: Distended, soft, NT abdomen.
Skin: Red/purple area of cellulities involved right shin. On
vanco day [**3-20**].
At time of transfer patient has no complaints.
Past Medical History:
-Seizure disorder
-ESRD on HD (M,W,F) due to idiopathic glomerulonephritis, s/p 2
failed renal transplants
-labile hypertension
-hypothyroidism
-peripheral [**Month/Day (4) 1106**] disease
-hypoparathyroidism
-hepatitis C
-CHF-systolic w/ EF 45% and diastolic dysfunction (echo
[**12/2135**])
-SVT/AVNRT s/p ablation
-multiple fistulas
-H/O MRSA line infection
-Recent admission [**2136-2-29**] for infected L upper arm AV fistula.
-h/o mechanical falls admitted [**1-16**]
-h/o VRE, MRSA
Social History:
Lives at home, on disability, has two sons. Smokes 1ppd x 40
yrs, no etoh, drugs.
Family History:
Mother with breast CA; father alive with CAD & CHF; sons
healthy.
Physical Exam:
Gen - NAD lying in bed. Patient appears malnurished OX3
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - No JVD, no cervical lymphadenopathy
Chest - Faint crackles at bases
CV - Normal S1/S2, RRR, 1/6 systolic murmur
Abd - Distend, Soft, NT, Caput medusae apparent
Extr - RLE swelling with ecchymoses and surrounding erythema. 2+
DP pulses bilaterally, no R calf tenderness
Neuro - AOx3. Moving all extremities
Skin - See above
Pertinent Results:
[**2137-4-26**] 05:58AM BLOOD WBC-4.8 RBC-3.56* Hgb-10.0* Hct-30.5*
MCV-86 MCH-28.0 MCHC-32.6 RDW-17.9* Plt Ct-270
[**2137-4-25**] 05:30AM BLOOD WBC-4.6 RBC-3.50* Hgb-10.0* Hct-29.5*
MCV-84 MCH-28.7 MCHC-34.0 RDW-17.9* Plt Ct-264
[**2137-4-26**] 05:58AM BLOOD PT-12.9 PTT-31.8 INR(PT)-1.1
[**2137-4-26**] 05:58AM BLOOD Glucose-86 UreaN-34* Creat-5.3*# Na-137
K-5.1 Cl-99 HCO3-26 AnGap-17
[**2137-4-19**] 06:05AM BLOOD ALT-12 AST-23 LD(LDH)-224 AlkPhos-87
Amylase-27 TotBili-0.7
[**2137-4-19**] 06:05AM BLOOD Lipase-20
[**2137-4-17**] 04:14AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2137-4-17**] 12:16AM BLOOD CK-MB-5 cTropnT-0.11*
[**2137-4-16**] 05:00PM BLOOD CK-MB-8 cTropnT-0.12*
[**2137-4-26**] 05:58AM BLOOD Calcium-9.1 Phos-5.7* Mg-2.4
[**2137-4-16**] 05:00PM BLOOD Ammonia-32
.
[**2137-4-20**] - Calf films
IMPRESSION: Soft tissue swelling, which may be due to the
provided history of cellulitis. No evidence of acute fracture.
.
[**2137-4-19**] - abdominal ultrasound.
IMPRESSION: Large amount of ascites. Spot marked in right flank
for possible bedside paracentesis.
[**2137-4-22**] MRI calf
IMPRESSION:
Large superficial anterior collection with signal
characteristics that are most suggestive of a hematoma.
Superimposed infection is not excluded. Surrounding edema
extends into the deep muscles and fascial planes involving all
three leg compartments. No evidence of underlying osteomyelitis.
Brief Hospital Course:
A/P: 58 yo M with a h/o ESRD on HD, sz disorder, labile HTN
presenting to ED with mental status changes, hypertensive
urgency, and RLE trauma.
.
Mental status changes: Likely result of a combination of
hypertensive encephalopathy given degree of hypertension on
admission (SBP in the 260s) and uremia since his mental status
has cleared following BP management and dialysis.
HTN: Patient was hypertensive to the 260s requiring Labetalol
drip in the MICU. He was transitioned back to his home
antihypertensive regimen when he was transferred to the medicine
floor. There, he continued to have episodes of HTN with SBPs in
the low 200s requiring IV hydralazine. His BP medication was
optimized by increasing his his Nifedipine to 180mg daily, and
his Toprol XL to 250mg daily, and his clonidine at 0.3mg [**Hospital1 **].
He responds well to Hydral for elevated BP so if hypertensive
can try IV hydral.
.
ESRD: Pt receiving urgent dialysis in ICU. He was then
transitioned back onto his usual MWF HD schedule. His calcitriol
was discontinued and Sensipar 30mg daily was started per renal.
.
Cirrhosis: Abdominal distension w/o tenderness and low grade
temp to 100.7 on transfer to the medicine floor. Liver enzymes
and coags normal. Abdominal ultrasound with large volume ascitic
fluid. Given fever we did a diagnsotic para. Paracentesis
revealed ascitic fluid with < 250 WBCs and negative G stain.
.
EKG changes: Discussed with cardiology. EKG changes likely
related to ESRD and stable LVH.
.
LE erythema/swelling: Cellulitis/ecchymoses. Blood x 3 NGTD.
Area seemed to be resolving clinically on medicine floor,
however the patient's pain remained moderate/severe. He was
treated with broad spectrum antibiotic coverage including unasyn
and vancomycin. Unasyn was discontinued do to concern of
allergic drug reaction (see below). Plain film and MRI of lower
extremity negative revealed superficial hematoma collections,
there was no eveidence of deep soft tissue infection or
osteomyelitis.
.
Respiratory distress: Patient's respiratory status quickly
improved. He no longer has an oxygen requirement.
.
Anemia: Baseline Hct in 30s. Hct trending down to 26. Likely
anemia in setting of ESRD. Now HCT stable.
.
Rash: Patient developed a macular erythematous rash involving
the neck and surrounding the RLE. Given that the patient has a
history of penicillin allergy it is likely the rash developed as
a result of the addition of unasyn to his antibiotic regimen. It
was discontinued after one day and his rash is slowly improving.
He recieved benadryl for pruritis associated with the rash.
Medications on Admission:
Nephrocaps 1 daily
Lamictal 250 mg b.i.d.
Keppra 375 mg b.i.d. and 250 mg after each HD session (3x per
wk)
Lorazepam 0.5 mg b.i.d.
lorazepam 1 mg qhs
Toprol-XL 200 mg once daily
Nifedipine 120 mg once daily
Lisinopril 20 mg once HS
Plavix 75 mg once daily
ASA 81 mg once daily
Clonidine 0.1 mg b.i.d.
Prevacid 30 mg once daily
Nortriptyline 10 mg q.h.s.
sevelamer 800 mg tid
Calcitriol 0.25 mcg
Discharge Medications:
1. Lamotrigine 100 mg Tablet [**Hospital1 **]: 2.5 Tablets PO BID (2 times a
day).
2. Levetiracetam 250 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2 times
a day).
3. Levetiracetam 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO AFTER HD
(3X PER WEEK) ().
4. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Nortriptyline 10 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at
bedtime).
7. Sevelamer 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
9. Clonidine 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
10. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
12. Cinacalcet 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
13. Clonidine 0.3 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
14. Nifedipine 60 mg Tablet Sustained Release [**Hospital1 **]: Three (3)
Tablet Sustained Release PO DAILY (Daily).
15. Toprol XL 100 mg Tablet Sustained Release 24 hr [**Hospital1 **]: 2.5
Tablet Sustained Release 24 hrs PO once a day.
16. Diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO
Q6H (every 6 hours) as needed.
17. Nephrocaps 1 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day.
18. Prevacid 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
19. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day).
20. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
21. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Labile HTN
ESRD
CHF EF 45%
Siezure Disorder
s/p Fall
Hypothyroidism
PVD
H/o VRE/MRSA
Hepatitis C w/ cirrhosis
hypoparathyroidism
SVT/AVNRT s/p ablation
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital after a fall and were noted to
have elevated blood pressure.
Your medication changes are as follows:
Calcitriol 0.25 mcg was stopped and you were started on
Cinacalcet 30 mg daily.
Lisinopril was increased to 40mg once daily
Nifedipine was increased to 180mg once daily
Please follow up with your appointments and take your
medications as prescribed.
If you experience any change in mental status, siezures,
dehydration, lower extremity swelling, severe hypertension
(Blood pressure >190), fevers, chills, sweats, or skin changes,
please return to the ED.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**2-12**] weeks. Also, restart
scheduled hemodialysis treatment Monday, Wenesday, and [**Date Range 2974**].
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2137-6-21**] 8:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2137-7-4**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2137-7-4**]
11:00
Completed by:[**2137-4-26**]
|
[
"428.0",
"585.6",
"571.5",
"244.9",
"682.6",
"070.54",
"693.0",
"285.21",
"437.2",
"428.42",
"443.9",
"E930.0",
"403.01",
"345.90",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10428, 10498
|
5382, 7976
|
387, 393
|
10694, 10701
|
3953, 5359
|
11342, 11936
|
3387, 3455
|
8423, 10405
|
10519, 10673
|
8002, 8400
|
10725, 11319
|
3470, 3934
|
279, 349
|
421, 2757
|
2779, 3271
|
3287, 3371
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,907
| 171,177
|
34490
|
Discharge summary
|
report
|
Admission Date: [**2128-4-19**] Discharge Date: [**2128-6-7**]
Date of Birth: [**2075-1-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Admission for liver transplant
Major Surgical or Invasive Procedure:
[**2128-4-19**] liver transplant
[**2128-4-20**] redo arterial anastomosis
[**2128-4-25**] ercp:Stricture at the anastomotic site between the donor
and recipient common bile duct with stent placement
[**2128-5-19**]: Ex lap, lysis of adhesions, small bowel resection
[**2128-5-28**] ercp with stent removal
[**2128-5-31**] liver biopsy
History of Present Illness:
52-year-old male with a history of cirrhosis secondary to
HCV and alcohol who developed portal hypertension and an
esophageal variceal hemorrhage, necessitating performance of a
distal splenorenal shunt in [**2121**]. Last year he was found to
have
a 4.4-cm hepatocellular carcinoma. He has undergone
chemoembolization followed by radiofrequency ablation of
a Segment VI lesion. A repeat CT of the abdomen and chest on
[**2128-2-25**] demonstrated no evidence of tumor recurrence at
the
ablation site and no evidence of new or concerning lesions
elsewhere in the liver or lungs.
He is in good spirits today. No recent infections or illnesses.
He has not been taking his lactulose because he has been having
2
bms a day without it.
His blood sugars have been well controlled with the 68 of lantus
at night.
Past Medical History:
Cirrhosis secondary to hepatitis C (diagnosed [**2119**]) as well as
alcohol use
- attempted treatment with interferon and ribavirin, but only on
it for a couple of weeks at 1/3 of the normal dosage and
experienced thrombocytopenia and stopped
- decompensated with a variceal bleed in [**2121**]/[**2122**]
- status post splenorenal shunt
Hepatocellular carcinoma
- s/p chemoembolization on [**2127-7-9**], at [**Hospital3 2358**].
- Turned down for liver transplant at [**Hospital3 2358**] secondary to
marijuana use.
History of a right leg fracture and a left leg fracture
Social History:
Currently living with a friend and is separated from his second
wife. [**Name (NI) **] has two children ages 7 and 24. He quit smoking two
years ago but previously smoked heavily. No current alcohol use.
Past history of cocaine use but none recently. No history of
IVDU. Currently not working.
Family History:
Dad - died at age 70 of CAD and CVA
Mom - aged 83 and healthy
Brother and Sister - both healthy
Denies family history of liver disease, liver cancer or colon
cancer
Physical Exam:
96.6 88 160/100 18 97RA
A&Ox4
No jaundice
Neck no lymphadenopathy
Lungs: CTAB
Heart: RRR
Abd: soft, nt, no hernias
Ext: no edema
Skin: psoriasis patches and vitiligo on his hands
Pertinent Results:
[**2128-4-19**] 08:14AM BLOOD WBC-3.6* RBC-3.45* Hgb-12.8* Hct-35.2*
MCV-102*# MCH-37.0* MCHC-36.3* RDW-15.3 Plt Ct-96*
[**2128-4-19**] 08:14AM BLOOD PT-16.2* PTT-33.9 INR(PT)-1.4*
[**2128-4-19**] 08:14AM BLOOD Glucose-144* UreaN-8 Creat-0.7 Na-139
K-3.3 Cl-109* HCO3-24 AnGap-9
[**2128-4-19**] 08:14AM BLOOD ALT-81* AST-108* AlkPhos-109 TotBili-1.9*
[**2128-4-19**] 08:14AM BLOOD Albumin-3.6 Calcium-8.4 Phos-3.7 Mg-1.8
Studies:
[**2128-3-8**] bone scan - No evidence of osseous metastasis.
[**2128-2-25**] CT torso - Stable appearance of the torso. No evidence
for recurrence or metastatic disease. Enlarged spleen unchanged.
[**2128-2-12**] Cardiac stress test - 1. Normal myocardial perfusion. No
discrete defect to suggest ischemia. 2. Enlarged left
ventricular
cavity size. Estimated LVEDV of 145 ml.
- Normal LVEF of 52 %.
Brief Hospital Course:
On [**2128-4-19**], he underwent piggyback liver transplant; ligation of
distal
splenorenal shunt; lysis of adhesions. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]
assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note.
Drains were placed. Induction immunosuppression was given.
Postop, he went to the SICU. LFTs increased and a liver duplex
was done showing relatively slowed acceleration times and low
resistive indices, with waveforms suggestive of the possibility
of hepatic arterial stenosis.
There was bidirectional flow within the left portal vein. A CTA
was then done noting marked focal kink and abrupt caliber change
at the hepatic arterial anastomosis, narrowing at the portal
venous anastomosis and an area of hypodensity in the liver
transplant, which suggested a site of ischemia/hypoperfusion or
perhaps early infarction, although the vast majority of the
liver opacified normally.
He was then taken back to the OR on [**4-20**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] who
performed excision of hepatic artery atheroma, with revision and
reanastomosis for hepatic artery stenosis and liver biopsy.
Postop, he was sent to the SICU where he was extubated. LFTs
trended down. He was started on prograf on [**4-20**] as well as
cellcept and steroid taper. Liver duplex on [**4-21**] showed improved
flow within the hepatic arteries, with prompt systolic
upstrokes, hepatopetal flow in the main and right portal veins.
Flow in the left portal vein was hepatopetal, but slow and
intermittent; however, to and fro flow in the left portal vein
was no longer observed. There was a right pleural effusion.
He was transferred out of the SICU on [**4-22**] where his diet was
advanced. Pain was hard to control requiring higher doses of
dilaudid (6mg prn q 3 hours). LFTs increased on [**4-23**] and again on
[**4-24**] witih t.bili increasing to 6.7 on [**4-25**]. Duplex of the liver
revealed patent main, left and right portal veins with normal
hepatic veins and hepatic arteries. There was no biliary
dilatation or ascites. On [**4-25**], an ERCP was done with a stricture
at the anastomotic site between the donor and recipient common
bile duct, with mild extravasation of contrast seen at that
site.
A plastic biliary stent was placed. He tolerated this procedure
well with subsequent downward trend of all LFTs.
ERCP was repeated on [**5-5**] as his LFTs were trending upwards with
alk phos at 715.
The plastic stent placed in the biliary duct with previous ERCP
was found in the major papilla. A sphincterotomy had not been
performed at the initial ERCP.
Given the new pancreatic duct dilation on CT a sphincterotomy
was performed over the stent in the 12 o'clock position using a
needle-knife. A new biliary stent was placed and the patient was
started on ursodiol.
Due to pain control issues, he was being given morphine and
dilaudid with moderate relief of pain. He continued to complain
of abdominal pain and developed abdominal distension. An
abdominal CT on [**5-7**] showed improved small-bowel obstruction
with transition point in the mid right abdomen compared to
[**2128-5-2**], although there was distention of mid small bowel loops
with respect to the distal small bowel. There was decreased
small amount of fluid with locules of air along the liver
transplant bed. Previously noted pancreatic ductal dilatation
was improved. Daily KUBs demonstrated decreased small bowel
distension. ABD CT was repeated on [**5-10**] showing Patent
transplant vasculature with caliber change in the hepatic artery
at
the anastamosis due to size mismatch and partial small bowel
obstruction.
Due to rising LFTs, a liver biopsy was performed on [**5-12**] with
changes consistent with moderate acute cellular rejection with
centrivenulitis,mild cholestasis. There was no biliary necrosis
or obstruction. He was enrolled in the Prograf study which
involved treating rejection with higher trough prograf levels.
Prograf levels were high at that time (22 on [**5-13**]) already due
to diarrhea that he was experiencing. Prograf was adjusted
achieving goal trough levels of 14-18. Cellcept which had been
decreased to 250mg qid due to GI intolerance was increased to
500mg qid. LFTs trended down each day. Although, he did
experience a rising creatinine with creatinine increasing to 3.5
on [**5-19**] likely due to prograf.
On [**5-19**], he was taken to the OR for laparoscopy for persistent
complaints of abdominal pain. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. He
underwent exploratory laparotomy, lysis of adhesions and small
bowel resection with primary anastomosis. A twist in the bowel
and a stitch was which was tenting up the omentum was noted
causing the twist in the bowel. Vancomycin and zosyn were given
for 48 hours postop. NG was removed and diet was gradually
resumed, but he developed diarrhea and complaints of abdominal
discomfort.
On [**5-24**], he was febrile to 101. Blood and urine culture were sent
with growth of Gram negative rods on blood cultures. The picc
line was removed and TPN stopped. Cefepime and Flagyl were
started on [**5-25**].
ABD CT was done on [**5-25**] showing new small bowel wall thickening
possibly representing infectious or inflammatory process. Air in
the bladder 1 week after removal of foley catheter was
concerning for cystitis. There as also new small amount of
ascites. Cefepime and Flagyl were continued and cellcept was
decreased to 250mg [**Hospital1 **] on [**5-26**]. Diarrhea resolved. A picc line
was inserted on [**5-26**] and TPN was resumed. Of note, the picc tip
culture was negative as well as urine and stool for C.diff.
On [**5-28**], alk phos was increased to 606 from 552 and t.bili
increased to 4.2 from 2.3. An ERCP was performed noting mismatch
donor/recipient size otherwise there was no leak/stenosis and
the stent was removed. Alk phos continued to trend up after the
ERCP. On [**5-31**], a liver biospy was performed showing resolving
rejection. There were biliary centric features concerning for an
infectious vs obstructive/ischemic process. Viral stains were
done. A CMV viral load was sent and is negative, as well as an
HCV VL which is reported as 8,400,000 IU/mL. Remeron was stopped
due to potential to affect LFTs as was Bactrim. Pentamadine was
not started and this will need to be addressed at outpatient
clinic. Cefepime was stopped on [**6-2**]. Flagyl is due to be
completed [**6-8**].
Patient had calorie counts done which were very variable
(700->[**2118**]). Patient discharged to home with VNA for medication
teaching, blood glucose management and monitoring the abdominal
incision (staples are d/c'd)
Medications on Admission:
Lantus insulin 68 units in the evening
Humalog sliding scale
Mirtazapine 50 mg. tab at night for sleep
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
5. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*60 Capsule(s)* Refills:*0*
8. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty
(40) units Subcutaneous once a day: AM dose.
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Eight (28) units Subcutaneous once a day: PM dose.
Disp:*2 bottles* Refills:*2*
11. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Before meals and bedtime.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 2 days.
Disp:*5 Tablet(s)* Refills:*0*
13. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
HCV
s/p liver transplant
Hepatic artery stenosis
Stricture at the anastomotic site between the donor and
recipient
common bile duct,
DM
Ileus
partial small bowel obstruction
liver rejection
bile leak
diarrhea
depression
malnutrition
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
abdominal pain, diarrhea or any concerns
Take loperamide for management of frequent/loose stool. If you
are starting to get constipated, stop the loperamide. Take
colace if you becoming constipated
Labs every Monday and Thursday
No driving if taking narcotic pain medication
[**Month (only) 116**] shower
check blood sugar prior to meals and bedtime. Now on NPH and
humalog for glucose management. Please follow up with [**Last Name (un) **]
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2128-6-10**] 10:00
ERCP 2 (ST-4) GI ROOMS Date/Time:[**2128-6-29**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2128-6-29**]
1:00
Completed by:[**2128-6-7**]
|
[
"041.84",
"584.9",
"E878.0",
"V10.07",
"996.82",
"311",
"571.2",
"560.2",
"440.8",
"263.9",
"997.4",
"568.0",
"998.2",
"070.54",
"790.7",
"250.02",
"572.3",
"576.2",
"560.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.87",
"50.12",
"39.49",
"50.11",
"51.85",
"00.93",
"51.10",
"38.87",
"97.05",
"54.59",
"50.51",
"99.15",
"45.62",
"97.55"
] |
icd9pcs
|
[
[
[]
]
] |
11903, 11961
|
3690, 10496
|
344, 682
|
12238, 12245
|
2833, 3667
|
12876, 13245
|
2451, 2618
|
10650, 11880
|
11982, 12217
|
10522, 10627
|
12269, 12853
|
2633, 2814
|
273, 306
|
710, 1524
|
1546, 2123
|
2139, 2435
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,520
| 161,757
|
32041+57779
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-6-15**] Discharge Date: [**2132-9-25**]
Date of Birth: [**2061-5-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
re-admitted with acute renal failure in [**5-29**]
Major Surgical or Invasive Procedure:
[**2131-9-28**]: Admission to [**Hospital1 18**] w/ high output EC fistula
(max 2700cc/day; initial albumin 1.9 TRF 80)
[**2131-11-23**]: Repositioning of postpyloric feeding tube (Dr [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 957**])
2/26/08Ex lap, LOA, closure of 2 enterotomies, transverse end
colostomy, feeding jejunostomy #14 (Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**])
[**2132-4-17**]: Redo [**Last Name (un) **] gastrostomy #20, change of jejunostomy tube
#14
revision of end colostomy (Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**])
[**2132-6-2**]: Colonoscopy showing 5cm stricture in distal colon,
stented w/ 20F latex catheter
[**2132-9-16**]: ERCP w/ pancreatic duct stent placed
History of Present Illness:
71F discharged [**6-12**] after ~3mos hospital stay, briefly
summarized
as follows: ruptured AAA in [**5-28**] complicated by development of
colocutaneous fistula s/p exploratory laparotomy, adhesiolysis,
colocutaneous fistulectomy, transverse colostomy, and feeding
jejunostomy on [**2132-3-18**] with Dr. [**Last Name (STitle) 957**]. On [**4-17**] she had an G
tube placed to assist in management of her increasing NGT
output,
but she continued to put out thick bilious fluid despite
prokinetic therapy. Stomal colonoscopy demonstrated a 5cm
stricture at the colostomy site which was subsequently stented
open with a 20F whistle-tip catheter draining within the ostomy
appliance. At the time of discharge to [**Hospital **] Rehab on [**2132-6-12**]
she was to continue with TPN and tube feeding as well as
increase
her intake of a regular diet. Her G tube was open to gravity and
she was tolerating progressive clamping intervals.
On [**6-14**] the 20F whitsle-tip cath dislodged from her ostomy and
she was sent back to the [**Hospital1 18**] ED. Prior to her transfer, labs
drawn at [**Hospital1 **] were notable for a Cr of 1.7, up from 1.0 on
[**6-12**]. Upon arrival to our ED, she became hypotensive to 75/52
with a HR of 88. She had no complaints of fever, chills, rigors,
abdominal pain, dyspnea or cough. She did have some difficulty
urinating, describing needing to cough in order to void.
Past Medical History:
*open [**Last Name (un) **] gastrostomy tube x 2 [**11-28**], [**10-28**]
*Ruptured AAA; s/p endovascular abdominal aortic aneurysm repair
[**2131-6-2**]
*[**2109**]: colon cancer; s/p right hemicolectomy; treated with s/p
radiation treatment (has bowel damage from XRT).
*[**2127**]: Postoperative radiation resulted in bowel damage;
developed small bowel obstruction underwent exploratory lap with
loa, complicated by developement EC fistula that closed with
after 1 year of treatment with TPN/enteral feedings.
*Incarcerated hernia
*Coronary artery disease s/p PCI (MI in '[**07**])
*Chronic obstructive pulmonary disease
*Chronic renal failure
*Hypertension
*Hypercholesterolemia
*Choleithiasis (asymptomatic)
*Urinary tract infection (Kleb, VRE)
*Chronic diarrhea
*Small bowel obstructions
*Weight loss (since [**2127**]) from 200lbs to 80lbs per patient
report
*Malnutrition/ failure to thrive
*History of C. Diff
*Hearing loss - wears right hearing aid
Social History:
Pt comes from Rehab facility, prior to which she has been
hospitalized since [**2131-5-22**] at various facilities. Prior to
[**May 2131**] she smoked 1 ppd for 55 years, and was drinking several
drinks per night for 12 years as well. She denies any
recreational drug use. Prior to [**5-28**] she was independent and
living on her own.
Family History:
Significant for father who died of MI at age 79; grandmother
with ? eye cancer
Physical Exam:
Gen: NAD, A&Ox3, MM dry (-)scleral icterus, poor skin turgor
Pul: CTAB
Cor: RRR
Abd: soft/ND (-)tenderness (-)guarding (-)rebound (-)tympani
colostomy well-perfused with loose stool in appliance;
GT to gravity with ~400cc dark brown fluid; JT capped;
Ext: well-perfused without edema, ankle contractures bilaterally
Pertinent Results:
[**2132-6-15**] 12:01AM BLOOD WBC-23.8*# RBC-4.34# Hgb-12.2# Hct-37.4#
MCV-86 MCH-28.0 MCHC-32.6 RDW-15.5 Plt Ct-473*
[**2132-6-15**] 12:52PM BLOOD WBC-14.9* RBC-3.64* Hgb-10.1* Hct-31.0*
MCV-85 MCH-27.7 MCHC-32.5 RDW-15.5 Plt Ct-320
[**2132-6-15**] 07:33PM BLOOD WBC-11.8* RBC-3.16* Hgb-9.3* Hct-27.3*
MCV-86 MCH-29.6 MCHC-34.2 RDW-15.8* Plt Ct-306
[**2132-6-16**] 04:18AM BLOOD WBC-9.4 RBC-2.73* Hgb-7.8* Hct-24.0*
MCV-88 MCH-28.4 MCHC-32.4 RDW-15.7* Plt Ct-252
[**2132-6-16**] 07:45PM BLOOD WBC-11.6* RBC-3.55*# Hgb-10.5*#
Hct-31.8*# MCV-90 MCH-29.5 MCHC-32.9 RDW-16.2* Plt Ct-273
[**2132-6-17**] 10:37AM BLOOD WBC-10.7 RBC-3.46* Hgb-10.2* Hct-30.3*
MCV-88 MCH-29.5 MCHC-33.6 RDW-16.0* Plt Ct-284
[**2132-6-18**] 05:30AM BLOOD WBC-9.6 RBC-3.25* Hgb-9.2* Hct-28.4*
MCV-88 MCH-28.5 MCHC-32.5 RDW-16.0* Plt Ct-273
[**2132-6-15**] 12:01AM BLOOD Glucose-90 UreaN-111* Creat-3.9*# Na-136
K-4.2 Cl-84* HCO3-37* AnGap-19
[**2132-6-15**] 12:52PM BLOOD Glucose-112* UreaN-104* Creat-3.6* Na-136
K-3.0* Cl-83* HCO3-41* AnGap-15
[**2132-6-15**] 07:33PM BLOOD Glucose-96 UreaN-93* Creat-3.2* Na-136
K-3.5 Cl-89* HCO3-42* AnGap-9
[**2132-6-16**] 12:54AM BLOOD Glucose-113* UreaN-81* Creat-2.8* Na-143
K-3.4 Cl-100 HCO3-37* AnGap-9
[**2132-6-16**] 04:18AM BLOOD Glucose-113* UreaN-77* Creat-2.6* Na-141
K-3.3 Cl-101 HCO3-34* AnGap-9
[**2132-6-16**] 07:45PM BLOOD Glucose-112* UreaN-58* Creat-2.0* Na-143
K-3.4 Cl-110* HCO3-23 AnGap-13
[**2132-6-17**] 10:37AM BLOOD Glucose-106* UreaN-48* Creat-1.6* Na-144
K-3.4 Cl-110* HCO3-24 AnGap-13
[**2132-6-18**] 05:30AM BLOOD Glucose-96 UreaN-39* Creat-1.4* Na-149*
K-3.5 Cl-113* HCO3-25 AnGap-15
[**2132-9-25**] 04:48AM BLOOD WBC-6.2 RBC-2.86* Hgb-8.6* Hct-28.4*
MCV-99* MCH-30.1 MCHC-30.3* RDW-17.2* Plt Ct-254
[**2132-9-13**] 04:14AM BLOOD WBC-9.1 RBC-2.69* Hgb-8.1* Hct-25.3*
MCV-94 MCH-30.0 MCHC-31.9 RDW-16.7* Plt Ct-237
[**2132-7-25**] 07:00AM BLOOD WBC-9.3 RBC-3.20* Hgb-9.1* Hct-27.6*
MCV-86 MCH-28.6 MCHC-33.1 RDW-16.4* Plt Ct-263
[**2132-9-25**] 04:48AM BLOOD Plt Ct-254
[**2132-9-22**] 05:35AM BLOOD Plt Ct-249
[**2132-9-20**] 05:19AM BLOOD Plt Ct-232
[**2132-9-25**] 04:48AM BLOOD Glucose-83 UreaN-63* Creat-1.1 Na-146*
K-4.6 Cl-113* HCO3-27 AnGap-11
[**2132-8-30**] 03:56AM BLOOD Glucose-91 UreaN-79* Creat-1.3* Na-135
K-4.4 Cl-101 HCO3-26 AnGap-12
[**2132-8-4**] 05:09AM BLOOD Glucose-81 UreaN-36* Creat-1.0 Na-141
K-3.8 Cl-107 HCO3-24 AnGap-14
[**2132-9-21**] 03:32AM BLOOD ALT-11 AST-14 LD(LDH)-131 AlkPhos-195*
Amylase-40 TotBili-0.3
[**2132-6-25**] 03:32PM BLOOD ALT-20 AST-17 AlkPhos-180* Amylase-27
TotBili-0.7
[**2132-9-21**] 03:32AM BLOOD Lipase-15
[**2132-9-25**] 04:48AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
[**2132-9-18**] 05:45PM BLOOD Albumin-2.7* Calcium-8.9 Phos-2.2* Mg-2.0
[**2132-9-15**] 04:52AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
[**2132-9-21**] 03:32AM BLOOD calTIBC-211* Ferritn-439* TRF-162*
[**2132-9-14**] 04:47AM BLOOD calTIBC-208* Ferritn-610* TRF-160*
[**2132-9-7**] 05:16AM BLOOD calTIBC-200* Ferritn-515* TRF-154*
[**2132-8-30**] 09:52AM BLOOD calTIBC-209* Ferritn-600* TRF-161*
[**2132-8-24**] 09:00AM BLOOD calTIBC-198* Ferritn-725* TRF-152*
[**2132-8-17**] 04:25AM BLOOD calTIBC-152* Ferritn-842* TRF-117*
[**2132-8-3**] 05:11AM BLOOD calTIBC-182* Ferritn-761* TRF-140*
[**2132-7-27**] 02:24AM BLOOD calTIBC-202* Ferritn-1296* TRF-155*
[**2132-7-20**] 03:49AM BLOOD calTIBC-189* Ferritn-962* TRF-145*
[**2132-7-16**] 02:31AM BLOOD calTIBC-135* Ferritn-883* TRF-104*
[**2132-7-14**] 04:20AM BLOOD calTIBC-107* Ferritn-705* TRF-82*
[**2132-7-7**] 04:00AM BLOOD calTIBC-176* Ferritn-805* TRF-135*
[**2132-6-30**] 06:00AM BLOOD calTIBC-125* Ferritn-829* TRF-96*
[**2132-9-21**] 03:32AM BLOOD Triglyc-76 HDL-36 CHOL/HD-4.7 LDLcalc-117
[**2132-9-14**] 04:47AM BLOOD Triglyc-101 HDL-28 CHOL/HD-5.8
LDLcalc-113
Brief Hospital Course:
Patient's HPI as above. Given the degree of hemoconcentration
evident from her laboratory trend, the transient hypotension was
likely secondary to severe hypovolemia although urosepsis was
also considered. She was admitted to the hospital for IV
antibiotics and fluid resuscitation for her acute renal failure.
.
Hospital course by system:
Neuro: pt remained alert and oriented. Her pain was
well-controlled with low dose liquid oxycodone.
CV: Pt did have several episodes of hypertension of SBPs in the
190's. This was treated with IV hydralazine. Otherwise she
remained hemodynamically stable. She continued to be in afib
that was rate controlled with beta-blockers and diltiazem.
Pulmonary: No major issues
GI: tubefeeds were initially held, then restarted at 10cc per
hour and increased as tolerated with clamping trials. She was
initially given nephramine while her renal function improved as
well as nutrition via TPN and tubefeeds. However, on HD4 her
tubefeeds were held for obstructive symptoms. For further
details, see "Events" section below.
GU: 1) acute renal failure - She was treated with aggresive
fluid resuscitation and nepthramine as well as a brief course of
arginine. Her BUN and Cr trended down towards normal level (as
noted in the labs section above). 2) She was also found to have
a UTI and started on meropenum. Her cultures grew out VRE and
she was switched to linezolid.
Endocrine: she was kept on an insulin sliding scale during her
hospitalization and strict glucose control was employed.
Prophylaxis: pt was continued on SCH as well as pneumatic boots
T/L/D: pt has a g-tube, j-tube, a colostomy stent, and a PICC
line (this was exchanged over wire in interventional radiology
on HD4)
.
Events:
On HD4, ([**6-18**]) she was transferred to the ICU due to increased
demand of nursing care in terms of fluid replacements and drain
care - needing one-to-one care.
.
HD5 ([**6-19**]): she had several episodes of vomiting and decreased
colostomy output. She underwent a fluoroscopic fistulogram of
her colostomy as well as contrast being injected through the
J-tube. A small length of bowel was opacified, however, there
was a failure of the contrast to communicate with the
retrogradely opacified bowel loops to the colostomy suggesting
that she was obstructed. this was felt to be due to swelling in
the small bowel walls from aggresive fluid resuscitation and she
was started on albumin.
.
HD6 ([**6-20**]): full TPN continued, awaiting return of bowel
function
HD7 ([**6-21**]): episode of wheezing, CXR showed slight fluid
overload and lasix given with good effect
HD9 ([**6-23**]): Her ostomy output decreased significantly. Her stent
was flushed thoroughly and hardened contents were able to be
flushed out, showing that the pt likely had some inspisation.
She was started on mineral via j-tube and up the ostomy.
HD10 ([**6-24**]): pt underwent contrast fistulogram of ostomy which
again showed the same obstruction as demonstrated on the
previous fistulogram. Mineral oil and saline flushed were
continued via j-tube and ostomy stent.
HD11 ([**6-25**]): pt was noted to be slighted disoriented with visual
hallucinations. EKG, CXR, labs were unremarkable. Her urine
culture grew pseudomonas, but this was felt to be due to chronic
colonization. Her delirium was felt to be due to a response to
her fentanyl patch and IV fentanyl. Narcotic medication was
withheld then given only in small doses for the next few days as
needed.
HD12-18 ([**Date range (1) 75035**]): No major events, the pt was gently diuresed
with lasix as she was noted to be slightly fluid overloaded
given her weight was up, her chest exam revealed crackles with
evidence of fluid overload on her CXR, as well edema in her
extremities and elevated JVD. She seemed to be less confused as
well.
HD19-20 ([**Date range (1) 135**]): No major events. Her ostomy output began
to increase and we began j-tube clamp trials. Her fluid balance
was corrected and diuresis was discontinued. Her mental status
remained at baseline - alert and oriented.
HD21 ([**7-3**]): Pt started on gentamycin for +pseudomonas and kleb
in urine.
Volume (mL/day) Kcal/day Protein (g/day) Dex/carb (g/day) Fat
(g/day) Protein (g/kg/day) Kcal/kg/day
TPN 1650 1840 90 330 40 1.8 37
TF 1200 900 50 126 38 1.0 18
Total 2[**Telephone/Fax (3) 75036**] 78 2.8 55
Albumin 2.6 TRF 160 (highest values during all of [**Hospital1 18**]
admission)
71yoF admitted to [**Hospital3 75037**]??????s Hospital [**2131-8-16**] for
enterocutaneous fistula, which developed while she was at rehab.
Conflicting fistulograms suggested either distal SB or
colocutaneous fistula.
PMH/PSH prior to admission to [**Hospital1 18**]:
?????? Colon CA, s/p R hemicolectomy, s/p XRT (w/ resultant radiation
bowel injury)
?????? SBO s/p ex lap, LOA [**2127**] (Dr [**Last Name (STitle) **] [**Name (STitle) **]), c/b EC fistula, closed
w/ TPN then enteral feeding x 1 yr
?????? Ruptured AAA, s/p open AAA repair [**2131-6-2**] (Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
?????? CAD, MI ??????83, s/p PCI
?????? Hypertension
?????? Hypercholesterolemia
?????? COPD
?????? CRI
?????? Recurrent UTI (Klebsiella, VRE) - ? enterovesicular fistula on
cystogram but none seen on barium enema (evaluated by Dr [**Last Name (STitle) 75038**],
[**Hospital3 75037**]??????s Hospital; no intervention due to poor nutrition)
?????? Chronic diarrhea (radiation injury?)
?????? Hx of C diff colitis
?????? Hearing loss, requiring R hearing aid
?????? Bilateral cataracts, s/p intravitreal injections
Surgical History at [**Hospital1 18**]:
[**2131-9-28**] Admission to [**Hospital1 18**] w/ high output EC fistula
(max 2700cc/day; initial albumin 1.9 TRF 80)
Hematuria in the setting of ASA, Coumadin, Heparin > resolved
[**2131-11-6**] [**Last Name (un) **] gastrostomy and postpyloric feeding tube (Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**])
[**2131-11-23**] Repositioning of postpyloric feeding tube (Dr [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 957**])
[**2131-12-19**] Decreased fistula output to 500cc/day with TPN and TF
support (40cc/day)
Discharged to [**Hospital1 **] [**Hospital1 189**]
Tolerating soft mechanical diet + TPN at rehab
[**2132-3-12**] Readmit for planned OR
[**2132-3-18**] Ex lap, LOA, closure of 2 enterotomies, transverse end
colostomy,
feeding jejunostomy #14 (Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**])
Operative findings:
1) multiple transition points in SB due to adhesion
2) atrophic L colon and separation of her colonic anastomosis,
resulting in colocutaneous fistula
3) fibrotic tail of pancreas (not biopsied)
Postop rapid afib treated with diltiazem
Prolonged postop ileus
[**2132-4-17**] Redo [**Last Name (un) **] gastrostomy #20, change of jejunostomy tube
#14
revision of end colostomy (Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**])
[**2132-6-2**] Colonoscopy showing 5cm stricture in distal colon,
stented w/ 20F latex catheter
[**2132-6-12**] Discharged to [**Hospital1 **] [**Hospital1 8**]
[**2132-6-15**] Readmitted w/ urosepsis
Colostomy output improved w/o requiring stenting catheter
TF + TPN
Colostomy output 1400cc/day
New pancreatico-cutaneous fistula (based on output [**Doctor First Name **] 6340 Lip
[**Numeric Identifier 22065**]; fistulogram [**2132-9-9**] did NOT demonstrate it to be
enterocutaneous fistula as initially presumed)
MRCP showing normal anatomy, octreotide started
[**2132-9-16**] ERCP w/ pancreatic duct stent placed
Recurrent UTI (VRE [**2132-6-15**], Pseudomonas [**2132-6-25**],
ESBL Klebsiella, Pseudomonas, VRE [**2132-9-2**]) ?????? on Linezolid
Meropenem
Current nutritional status (based on feeding weight 50 kg):
Medications on Admission:
1. Papain-Urea-Chlrph Cpr Cmp Sod [**Telephone/Fax (3) 75039**]-5 unit-mg-mg/gram
Foam [**Telephone/Fax (3) **]: One (1) ML Topical DAILY () as needed for prn clogged
J tube.
2. Sertraline 50 mg Tablet [**Telephone/Fax (3) **]: 1.5 Tablets PO DAILY (Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Telephone/Fax (3) **]: Two (2) Inhalation Q6H (every 6 hours) as
needed.
4. Ipratropium Bromide 0.02 % Solution [**Telephone/Fax (3) **]: Two (2) Inhalation
Q6H (every 6 hours) as needed.
5. Camphor-Menthol 0.5-0.5 % Lotion [**Telephone/Fax (3) **]: One (1) Appl Topical
QID (4 times a day) as needed.
6. Ascorbic Acid 90 mg/mL Drops [**Telephone/Fax (3) **]: One (1) PO DAILY (Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
8. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: [**1-23**] PO Q6H (every 6
hours).
9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [**Month/Day (2) **]:
15-30 MLs PO QID (4 times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
11. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: [**1-23**] PO Q4H (every 4
hours) as needed.
12. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical HS
(at bedtime) as needed.
13. Diltiazem HCl 30 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO QID (4 times
a day).
14. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day (2) **]: One (1)
Injection Q8H (every 8 hours) as needed.
15. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day (2) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
16. HydrALAzine 10 mg IV Q3H:PRN for SBP>160
17. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN
Hold for RR<12 or excessive sedation
18. Metoprolol Tartrate 20 mg IV Q6H
hold for SBP<90, HR<60
19. Octreotide Acetate 50 mcg IV Q8H
20. Prochlorperazine 5 mg IV Q6H:PRN nausea
21. Metoclopramide 10 mg IV Q6H
22. Alteplase (Catheter Clearance) 2 mg IV PRN
Discharge Medications:
1. Papain-Urea-Chlrph Cpr Cmp Sod [**Telephone/Fax (3) 75039**]-5 unit-mg-mg/gram
Foam [**Telephone/Fax (3) **]: One (1) ML Topical DAILY () as needed for prn clogged
J tube.
2. Sertraline 50 mg Tablet [**Telephone/Fax (3) **]: 1.5 Tablets PO DAILY (Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Telephone/Fax (3) **]: Two (2) Inhalation Q6H (every 6 hours) as
needed.
4. Ipratropium Bromide 0.02 % Solution [**Telephone/Fax (3) **]: Two (2) Inhalation
Q6H (every 6 hours) as needed.
5. Camphor-Menthol 0.5-0.5 % Lotion [**Telephone/Fax (3) **]: One (1) Appl Topical
QID (4 times a day) as needed.
6. Ascorbic Acid 90 mg/mL Drops [**Telephone/Fax (3) **]: One (1) PO DAILY (Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
8. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: [**1-23**] PO Q6H (every 6
hours).
9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [**Month/Day (2) **]:
15-30 MLs PO QID (4 times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
11. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: [**1-23**] PO Q4H (every 4
hours) as needed.
12. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical HS
(at bedtime) as needed.
13. Diltiazem HCl 30 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO QID (4 times
a day).
14. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day (2) **]: One (1)
Injection Q8H (every 8 hours) as needed.
15. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day (2) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
16. HydrALAzine 10 mg IV Q3H:PRN for SBP>160
17. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN
Hold for RR<12 or excessive sedation
18. Metoprolol Tartrate 20 mg IV Q6H
hold for SBP<90, HR<60
19. Octreotide Acetate 50 mcg IV Q8H
20. Prochlorperazine 5 mg IV Q6H:PRN nausea
21. Metoclopramide 10 mg IV Q6H
22. Alteplase (Catheter Clearance) 2 mg IV PRN
23. Linezolid 600 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H (every
12 hours). Tablet(s)
24. Meropenem 500 mg IV Q8H
25. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback [**Month/Day (2) **]:
One (1) Intravenous Q24H (every 24 hours) for 6 days.
26. Lidocaine HCl 2 % Gel [**Month/Day (2) **]: One (1) Appl Mucous membrane
DAILY (Daily).
27. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Colon CA, s/p R hemicolectomy, s/p XRT (w/ resultant
radiation bowel injury)
2. SBO s/p ex lap, LOA [**2127**] (Dr [**Last Name (STitle) **] [**Name (STitle) **]), c/b EC fistula, closed
w/ TPN then enteral feeding x 1 yr
3. Ruptured AAA, s/p open AAA repair [**2131-6-2**] (Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
4. CAD, MI ??????83, s/p PCI
5. Hypertension
6. Hypercholesterolemia
7. COPD
8. CRI
9. Recurrent UTI (Klebsiella, VRE) - ? enterovesicular fistula
on cystogram but none seen on barium enema (evaluated by Dr
[**Last Name (STitle) 75038**], [**Hospital3 75037**]??????s Hospital; no intervention due to poor
nutrition)
10. Chronic diarrhea (radiation injury?)
11. Hx of C diff colitis
12. Hearing loss, requiring R hearing aid
13. Bilateral cataracts, s/p intravitreal injections
14. Enterocutaneous fistula
15. poor nutritional status
Discharge Condition:
Stable
Long-term prognosis guarded due to radiation injuries
Followup Instructions:
Transfer to the service of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (hospitalist - [**Hospital 75040**] Medical Center, [**Hospital1 1559**], MA ([**Telephone/Fax (1) 75041**]
F/u with PCP (Dr. [**Last Name (STitle) 17534**] [**Name (STitle) **]) in 1 week.
F/u with [**Hospital1 **] GI in 6 weeks re: stent assessment
Completed by:[**2132-9-25**] Name: [**Known lastname 12350**],[**Known firstname 2**] G Unit No: [**Numeric Identifier 12351**]
Admission Date: [**2132-6-15**] Discharge Date: [**2132-9-25**]
Date of Birth: [**2061-5-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10929**]
Addendum:
Patient has had Jtuplce placed back today by 7pm, needs contrast
study to eval the placement of the Tube, before starting the
tube feed.
Discharge Disposition:
Extended Care
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**] MD [**MD Number(1) 3596**]
Completed by:[**2132-9-25**]
|
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icd9cm
|
[
[
[]
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] |
[
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|
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364, 1134
|
21596, 21660
|
4364, 8140
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|
3921, 4002
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15987, 18057
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274, 326
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1162, 2567
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2589, 3551
|
3567, 3905
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,603
| 133,303
|
23703
|
Discharge summary
|
report
|
Admission Date: [**2130-2-24**] Discharge Date: [**2130-3-7**]
Date of Birth: [**2053-4-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Fatigue and Diarrhea
Major Surgical or Invasive Procedure:
Intubation [**2130-2-24**]
History of Present Illness:
76 M with metastatic gastric CA on week 2 of palliative
CIsplatin/CPT-11, presents with increasing weakness and diarrhea
x5days. There have been no fevers, chills at home, no cough,
dysuria, or other localizing symptoms besides the diarrhea. The
pt's family called the oncologist who encouraged them to seek
care in the ED.
.
In the ED at 1115 [**2130-2-24**]: vitals were t98.1 p 108 bp 98/60 rr
22 98 5 on 5L. He was noted to be neutropenic with ANC<200. At
2:45 pm, pt was noted to have pulse 148 which was demonstrated
on 12 lead to be a-fib. BP at this time was 95/52. His lactate
went from 1.4 at 1pm to 4.3 at 4pm. He started on sepsis
protocol and cnetral line was placed, he was aggressively volume
resuscitated wtih 6.5 liters NS. The bp became progressively
less stable and the pt was started on Neosynephrine. He was
given cefepime and vanc. He was intubated in the ED in
anticipation of possible cardioversion.
Past Medical History:
Gastric CA. Diagnosed [**4-21**] after presenting with abdominal pain,
melena, anemia, and weight loss. He was noted to have peritoneal
carcinomatosis. He underwent chemo with epirubicin, cisplatin
and 5-FU from [**Month (only) **] to [**2129-10-18**]. He recently started
CIsplatin/CPT-11 [**1-23**].
.
PMHx:
1) Nephrectomy in [**2123**] to remove RCC per daughter
2) ulcers 30 years ago
Social History:
Social History:
Mandarin/Japanese speaking man who grew up in northeast mainland
[**Country **]. Married, lives with his wife. Quit smoking and alcohol 5
years
ago post nephrectomy. Denied a history of heavy alcohol intake
in the past.
Family History:
Family History:
Denied a history of cancer
Physical Exam:
VS: T 96 BP 114/66 P 158 R 25
GEN: Cachectic appearing, sedated, intubated.
NECK: supple no LAD
LUNGS: CTAB
CV: tachycardic, irreg irreg.
ABD: firm mass in abdomen, soft NT/ND BS+ g tube c/d/i
EXT: muscle wsating, no edema.
Pertinent Results:
Admission Labs:
[**2130-2-24**] 12:06PM PLT SMR-NORMAL PLT COUNT-200
[**2130-2-24**] 12:06PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2130-2-24**] 12:06PM NEUTS-28* BANDS-28* LYMPHS-40 MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2130-2-24**] 12:06PM WBC-0.5*# RBC-3.51* HGB-10.9* HCT-31.3*
MCV-89 MCH-31.1 MCHC-34.8 RDW-16.0*
[**2130-2-24**] 12:06PM CALCIUM-9.0 PHOSPHATE-6.0*# MAGNESIUM-2.4
[**2130-2-24**] 12:06PM CK-MB-NotDone cTropnT-0.02*
[**2130-2-24**] 12:06PM CK(CPK)-20*
[**2130-2-24**] 12:06PM GLUCOSE-126* UREA N-83* CREAT-2.1*
SODIUM-131* POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-17* ANION GAP-20
[**2130-2-24**] 12:39PM LACTATE-1.4
[**2130-2-24**] 03:47PM HGB-9.7* calcHCT-29
[**2130-2-24**] 03:47PM LACTATE-4.3*
[**2130-2-24**] 03:47PM TYPE-ART PO2-90 PCO2-22* PH-7.37 TOTAL
CO2-13* BASE XS--10 INTUBATED-NOT INTUBA
[**2130-2-24**] 05:00PM PT-14.2* PTT-32.1 INR(PT)-1.3*
[**2130-2-24**] 05:00PM GLUCOSE-97 UREA N-70* CREAT-1.7* SODIUM-137
POTASSIUM-4.1 CHLORIDE-113* TOTAL CO2-15* ANION GAP-13
[**2130-2-24**] 05:50PM LACTATE-0.9
[**2130-2-24**] 05:50PM CK(CPK)-57 cTropnT-0.01 CK-MB-NotDone
[**2130-2-24**] 06:28PM URINE WBCCLUMP-OCC
[**2130-2-24**] 06:28PM URINE AMORPH-MOD
[**2130-2-24**] 06:28PM URINE GRANULAR-0-2 COARSE GRANULAR CASTS
HYALINE-0-2
[**2130-2-24**] 06:28PM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2130-2-24**] 06:28PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2130-2-24**] 06:28PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2130-2-24**] 09:48PM HCT-22.0*#
[**2130-2-24**] 09:48PM CALCIUM-6.2* PHOSPHATE-4.4# MAGNESIUM-1.7
[**2130-2-24**] 09:48PM LD(LDH)-73*
[**2130-2-24**] 09:48PM GLUCOSE-111* SODIUM-140 POTASSIUM-3.5
CHLORIDE-116* TOTAL CO2-13* ANION GAP-15
[**2130-2-24**] 10:11PM LACTATE-1.2
[**2130-2-24**] 10:47PM CORTISOL-49.2*
[**2130-2-24**] 11:19PM CORTISOL-50.1*
[**2130-2-24**] 11:33PM LACTATE-1.4
[**2130-2-24**] 11:33PM TYPE-ART TEMP-35.6 RATES-14/14 TIDAL VOL-500
PEEP-5 O2-100 PO2-397* PCO2-25* PH-7.28* TOTAL CO2-12* BASE
XS--12 AADO2-298 REQ O2-55 -ASSIST/CON INTUBATED-INTUBATED
.
Admission CXR:
A right-sided subclavian central vein catheter is in unchanged
position. The heart size, mediastinal and hilar contours are
stable. The ascending and descending aorta are tortuous. The
lung volumes are increased. Again seen are numerous small
calcified nodules within both lobes of the lungs. There is
stable pleural thickening on the right. No pleural effusions
are seen.
.
IMPRESSION: No evidence for pneumonia.
.
Admission KUB:
Single upright abdominal radiograph demonstrates a gastric tube
projecting
over the left upper quadrant. Surgical staples project over the
epigastrium and right lower quadrant. No pneumoperitoneum
detected. There is a paucity of bowel gas. Visualized osseous
structures are grossly unremarkable.
.
IMPRESSION:
No pneumoperitoneum. Paucity of bowel gas represents a
nonspecific bowel gas pattern.
.
CHEST, [**2130-2-26**]: AP portable semi-upright view. The
endotracheal tube terminates in good position between the
thoracic inlet and the carina. The left internal jugular
central venous line and the right subclavian Port-A-Cath remain
in stable positions. The patchy opacity at the right lung base
is unchanged. Pulmonary vessels appear larger than on [**11-25**], [**2128**], suggestive of pulmonary venous congestion, without
frank pulmonary edema. The costophrenic sulci are not fully
imaged. There is no definite pleural effusion. Bilateral
calcified pulmonary nodules are again noted.
.
IMPRESSION:
1. Satisfactory endotracheal tube position.
2. Unchanged patchy opacity in the right lower lobe
representing
atelectasis versus pneumonia.
Brief Hospital Course:
[**Hospital Unit Name 153**] Course:
In the [**Hospital Unit Name 153**] Vanc and Cefepime were initially continued, and
Ambisome and PO Flagyl were added, for fungal coverage and C
diff coverage respectively. Blood cultures grew Klebsiella and
E coli -> Abx narrowed to IV Cipro + Flagyl for C diff. C diff
toxin x 4 negative, but given high suspicion and continued
diarrhea Flagyl was continued. He was started on Neupogen for
neutropenia, and transfused 3 U PRBCs to maintain hct. His
platelets were noted to be low, so DIC labs were checked and
were negative, and a HIT Ab was sent and was negative.
Thrombocytopenia was felt to be [**1-19**] recent chemotherapy and was
stable, with no evidence of bleeding. He was noted to be in A
fib with baseline HR 110s, episodes of HR up to 140-150s. Rate
control was initially limited by low BP, but as pressors were
weaned and BP stabilized low-dose Metoprolol was started. He
was weaned from the vent and extubated in the evening on [**2-25**],
and weaned off of pressors on [**2-27**]. As BP and oxygenation were
stable he was transferred to the floor for further care.
.
11R Course:
Bacteremia: Surveillance blood cultures [**Date range (1) 60577**] negative. E
coli and Klebsiella pan-sensitive. Continued Cipro for a 14 day
course given bacteremia (day 14 = [**3-9**]) BP stable on the floor
over admission.
.
Diarrhea: Thought to be most likely [**1-19**] chemotherapy, although C
diff was considered given recent antibiotics. C diff negative x
4. Continued Lomotil, Cholestyramine as needed. Diarrhea
decreased in frequency and volume over his course on the floor.
Continued Flagyl for a 14 day course (day 14 = [**3-9**])
.
Thrombocytopenia: Though to be most likely a chemotherapy
effect. HIT Ab negative, DIC labs negative. Monitored Plts QD,
stable over admission with no signs or symptoms of bleeding.
Did not require platelet transfusion.
.
A fib: Continued low dose Metoprolol started in [**Hospital Unit Name 153**]. HR
initially 100s on the floor, pt in A fib, but without symptoms
of SOB, palpitations or CP. HR decreased to 70-80s and pt.
converted to sinus rhythm, which he stayed in for the last 3
days of admission.
.
Anemia: Likely [**1-19**] myelosuppression [**1-19**] chemotherapy, stable s/p
3 U PRBCs. Monitored hct QD -> continued to be stable on the
floor.
.
Gastric CA: Chemo held over hospitalization. ANC increased to
2900 on [**3-2**] -> d/ced Neupogen
Pt. to f/u with Dr. [**First Name (STitle) **] re: further treatment after
discharge.
.
FEN: Continued tube feeds
.
Medications on Admission:
CIsplatin/CPT-11s:
COLACE
DEXAMETHASONE 4 MG--One by mouth twice a day x 2 days after
chemotherapy
FEEDING PUMP --For continuous slow feeding
FINASTERIDE 5 MG--One by mouth at bedtime
JEVITY --6 cans a day, as directed by nutrition, per j tube
METOCLOPRAMIDE 1 MG/ML--[**Last Name (LF) **], [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 60578**] WITH FIBER--One month supply
PROCHLORPERAZINE 10 MG--One by mouth every 8 hours x 2 days
after chemo, then as needed for nausea
SENNA 8.6MG--One by mouth [**Hospital1 **], hold for loose stool
WARFARIN 1 MG--One by mouth every day
ZANTAC 300MG--One at bedtime
Discharge Medications:
1. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
Intravenous Q12H (every 12 hours) for 7 doses.
2. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 doses: through [**3-9**].
4. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for Diarrhea.
5. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
8. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Metastatic Gastric Cancer
Bacteremia and Sepsis [**1-19**] E coli and Klebsiella infection
Atrial Fibrillation
Thrombocytopenia secondary to chemotherapy administration,
stable
Diarrhea secondary to chemotherapy administration
Discharge Condition:
Improved- blood pressure stable and diarrhea improved, breathing
comfortably on room air for several days
Discharge Instructions:
Please call your doctor or go to the ER if you develop any
fevers, chills, worsening diarrhea, abdominal pain, nausea,
vomiting, or any other symptoms that concern.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2130-3-10**] 10:30
Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2130-3-10**] 11:00
Provider: [**Name Initial (NameIs) 4426**] 18 Date/Time:[**2130-3-10**] 11:00
Completed by:[**2130-3-6**]
|
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"V10.52",
"263.9",
"276.51",
"197.6",
"284.8",
"038.49",
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icd9cm
|
[
[
[]
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[
"38.93",
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"96.04",
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icd9pcs
|
[
[
[]
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10238, 10310
|
6208, 8778
|
335, 363
|
10581, 10689
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2307, 2307
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2062, 2288
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391, 1317
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2324, 6185
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1339, 1730
|
1762, 1986
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,299
| 102,503
|
49261
|
Discharge summary
|
report
|
Admission Date: [**2119-6-1**] Discharge Date: [**2119-6-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
At time of encounter patient was intubated, thus history is from
patient's wife and prior records. Mr. [**Known lastname **] is an 87yo man who
was in his USOH until about 10:30am this morning, when he
"didn't feel right" while walking to the bathroom. He then lay
down again and told his wife he "felt fine," however a short
while later he went downstairs and his wife heard a "thud" and
found her husband on the floor in the kitchen with a chair
overturned on top of him. He told her he was fine but was
apparently holding his head. His wife called 911 and when she
returned he was unresponsive. No seizure activity noted. Per EMS
the patinet was confused and then one minute later was entirely
unresponsive with GCS 3.
.
There, head CT showed a small L posterior temporal SAH, which
was confirmed on head MRI/A. He was given thiamine and was
intubated. He was transferred to [**Hospital1 18**] for further evaluation.
.
In the ED, he was sedated with propofol and was seen by
neurosurgery who assessed that his SAH was too small for
operative management, and care was deferred to neurology. He was
evaluated by neurology, who believed that his SAH was likely
traumatic and related to his fall rather than the cause of his
fall. Electrolytes returned markedly abnormal and the patient
reported had a 7 beat run of vtach, followed by wavering heart
rates greater than 100 in afib, and then in NSR and in the low
60s. Cardiology was in the department, and saw the pt's rhythm
strips, declaring that this particular rhythm was unlikely the
cause of his syncopal episode. Neuro believed that, given his
electrolyte abnormalities, the most likely etiology was
"metabolic" versus cardiac. They recommended repeat head CT to
evaluate his SAH, and will assess for need for EEG based on his
course and responsiveness. They recommended repleting his
electrolytes, however after this recommendation, repeat studies
returned and were relatively unremarkable. The ER covered with
vancomycin and ceftriaxone for possible meningitis, but LP was
not performed in the ER due to the pt's "changing heart
rhythms." He was given a total of 1L of IVF, and he received
most of a 40mEq IV potassium repletion as well as 20meq of PO
potassium and 2g IV magnesium. He was transferred to the MICU
for further management.
.
ROS: unable to perform given intubated. Per wife, has not been
complaining of headache, has felt very sleepy for last few
weeks, no c/o CP, no SOB over usual baseline (dyspneic with
walking one flight of stairs), no c/o abd pain, no diarrhea,
+constipation. No fever/chills/sweats.
Past Medical History:
- Per prior cardiology note, had an echo with trivial to mild
TR, enlarged RV and possibly a PFO.
- Longstanding exertional dyspnea - has pulmonologist who
reportedly has done "multiple tests with no abnormalities"
- Polymyalgia rheumatica (ESR initially 100, now 6)
- HTN
- TIAs - per wife, 10yrs ago he had a few minutes of
unsteadiness
- Hyperlipidemia
- h/o prostate cancer, s/p resection [**2096**]
- Recent admission for rapid heart rate (wife does not know why)
- R postsurgical pupil
- MGUS
- Baseline Cr 1.4-1.7 in [**10-22**] (no earlier levels known)
- PALPITATIONS - shown to be ventricular premature beats in
multiple Holter monitors
- MITRAL VALVE DISORDER
- ATRIAL FIBRILLATION
- LUMBOSACRAL SPONDYLOSIS
- ATRIAL PREMATURE BEATS
- GERD
- Degenerative disk disease in the thoracic spine.
Social History:
retired engineer at [**University/College **]. No etoh/tob/illicits.Functions
independently. Lives home alone with wife. [**Name (NI) **] lives in
[**State 4565**].
Family History:
negative for stroke, seizures
Physical Exam:
VS 68, 124/64, 99.5, 16, 100%
Gen: sedated, intubated. Moves L arm and B legs spontaneously,
grimaces to sternal rub
HEENT: R surgical pupil, L pupil min reactive, dark blood in OG
tube
Cor: RRR, no r/g/m
Pulm: CTAB
Abd: soft, NTND, +BS
Ext: no c/c/e
Neuro: withdraws all 4 to pain, moves R arm and leg much less
than other extremities, B toes upgoing (per neuro note wife said
this is baseline increased tone in toes)
Skin: no obvious rashes
GU: yellow urine in foley
Pertinent Results:
Note that lab draw was repeated and electrolytes were WNL except
for low phosphate level. Ck/MB/trop negative. WBC 12.7 with no
bands and 77% pmns. Creatinine at baseline of 1.4 (unchanged
from [**10-22**]).
.
STUDIES:
.
Echo [**6-2**]: The left atrium is normal in size. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast (rest injection only). Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%) Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. 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 no pericardial effusion.
.
Head CT [**6-2**]: Small subarachnoid hemorrhage in left posterior
temporal lobe unchanged from study 14 hours prior. MRI would be
recommended if clinical concern for infarct remains.
.
CXR: Endotracheal tube as above. Advance nasogastric tube [**6-24**]
cm. No
acute process.
.
[**Location (un) 620**] chest CT with contrast performed for r/o dissection: NO
EVIDENCE OF AORTIC DISSECTION. ASCVD. HH. BILATERAL
COMPRESSIVE
ATELECTASIS. HEPATIC AND RENAL CYSTS. SMALL LOW DENSITY LESION
IN THE SPLEEN CONSISTENT WITH A CYST OR HEMANGIOMA.
- per discussion with radiology resident, also no central PEs
seen on this study. Cannot rule out subsegmental PE given timing
of contrast not ideal for this.
.
[**Location (un) 620**] head CT: PROBABLE SMALL SUBARACHNOID HEMORRHAGE IN THE
LEFT POSTERIOR TEMPORAL LOBE. NO OTHER ACUTE ABNORMALITIES ARE
DETECTED. THERE IS EVIDENCE OF CHRONIC ISCHEMIA WITH NUMEROUS
LACUNAR INFARCTIONS.
.
repeat head CT: Small subarachnoid hemorrhage in the left
posterior temporal lobe, without significant change in size from
12:30 p.m. today. Findings were posted to the ED dashboard at
10:30 p.m. on [**2119-6-1**].
.
CT C-spine: 1. No acute traumatic injury in the cervical spine.
2. Nasogastric tube coiled in the hypopharynx.
.
head MR/MRA (neuro attg read) from [**Location (un) 620**]: scattered FLAIR and
T2 abnormalities c/w small vessel disease. There was a small SAH
in the left parieto-temporal region. There were no DWI or T2*
abnormalities. His MRA was normal with good flow in the VA & BA
arteries. No aneurysms were noted.
.
(rads read) INCREASE SIGNAL SEEN IN THE UPPER MID BRAIN AND
MEDIAL THALAMI COULD BE CONSISTENT WERNICKE'S ENCEPHALOPATHY IN
PROPER CLINICAL SETTING. CLINICAL CORRELATION RECOMMENDED.
EVIDENCE OF SUBARACHNOID HEMORRHAGE IN THE LEFT TEMPORAL SULCI
CONSISTENT WITH THE FINDINGS SEEN ON THE RECENT CT. MILD TO
MODERATE BRAIN ATROPHY AND SMALL VESSEL DISEASE. NORMAL MRA OF
THE HEAD.
.
R shoulder XR: Three views of the right shoulder show no
fracture, dislocation, bone destruction, or diminution in the
acromio-humeral soft tissues. The partially visualized right
lung is clear. Incidental degenerative changes AC joint and
central line catheter via right arm.
.
EKg: NSR at 70, nl axis, nl intervals, no TWI, no STT changes,
no Qs. also have EKG rhythm strips showing several instances of
sinus pauses up to longest of about 2 seconds interspersed with
a narrow tachycardia.
.
UA: blood but negative for infection
Blood culture: pending
serum tox screen negative except for positive benzos
urine tox screen negative
.
.
Holter monitor [**6-21**]: 1. Predominantly sinus rhythm with a brief
episode of sinus bradycardia to 47 BPM at 9:34 am. Normal
intervals and no significant pauses. 2. Frequent isolated APBs
and 2 atrial couplets. 3. Moderate isolated ventricular ectopy.
4. One episode of "palpitations" showed sinus tachycardia at 107
BPM with a single isolated APB. 5. Compared to Day 1 (2-day
study), atrial tachycardia
was not seen.
.
stress echo [**5-22**]:
1. Limited exercise tolerance.
2. No symptoms of chest pressure or chest tightness.
3. No EKG changes of ischemia with exercise performed.
4. Echocardiographic images reported separately and attached.
.
Brief Hospital Course:
Mr. [**Known lastname **] is an 87M with a history of TIA and HTN who presented
s/p fall with loss of consciousness to [**Location (un) 620**] and was found to
have a small left subarachnoid hemorrhage, a thalamic CVA, and
atrial fibrillation with rapid ventricular rate.
Stroke: The patient was admitted to the MICU service, intubated
from the OSH. He was initially started on levofloxacin and
vancomycin for possible aspiration, however when sputum cultures
were negative antibiotics were discontinued. He quickly weaned
from the ventilator and was extubated on [**6-8**] when his mental
status was improved. EEG showed no epileptiform foci. Lumbar
puncture was negative for infection, and blood and urine
cultures were negative. Repeat head imaging showed a CVA in the
thalami and Left caudate nucleus. CVA is likely thromboembolic
related to atrial fibrillation. Echo showed no structural
abnormalities and no patent foramen. The patient was followed
closely by they neurology team, and he was maintained on heparin
drip (ASA and plavix were held per neurology recommendations)as
well as statin, and he was treated with thiamine and folate. He
continued to have waxing and [**Doctor Last Name 688**] mental status consistent
with hospital-related delirium and was treated with haldol prn
agitation. His deficits throughout hospital course and at
discharge were right sided hemiparesis and eyelid opening
apraxia. He had a G-J tube placed and he was transitioned from
heparin gtt to lovenox as bridge to coumadin.
Paroxysmal Atrial fibrillation: He had a newly diagnosed atrial
fibrillation on admission with RVR. He was treated with
metoprolol prn and was started on amiodarone load. He remained
in sinus rhythm throughout the remainder of his hospitalization.
He was treated with anticoagulation as above (the left sided
subarachnoid hemorrhage had resolved radiographically as of [**6-18**])
and was also started on a beta blocker.
Leukocytosis: WBC 31 on [**6-14**], blood culture on [**6-12**] right PICC
with coag neg staph in [**2-15**] sets (likely contaminant). All
cultures subsequently are negative to date. C. diff is negative
x 3 now. Toxin B is still pending. Completed 10 day course of
flagyl, PO vancomycin for empiric treatment of c.diff colitis.
Also completed 7 day course of vanc/cefepime for hospital
acquired pneumonia on [**6-25**].
Anemia: Hct remained stable over the last few days at around
24-25. This is down from his baseline (mid-30s), prior to
hospitalization. Nevertheless, he has been hemodynamically
stable. Hemolysis labs were negative. He did have FOBT stools
on [**6-20**], but no melena or BRBPR. He was continued on [**Hospital1 **] PPI.
He should have a colonoscopy as an outpt when his medical issues
become more stable.
Medications on Admission:
ASA 81mg po qday
Plavix 75 mg po qday (started after the TIA)
Enalapril 15 po qday
Metoprolol 25 [**Hospital1 **], started after recent rapid heartrate
Lipitor 40 mg po qday
Ditropan wife unsure of dose
Prednisone tapered down to 7mg daily (has been on for 2 months)
Prilosec 20mg po daily
Celexa dose unknown
Discharge Medications:
1. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Prednisone 1 mg Tablet [**Hospital1 **]: Seven (7) Tablet PO DAILY
(Daily).
3. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Lidocaine HCl 2 % Gel [**Hospital1 **]: One (1) Appl Mucous membrane PRN
(as needed).
6. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Enoxaparin 80 mg/0.8 mL Syringe [**Hospital1 **]: One (1) Subcutaneous
[**Hospital1 **] (2 times a day) for Until INR is therapeutic [**3-19**] for at
least 24 hours days.
8. Miconazole Nitrate 2 % Powder [**Month/Day (3) **]: One (1) Appl Topical TID
(3 times a day) as needed.
9. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (3) **]: One (1) PO BID (2
times a day).
10. Senna 8.6 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2 times a
day).
11. 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.
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Month/Day (3) **]:
One (1) Inhalation q6hours prn as needed.
13. Haloperidol 0.5 mg IV BID:PRN agitation
14. Warfarin 6 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO Once Daily at 4
PM.
15. Toprol XL 200 mg Tablet Sustained Release 24 hr [**Month/Day (3) **]: One (1)
Tablet Sustained Release 24 hr PO once a day.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary
Subarachnoid hemorrhage left posterior temporal lobe
Thromboembolic stroke, left thalamic infarct
Atrial fibrillation with rapid ventricular rate
Anemia
Delirium
Secondary
Chronic renal insufficiency
Hypertension
Hyperlipidemia
Polymyalgia rheumatica
Discharge Condition:
stable, PEG tube in place, afebrile
Discharge Instructions:
You were admitted with a stroke and bleed in your head. Your
bleed was stable on discharge. Your stroke is likely from your
atrial fibrillation (irregular rhythm). You were treated with
several medications including blood thinners and medications for
your irregular heart rhythm. In addition, you were found to
have an infection and were treated with multiple antibiotics.
Several important medications have been started for you. These
include amiodarone, coumadin and lovenox. It is very important
that you take these medications.
If you have any of the following symptoms, you should return to
the emergency room:
Fevers, chills, cough, diarrhea, new weakness, headaches or any
other serious concerns.
Followup Instructions:
We have scheduled an appointment for you with the neurologist
who saw you.
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 12454**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2119-8-9**] 1:00
In addition you should schedule an appointment with your primary
care provider in the next 2-3 weeks.
You should also follow up with cardiology as below.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2119-8-4**] 1:00
Completed by:[**2119-6-29**]
|
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icd9cm
|
[
[
[]
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[
"96.6",
"96.72",
"38.93",
"46.32",
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|
[
[
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] |
13427, 13572
|
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|
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|
13875, 13913
|
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2916, 3720
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,105
| 138,421
|
47638
|
Discharge summary
|
report
|
Admission Date: [**2104-11-2**] Discharge Date: [**2104-11-9**]
Date of Birth: [**2070-8-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 49413**]
Chief Complaint:
Chest pain, fever, and pulmonary embolus.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 34 year old female with a history of SLE, lupus
nephritis with massive proteinuria, and pulmonary emboli as well
as DVT, who presented on [**11-2**] with two days of sharp, left
sided chest pain. She first started to feel unwell after her
rituximab infusion on the Friday prior to admission (this
represented her second dose of rituximab; first dose in [**9-19**]
was complicated by hypertension and facial swelling). She had
chills, sweating, nausea, vomiting, and diarrhea. On the day
prior to admission, she awoke with constant, non-pleuritic, left
sided shoulder/chest/back pain, worsened by movement and
coughing. At that time she denied shortness of breath or
dyspnea. Moreover, she noticed a fever to 101.9. Concerned, she
came to the ED.
.
In the ED, she admitted to having symptoms of a typical lupus
flare for her. These included rash on her hands, swelling of her
face and legs, and pains in her feet, legs, and fingers. She
noted that her INR had been much more difficult to manage
recently, and she attributed this to the concurrent lupus flare.
Her VS: 100.3, 149/92, 124, 24, 99% on RA. Blood and urine
cultures were sent. She was given levofloxacin 500mg for
possible pneumonia based on CXR and started on a heparin gtt
based on the findings of new pulmonary emboli on CTA. She
received 1L NS. She was also given morphine for pain, tylenol
for fever, and anzemet for nausea. A CT chest demonstrated
bilateral lower pulmonary embolis. LENIs were negative for DVT.
She was transferred to the MICU for observation.
.
During her MICU stay, heme/onc was consulted given her
complicated history. She was maintained on a heparin gtt.
Prednisone was started for her lupus, and she was maintained on
her hydroxychloroquine. She was also given azithromicin and
ceftriaxone for several days for possible community acquired
pneumonia. She remained clinically stable and was transferred to
the floor.
.
On transfer to the floor, patient feels well, although she still
complains of slight left chest/shoulder pain, that was worse
with deep inspiration.
Past Medical History:
- SLE (+RNP, +Sm) diagnosed in [**2103-7-16**]; on prednisone 30mg
qd and hydroxychloroqeuine 200mg [**Hospital1 **]
- lupus nephritis - severe proteinuria, failed CellCept
- Acute reaction to Rituximab infusion [**2104-9-16**] with swelling of
extremities, fever, hypertention SBP 170.
- Pulmonary emboli in [**2104-4-14**] and [**2104-7-15**]:
- ACA neg, Lupus anti-coag negative, Protein S deficiency +.
- Right IJ thrombus in [**9-19**]
- Right lower root canal performed 3 weeks ago
- Migraines
- Hypercholesterolemia
- Asthma
- Eczema
- History of recurrent cystitis
Social History:
- Quit smoking 8 years ago total of 1.5 pack years
- Quit drinking last year (used to drink 1 drink/day)
- Denies use of other drugs
- Lives at home with 2 children (age 15, 10) both girls. Used to
work in mailroom of law firm. Has not worked since last year
when SLE diagnosed. Rejected from disability. Currently has
difficulty supporting children though receives some help from
mother. Children currently staying with her mother. Middle of 3
children. Brother and sister live with mother.
- Mass Health
Family History:
Grandmother with CVA. Father passed age 45 with HIV
complications. Mom alive and well. No family history blood
clots. Grandmother with stomach cancer. No fanily history of
SLE.
Physical Exam:
Admission to Floor:
VS: T 99.1, BP 140/102, HR 97, RR 20, 96% RA
Gen: alert, talkative, NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM
Neck: supple, no LAD
Lung: decreased BS on L>R with faint crackles
Heart: RRR, nl S1 S2, no m/r/g
Abd: soft, NT/ND, normoactive bowel sounds
Back: no CVA tenderness
GU: deferred
Ext: warm, well perfused, 2+ DP pulses
Skin: warm, moist
Pertinent Results:
IMAGING:
CXray ([**2104-11-6**]): Bilateral pleural effusions with L>R.
.
Cxray ([**2104-11-2**]): New consolidation in left lower lobe with
possible effusion, and new faint patchy opacity in right lower
lobe. The findings are concerning for pneumonia in this patient
with fever. Alternatively, thromboembolic disease with
parenchymal opacity versus infarction cannot be excluded in this
patient with right jugular venous thrombosis. Evaluation by CT
study is recommended.
.
CT chest ([**2104-11-2**]): 1. Bilateral segmental and subsegmental
pulmonary emboli within the lower lobes more prominent on the
right. Bilateral atelectasis and pleural effusions within the
lower lung fields. 2. Stable bilateral axillary lymphadenopathy
consistent with patient's known lupus. 3. Stable pulmonary
nodule.
.
Bilateral Lower Extremity U/S ([**2104-11-2**]): Negative bilateral
lower extremity DVT study.
.
Bilateral Upper Extremity U/S ([**2104-11-3**]): No evidence of
bilateral upper extremity deep venous thrombosis. Mild edema
within the subcutaneous soft tissues.
.
Cardiac Echo ([**2104-11-3**]): The left atrium is normal in size.
Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2104-10-8**],
the heart rate is lower, left ventricular systolic function is
now low normal, and the estimated pulmonary artery systolic
pressure is slightly higher. Right ventricular cavity size and
free wall motion remain normal.
Based on [**2094**] 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.
.
Labs:
[**2104-11-9**] 06:05AM BLOOD WBC-6.0 RBC-2.97* Hgb-8.1* Hct-23.2*
MCV-78* MCH-27.1 MCHC-34.8 RDW-16.6* Plt Ct-325
[**2104-11-8**] 05:32PM BLOOD WBC-9.0 RBC-3.25* Hgb-8.7* Hct-25.4*
MCV-78* MCH-26.9* MCHC-34.4 RDW-16.8* Plt Ct-326
[**2104-11-8**] 10:13AM BLOOD WBC-8.2 RBC-2.94* Hgb-7.9* Hct-23.4*
MCV-80* MCH-26.9* MCHC-33.8 RDW-17.0* Plt Ct-305
[**2104-11-7**] 06:38AM BLOOD WBC-15.8* RBC-3.34* Hgb-8.8* Hct-26.2*
MCV-79* MCH-26.2* MCHC-33.4 RDW-17.0* Plt Ct-287
[**2104-11-6**] 08:30AM BLOOD WBC-12.5*# RBC-3.65* Hgb-9.4* Hct-29.1*
MCV-80* MCH-25.7* MCHC-32.2 RDW-16.9* Plt Ct-325#
[**2104-11-2**] 01:25PM BLOOD WBC-8.7# RBC-3.67* Hgb-10.1* Hct-29.0*
MCV-79* MCH-27.5 MCHC-34.8 RDW-17.0* Plt Ct-174
[**2104-11-8**] 10:13AM BLOOD Neuts-91.3* Lymphs-6.5* Monos-1.6*
Eos-0.4 Baso-0.2
[**2104-11-6**] 08:30AM BLOOD Neuts-80.1* Lymphs-17.7* Monos-1.5*
Eos-0.3 Baso-0.5
[**2104-11-9**] 06:05AM BLOOD PT-32.9* PTT-41.4* INR(PT)-3.5*
[**2104-11-9**] 06:05AM BLOOD Plt Ct-325
[**2104-11-5**] 06:35AM BLOOD PT-15.9* PTT-96.0* INR(PT)-1.4*
[**2104-11-4**] 09:21PM BLOOD PTT-52.3*
[**2104-11-2**] 01:25PM BLOOD PT-51.2* PTT-47.8* INR(PT)-6.1*
[**2104-11-8**] 01:15PM BLOOD FDP-10-40
[**2104-11-8**] 07:10AM BLOOD Fibrino-876* D-Dimer-1338*
[**2104-11-7**] 06:38AM BLOOD ESR-150*
[**2104-11-8**] 10:13AM BLOOD Ret Aut-1.6
[**2104-11-9**] 06:05AM BLOOD Glucose-94 UreaN-7 Creat-0.4 Na-138 K-4.1
Cl-105 HCO3-27 AnGap-10
[**2104-11-2**] 01:25PM BLOOD Glucose-87 UreaN-10 Creat-0.5 Na-138
K-3.4 Cl-104 HCO3-27 AnGap-10
[**2104-11-8**] 07:10AM BLOOD LD(LDH)-139 TotBili-0.1 DirBili-<0.1
[**2104-11-2**] 01:25PM BLOOD ALT-19 AST-27 CK(CPK)-79 AlkPhos-77
Amylase-67 TotBili-0.2
[**2104-11-2**] 01:25PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-407*
[**2104-11-9**] 06:05AM BLOOD Calcium-8.0* Phos-4.5 Mg-1.6
[**2104-11-2**] 01:25PM BLOOD Calcium-7.3* Phos-3.5 Mg-1.6
[**2104-11-8**] 07:10AM BLOOD Hapto-531*
[**2104-11-5**] 06:35AM BLOOD TSH-8.2*
[**2104-11-7**] 06:38AM BLOOD PEP-PND
Brief Hospital Course:
34 year old female with SLE, lupus nephritis with significant
proteinuria, protein S deficiency, multiple PEs/DVTs presenting
with chest pain and fevers and found to have bilateral PEs while
on warfarin. Ultrasound of lower and upper extremities revealed
no evidence of DVTs. Currently stable on heparin gtt.
.
.
1) Pulmonary emboli:
Given the history of proteinuria and hypercoagulability, with
multiple thromboses in the past, patient has proven difficult to
anticoagulate. These current pulmonary emboli developed while on
coumadin with INR of 6.0, although it has also been as low as
1.2 on [**10-30**]. Patient's INR is extremely labile and can change
from 6-->2 in 24 hours. Patient realizes and appreciates that
her INR is difficult to control, but refuses to reinstitute
lovenox permanently, as the injections are painful.
- During hospitalization, she remained hemodynamically stable,
despite tachycardia to the 160's when ambulating. EKG on
[**2104-11-6**] revealed sinus tachycardia. During these episodes, she
denied shortness of breath or palpations. Her blood pressure
was stable. TSH on [**11-5**] was 8.2.
- During her hospitalization, heparin gtt and warfarin 10mg PO
qHS were used. Her INR fell to 1.4 on [**11-5**], so she received an
extra 5mg PO on [**11-5**] AM, in addition to her usual 10mg qPM. By
[**11-6**], her INR was 5.8. On [**11-7**], INR was 9.8, so coumadin and
heparin were held for the day. On day of discharge, [**11-9**], INR
was 3.5 and her coumadin dose was 5mg qHS. Patient was not
requiring a bridge with lovenox, as goal INR level achieved
(3.5-4.0). Patient will need to have blood work checked at
PCP's office on Monday, [**2104-11-10**].
- Of note, TTE done on [**11-3**], with mildly depressed EF from
[**2104-10-8**]. No gross abnormalities.
.
2) Fever:
On admission, fever thought to be secondary to pulmonary
embolus, although initial radiographic data suggested a
potential community acquired pneumonia. She initially received
ceftriaxone and azithromicin for several days, but when
transferred to the medicine floor on [**11-5**], she was not
receiving antibiotic therapy.
- On [**11-6**], patient's white count began to rise and she
developed a low grade fever to 100.5, in the setting of
immunosupression). Chest Xray on [**11-6**] revealed bilateral
pleural effusions with L>R. As patient's fever had resolved and
these findings were difficult to discern in the setting of a
pulmonary embolus, no antibiotics were initiated. Urine and
blood cultures from [**11-6**] pending. Urine cultures from [**11-3**]
negative for legionella. Blood cultures from [**11-2**] pending, but
negative to date.
-Patient was started on bactrim, for PCP prophylaxis, as she
remains on immunosuppressant (prednisone hydroxychloroquine)
therapy.
.
3) SLE:
[**Month (only) 116**] have potential lupus flare. Pain management with morphine
(cannot take NSAIDs due to nephritis, and pain is fairly severe
currently). Triamcinolone cream for rash. Increased ankle pain
on [**11-7**] concerning for lupus flare. Continued prednisone and
hydroxychloroquine. Follow up rheumtology appointment scheduled
on [**11-27**].
Patient followed by nephrology. Urine protein/cr ratio was 5.9
on [**11-7**]. Urine and serum protein levels pending.
Pain well controlled with IV and PO dilaudid.
.
4) Generalized myalgia and ankle pain:
Patient developed episode of emesis on night of [**11-26**]
after eating pizza brought in by family members. Subsequent to
emesis, patient noted generalized myalgias, but these resolved
in one day. Thought to be a viral prodrome, although oropharynx
did not reveal any exudate. Not consistent with myositis on
examination and CK was 44.
On [**2104-11-7**], patient developed severe bilateral ankle pain. On
examination warm and diffusely tender. Resolved in less than 24
hours and well controlled with pain medications. Most likely,
represented a lupus flare. Will discharge with PO morphine
course for several days.
-Patient will require close follow with rheumatology.
.
4)Anemia:
Hematocrit remained in the mid 20's during most of the
admission. On [**11-8**], Hct noted to have fallen from 26.2 to
21.6. Repeat Hct revealed a level of 23.4. As concern for
hemolytic anemia, sent hemolytic panel on [**11-8**]. Panel negative
and hematocrit stable on discharge.
MCV near 80. Anemia most likely from chronic inflammatory state
(lupus nephritis) with decreased EPO production.
.
5)HTN:
Continued lasix and lisinopril, but per renal's recommendations,
increased lisinopril to 40mg [**Hospital1 **], as diastolic pressures
increased. This modification resulted in better control.
.
6)Hyperlipidemia:
Continued atorvastatin 10mg PO qd.
.
7)FEN:
Continued low sodium diet and encouraged PO intake. Repleted
electrolytes, as needed. Calcium, magnesium, phosphate remained
low. Outpatient supplementation may need to be considered. MVI
not started in hospital, as vitamin K contained and could
further complicate coumadin dosing.
Provided prescriptions for magnesium, calcium, iron
supplementation.
.
8)Prophylaxis:
Continued patient on heparin gtt and coumadin initially.
Coumadin dosing difficult, but discharged home on 5mg qHS.
As patient on prednisone, initiated Bactrim.
.
9)Dispo:
Goal INR 3.5-4. PCP will reevaluate on Monday [**2104-11-10**].
.
Code:
FULL
.
Medications on Admission:
1. Lisinopril 40 mg qam and 20mg qpm
2. Atorvastatin 10 mg DAILY
3. Prednisone 30 mg DAILY
4. Hydroxychloroquine 200 mg [**Hospital1 **]
5. Amitriptyline 30 mg HS
6. Warfarin (doses ranging 7mg-10mg hs)
7. Elidel cream three days a week (alternating with
triamcinolone)
8. triamcinolone 0.1% cream 4 days a week (alternating with
elidel)
9. lasix 20mg daily
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*1*
4. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Amitriptyline 10 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. Furosemide 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
4X/WEEK ([**Doctor First Name **],TU,TH,SA).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
Disp:*15 Tablet(s)* Refills:*2*
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*18 Tablet(s)* Refills:*0*
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Pulmonary embolus
-SLE
.
Secondary:
-lupus nephritis
-migraines
-hypercholesterolemia
-asthma
Discharge Condition:
Improved.
Discharge Instructions:
**You were admitted to the hospital for a pulmonary embolus.
You were treated in the medical intensive care unit and
transferred to the general medical team for management. While
in the hospital, you received medications to treat the pulmonary
embolus. You received antibiotics for several days, after which
point you did not develop a fever.
**Your hypertension medication, lisinopril, was increased to 40
mg twice a day. You should continue on that dose and alert Dr.
[**Last Name (STitle) 4888**] of that change.
**You were started on bactrim to prevent against infections.
You will take this medication on monday, wednesday, and friday.
**The management of your lupus nephritis remained the same
during your hospitalization.
**You will need to continue the coumadin, 5mg at night, until
instructed otherwise by Dr. [**Last Name (STitle) 4888**]. You will need to have your
blood drawn at Dr.[**Name (NI) 100642**] office on Monday, [**11-10**].
**You were also started on other vitamins and mineral
supplements. Continue to take these and show Dr. [**Last Name (STitle) 9123**] your
updated medication list.
**If you develop any shortness of breath, fever, rapid heart
rate causing chest pain or difficulty breathing, or any other
concerning symptoms, please call your doctor or come to the
emergency department immediately.
Followup Instructions:
**You need to go to Dr.[**Name (NI) 69229**] office on Monday, [**11-10**] for blood testing.
**You will need to schedule an appointment with Dr. [**Last Name (STitle) 4888**]
([**Telephone/Fax (1) **]) for the next week.
**You have an appointment with your rheumatologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], on [**11-27**] at 9:00am.
|
[
"285.29",
"710.0",
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"276.52",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15674, 15680
|
8479, 13837
|
357, 364
|
15828, 15840
|
4187, 8456
|
17222, 17596
|
3600, 3782
|
14245, 15651
|
15701, 15807
|
13863, 14222
|
15864, 17199
|
3797, 4168
|
276, 319
|
392, 2462
|
2484, 3060
|
3076, 3584
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,254
| 106,439
|
3109
|
Discharge summary
|
report
|
Admission Date: [**2114-1-24**] Discharge Date: [**2114-2-13**]
Date of Birth: [**2070-12-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Abdominal discomfort, nausea.
Major Surgical or Invasive Procedure:
Cardiac catheterization, [**2114-1-31**].
Hemodialysis, initiated on [**2114-2-9**].
PA cathether placement, AV-fistula repair.
History of Present Illness:
A 43yoM with h/o ESRD [**3-1**] GN, s/p kidney transplant x 2 ([**2089**],
[**2097**]), CAD s/p MI, VF arrest, cath/stent to proximal LAD, s/p
ICD placement, stroke in [**2105**], recent history of left olecranon
bursitis, admitted for AV fistula repair. Transferred from the
PACU for w/u of persistent nausea/abd. pain and diarrhea.
Abdominal pain thought to be [**3-1**] to poor outflow from heart
leading to bowel edema or abdominal angina.
.
Pt's ICD was triggered twice while Pt. was in shower on day of
admission to CCU. Pt. underwent right-sided cardiac
catheterization and Swan-Ganz catheter placement, which revealed
elevated wedge pressures and preserved RA/RV pressures,
consistent with left heart failure. Pt. and was transferred to
CCU for management of elevated PCWP and severe low-output heart
failure.
Past Medical History:
1. ESRD: [**3-1**] GN s/p kidney transplant x2 in [**2089**] and [**2097**];
followed by [**First Name8 (NamePattern2) 3122**] [**Doctor Last Name 1860**].
2. CAD: s/p MI and PCI & stent in [**2105**]; s/p right sided
placement of ICD d/t AVF in the left arm; cardiologist is [**First Name4 (NamePattern1) 919**]
[**Last Name (NamePattern1) 911**].
3. CHF: ([**1-1**]) LVEF=20%, 3+ MR.
4. CVA in [**2105**]: no residual complications/defiicits
5. AFib
6. HTN
7. multiple basal cell and squamous cell ca s/p multiple
resections and XRT to lower face.
8. Gout
9. Erectile dysfunction
10. Right lung pneumonia with pleurisy
Social History:
He is married, lives in [**Location 13011**] with wife of 11 years, son (6yo)
and daughter (2yo). He owns and runs a landscaping/contracting
business and works for the city sanding the streets during the
winter. He denies tobacco or recreational drug use. He drinks
EtOH socially.
Family History:
Alcoholism in Mother, maternal uncle and grandfather,
Parkinsons??????s Disease in paternal grandmother, Lymphoma in
paternal grandfather, peripheral vascular disease in maternal
grandmother, no h/o kidney disease, other CA, heart disease,
CVA, or psychiatric diseases.
Physical Exam:
PE: VS: 96.8 | 125/83 | 123(AFib) | 16 | 96% on 2L NC
gen: NAD, pleasant and cooperative.
HEENT: PERRL and EOM intact, OP clear, MMM.
neck: no masses, no LAD, no JVD, no carotid bruit.
CV: irreg irreg, nl s1s2, no murmurs.
chest: cta b/l, no crackles or wheezes.
abd: soft, nt/nd, +bs, no organomegaly.
extr: no cyanosis, no clubbing; [**3-2**]+ LE edema up to knees; 1+ dp
pulses b/l.
neuro: awake, alert, a&ox3, cn ii-xii intact; motor, sensory,
coordination, and language grossly intact.
Pertinent Results:
[**2114-1-7**] Liver U/S - Gallbladder wall thickening without other
signs to suggest cholecystitis. Clinical correlation is
recommended to exclude other etiologies for gallbladder wall
thickening such as hypoalbuminemia, CHF or hepatitis.
.
[**2114-1-8**] Echo - LVEF<20%. Severe LV dilation. Severe global left
ventricular hypokinesis with septal and apical akinesis. Overall
left ventricular systolic function is severely depressed. An LV
mass/thrombus cannot be excluded. RV cavity is dilated. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. 1+AR, 2+MR, mod. PA HTN.
The end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
.
[**2114-1-9**] GB Scan - 1. No evidence of acute cholecystitis.2
Delayed uptake of tracer into the hepatic parenchyma consistent
with hepatocellular dysfunction. 3. Delayed tracer emptying into
the small bowel.
.
[**2114-1-12**] EGD - Erythema and congestion in the antrum compatible
with gastritis Erythema and congestion in the first part of the
duodenum compatible with duodenitis Otherwise normal EGD to
second part of the duodenum.
.
[**2114-1-25**] CT Abd - Ascites within the abdomen. Cardiomegaly.
Cholelithiasis without cholecystitis. Degenerative changes with
cystic changes seen in the right femoral head. Superior
displacement of the femoral head. These findings may be
post-traumatic or post- infectious in etiology. Dedicated hip
films are recommended.
.
[**2114-1-27**] Renal transplant u/s - 1. Stable appearance of the
right kidney without evidence of hydronephrosis or perirenal
collection. Patent renal vessels as described above. 2. Moderate
ascites.
.
[**2114-1-31**] Cath - 1. Resting hemodynamics demonstrated markedly
elevated left and right sided filling pressures. The mRA
pressure was 20 mmHg and the mean PCWP was 35-42 mmHg. The
cardiac output and cardiac index were significantly reduced at
3.5 l/min and 1.5 L/min/m2, respectively. There was reactive
pulmonary hypertension (pulmonary vascular resistance was 160
dynes.sec/cm2). FINAL DIAGNOSIS: 1. Severe low output heart
failure.
.
[**2114-1-31**] CXR - Severe cardiomegaly is chronic. There is no
longer any pulmonary edema. Transvenous pacer defibrillator lead
is unchanged in position with the tip projecting over the floor
of the right ventricle and the proximal electrode spanning the
superior vena cava and upper right atrium. A right internal
jugular line passes to the region of the pulmonary outflow
tract, but the tip is indistinct. There is no pneumothorax or
mediastinal widening. The left lateral aspect of the lower chest
is excluded from the examination. Lungs are grossly clear.
.
[**2114-2-5**]: CXR - Persistent Cardiomegaly. Cardiac pacer leads are
in good position. The lung fields are clear. There are no
pleural effusions. Note that the left CP sulcus is not included
in the film. IMPRESSION: Persistent cardiomegaly.
.
[**2114-2-13**] 12:30PM BLOOD WBC-8.9 RBC-3.92* Hgb-11.2* Hct-35.1*
MCV-90 MCH-28.6 MCHC-32.0 RDW-15.4 Plt Ct-184
[**2114-1-25**] 03:35PM BLOOD WBC-5.1 RBC-4.78 Hgb-14.6 Hct-43.9 MCV-92
MCH-30.5 MCHC-33.2 RDW-15.0 Plt Ct-161
[**2114-1-25**] 03:35PM BLOOD PT-39.4* PTT-42.9* INR(PT)-12.1
[**2114-1-25**] 03:35PM BLOOD Plt Ct-161
[**2114-2-13**] 12:30PM BLOOD UreaN-62* Creat-4.2* Na-140 K-4.4 Cl-101
HCO3-27 AnGap-16
[**2114-1-24**] 05:36PM BLOOD Glucose-83 UreaN-76* Creat-5.6*# Na-137
K-4.1 Cl-104 HCO3-17* AnGap-20
[**2114-1-24**] 05:36PM BLOOD ALT-32 AST-27 LD(LDH)-305* AlkPhos-122*
Amylase-67 TotBili-2.0*
[**2114-1-24**] 05:36PM BLOOD Lipase-70*
[**2114-2-13**] 12:30PM BLOOD Albumin-3.6 Calcium-9.2 Phos-2.7
[**2114-1-24**] 05:36PM BLOOD Albumin-3.6 Calcium-9.3 Phos-5.5* Mg-2.3
[**2114-2-1**] 04:20AM BLOOD TSH-1.0
[**2114-2-11**] 05:50AM BLOOD PTH-189*
[**2114-1-30**] 12:45PM BLOOD PTH-283*
[**2114-2-11**] 05:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE
[**2114-1-30**] 12:45PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2114-2-7**] 07:45AM BLOOD Cyclspr-76*
[**2114-1-25**] 03:35PM BLOOD Cyclspr-253
[**2114-1-24**] 05:36PM BLOOD tTG-IgA-5
[**2114-2-11**] 05:50AM BLOOD HCV Ab-POSITIVE
[**2114-2-8**] 07:30AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Pending.
Brief Hospital Course:
A 47yoM with ESRD secondary to glomerulonephritis, s/p kidney
transplant x 2 ([**2089**], [**2097**]) s/p MI, VF-arrest, cath/stent and
stroke in [**2105**], recent history of left olecranon bursitis,
admitted for AV-fistula repair, and also for w/[**Location 14755**]
nausea/abd pain and diarrhea.
.
The patient reported a 4 month history of chronic abdominal
pain. He had an extensive workup including HIDA/EGD/GB u/s all
of which have been unrevealing. The GI team followed the Pt.
and wanted to get a CTA to look for mesenteric ischemia. He was
given n-acetylcysteine and bicarbonate to preserve his renal
function. During administration of the contrast, it infiltrated
into his arm and the study could not be completed. A plastics
consult was called to r/o compartment syndrome. The recommended
elevation and ice to the arm. The swelling and erythema slowly
resolved. The patients kidney funtion continued to deteriorate
and further contrast studies could not be performed. When the
cardiology team was consulted they felt that any mesenteric
ischemia was likely [**3-1**] to poor forward flow rather than
mesenteric stenosis/ischemia so the CTA would not be as helpful
if this were the case. The patient also has an extended history
of diarrhea also worked up extensively by GI as an outpatient.
On admission, stool studies, SSYC, microsporidium, cyclospora,
cryptosporidium, C-Diff (given recent antibiotic use), and ova
and parasites were sent, all of which came back negative. GI
felt it was important at some point to get a colonoscopy but
given his tenuous cardiac status/poor renal function, it was
thought that a prep would dehydrate the patient and cause
further renal damage. The colonoscopy was put on hold to be
rescheduled by PCP at [**Name Initial (PRE) **] later date.
.
It was decided to admit the patient to the CCU for a PA catheter
(which was placed in cath lab) and tailored CHF therapy to
improve his cardiac function in the hopes that this would
improve his abdominal symptoms. The Pt. is known to have a
severely depressed left ventricular ejection fraction and mitral
regurgitation, and was volume overloaded, oliguric, and found to
have an elevated wedge pressure. Treatment was initiated with
milrinone (to maximize cardiac contractility and stroke volume),
and lasix (to decrease preload and achieve optimal filling
pressures). The Pt. responded favorably to this regimen with
improved cardiac function. With compression stockings, his
lower extremity edema began to resolve as well. With improved
forward flow to the kidneys, the Pt. began diuresing quite
briskly to IV lasix, and his creatinine trended down to
approximately 4.0. When the Pt. was nearing euvolemia, the
milrinone was weaned off, and the Pt. was switched to PO lasix
and transferred to a medical floor.
.
At this time, his abdominal symptoms had resolved, supporting
the hypothesis that his symptoms were secondary to elevated
preload leading to 3rd-spaced fluids in the bowel wall (bowel
edema). Unfortunately, the Pt. did not diurese to PO lasix (or
bumetamide) and experienced a rapid reaccumulation of lower
extremity edema, worsening of abdominal symptoms (including
abdominal cramping, nausea, and emesis), and rising creatinine.
The Pt. was seen by the renal team, who felt that if the pt.
could not be managed on PO diuretics, then with a rising
creatinine hemodialysis would be necessary. The Pt. underwent
dialysis for the first time on [**2114-2-9**], and had several
dialysis sessions while in the hospital, which were all well
tolerated, and yielded an improvement and ultimately a
resolution of all abdominal symptoms.
.
The Pt. was also seen by electrophysiology, as he was not
tolerating beta-blockers for rate control of atrial
fibrillation. The Pt. was started on amiodarone for rhythm
control (also because the Pt. had a history of a V-fib cardiac
arrest). When the tailored CHF therapy was completed, the Pt.
was started on low-dose digoxin for further rhythm control. The
Pt. has an ICD in place, and remained in A-Fib with rapid
ventricular response (avg. heart rate 90s-110s). The Pt. was
anticoagulated with coumadin with goal INR of 2.0-2.5.
.
For history of CAD, the Pt. was treated with aspirin and [**First Name8 (NamePattern2) **] [**Last Name (un) **]
(avapro, which he had been on in the past). Beta-blockers
(coreg, metoprolol) were tried but not tolerated, and statin
therapy was deferred because the Pt. was known to have a very
low LDL, and also because statins can alter the effectiveness of
Pt's immunosuppressive meds.
.
Patient had an episode of gout flare on his ankle 24 hours prior
to discharge. No evidence of fever or leukocytosis. Prednisone
dose was increased and patient felt better. After discussing
this issue with Dr [**Last Name (STitle) 1860**], it was decided to d/c azathioprine and
continue allopurinol. Patient will have a follow up appointment
with Dr [**Last Name (STitle) 1860**] in about a week, and in the mean time, prednisone
will be tapered back to immunosuppression dose.
.
Pt. has hyperparathyroidism (PTH [**2113-1-30**]: 283; PTH [**2114-2-12**]:
189). Pt. has been treated with calcium. Will continue to
periodically monitor calcium and phosphate levels.
.
Pt. met with nutritionist while in the hospital and was educated
re: low-sodium cardiac-healthy diet options.
Medications on Admission:
Azathioprine 50 mg PO QD
Prednisone 10 mg PO QOD
Metoprolol Tartrate XL 50 mg po QD
Calcitriol 0.25 mcg po qd
Isosorbide Mononitrate 30 mg SR po qd PRN HTN
Pantoprazole 40 mg po qd
Cyclosporine Modified 50mg PO bid
Warfarin 2/4 mg po qod
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*270 Tablet(s)* Refills:*2*
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily):
please check your INR frequently, goal is 2.0-2.5.
Disp:*60 Tablet(s)* Refills:*2*
5. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO QD ().
Disp:*15 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Cyclosporine 25 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day:
Take 30 mg (3 tab) for 1 day, then 20mg (2tab) for 3 days, then
10mg (1 tab) for 3 days and finally 1 tab every other day until
you see Dr [**Last Name (STitle) 1860**].
Disp:*40 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
1. severe low-output congestive heart failure.
2. acute on chronic renal insufficiency (ESRD s/p renal
transplant).
Discharge Condition:
Good, stable.
Discharge Instructions:
Please continue to take all of your medications exactly as
prescribed.
.
- take your prednisone [**Doctor Last Name 2949**] as prescribed- this is the
schedule: 30mg x 1 day, 20mg x 3 days, 10mg x 3 days and then 10
mg every other day until you see Dr [**Last Name (STitle) 1860**].
.
Please weigh yourself without clothes on today when you get
home, and record your weight. Then weigh yourself every day
without clothes, and if your weight increases by more than 3
pounds, call your PCP or Dr. [**Last Name (STitle) 911**] for instructions about
changing the dose of your diuretic.
.
If you experience abdominal symptoms, chest pain, shortness of
breath, leg swelling, or palpitations, please return to the
hospital.
Followup Instructions:
Please call Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] (cardiology) at [**Telephone/Fax (1) 920**] to
schedule an appointment within the next week.
.
Please call Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] (renal) at ([**Telephone/Fax (1) 773**] to
schedule an appointment within the next week. Dr.[**Name (NI) 14756**] office
will call you with an appointment time. If you do not hear from
them by tomorrow, you should call them at the above number.
Completed by:[**2114-2-14**]
|
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"414.8",
"412",
"424.0",
"274.9",
"585.6",
"V45.02",
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icd9cm
|
[
[
[]
]
] |
[
"37.21",
"39.42",
"89.64",
"88.55",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14406, 14412
|
7395, 12758
|
346, 475
|
14572, 14588
|
3079, 5217
|
15355, 15947
|
2282, 2553
|
13046, 14383
|
14433, 14551
|
12784, 13023
|
5234, 7372
|
14612, 15332
|
2568, 3060
|
277, 308
|
503, 1323
|
1345, 1967
|
1983, 2266
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,865
| 136,953
|
25418+25419
|
Discharge summary
|
report+report
|
Admission Date: [**2118-12-12**] Discharge Date: [**2118-12-16**]
Date of Birth: [**2057-7-20**] Sex: M
Service: MEDICINE
Allergies:
Meperidine
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Pruritis, abnormal labwork
Major Surgical or Invasive Procedure:
ERCP [**2118-12-14**]
History of Present Illness:
The patient is a 61-yo man with h/o EtOH cirrhosis & HCC s/p
OLTx [**2115-2-21**], c/b multiple episodes of acute cellular
rejection ([**2114**]), multiple episodes of biliary sludge/stones
requiring ERCPs (most recently [**5-/2117**]), delayed hepatic arterial
thrombosis [**10/2115**] with resultant ischemic cholangiopathy and
bile lakes, who is directly admitted from home with elevated
transaminases on outpatient labwork. He has had pruritus for the
last 7-10 days for which he called in to clinic on [**2118-12-8**] and
was prescribed Cholestyramine. He has been taking this [**Hospital1 **]
without any relief and increased it to TID today. He has also
noted jaundice for the last 3 days, and bilateral thigh myalgias
for the last 2 days (which he relates to mechanical reasons). He
denies any recent fevers, chills, abdominal pain, nausea,
vomiting, diarrhea, change in bowel habits, melena,
hematochezia, or hematemesis. His stools have become more tan in
color over the last 2 weeks, different from his usual black
stools that he has from iron. He has not noted any change in the
color of his urine, and denies any hematuria or dysuria. He has
never had these symptoms before, and his past ERCPs have been
done for elevated LFTs without symptoms.
Of note, the patient was recently switched to generic
Mycophenolate (produced by Mylan) from prescription CellCept in
the last 1-2 months. He also has a h/o calcineurin-induced renal
failure and is maintained on daily Rapamune. Finally, because of
his several post-[**Hospital1 **] complications, he is considered a
potential candidate for re-transplantation.
Past Medical History:
1. h/o EtOH cirrhosis:
-- c/b HCC, diuretic-resistant ascites, left hepatic
hydrothorax, variceal hemorrhage s/p banding, encephalopathy,
anemia
-- s/p OLTx [**2115-2-21**]
-- c/b renal failure [**1-10**] calcineurin toxicity, multiple episodes
of biliary sludge & stones s/p repeat ERCPs (most recent
[**2117-5-27**]), multiple episodes of acute cellular rejection ([**5-/2115**],
[**8-/2115**], [**11/2115**]), delayed hepatic arterial thrombosis [**2115-10-9**]
and resultant ischemic cholangiopathy and bile lakes
2. s/p Roux-en-Y hepaticojejunostomy [**2115-2-21**] at time of OLTx
3. CAD w/ MI s/p PTCA [**2099**]
4. hypertension
5. dyslipidemia
6. osteoporosis
7. s/p bilateral inguinal hernia repairs
8. s/p umbilical hernia repair
9. s/p lipoma removal from left posterior neck
Social History:
Denies smoking cigarettes or drinking alcohol. Married with
good social support.
Family History:
Non-contributory.
Physical Exam:
VS - Temp 97.8F, BP 117/79, HR 84, R 20, SaO2 100% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRL/EOMI, +scleral icterus, MMM, OP clear
NECK - supple, no LAD
LUNGS - CTA bilat, no r/rh/wh, good air movement
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, obese, well-healed [**Last Name (un) 8314**]-[**Last Name (un) **]
scar, no [**Last Name (un) **] tenderness, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ pedal pulses
SKIN - no rashes or lesions, no jaundice
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength 5/5 throughout and sensation grossly intact throughout
Pertinent Results:
Admission labs:
[**2118-12-12**] 11:02PM GLUCOSE-116* UREA N-39* CREAT-1.4* SODIUM-139
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17
[**2118-12-12**] 11:02PM estGFR-Using this
[**2118-12-12**] 11:02PM LIPASE-49
[**2118-12-12**] 11:02PM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-4.2
MAGNESIUM-2.2
[**2118-12-12**] 11:02PM HBsAg-NEGATIVE HBs Ab-BORDERLINE HBc
Ab-NEGATIVE
[**2118-12-12**] 11:02PM rapamycin-9.3
[**2118-12-12**] 11:02PM ACETMNPHN-NEG
[**2118-12-12**] 11:02PM WBC-5.6 RBC-4.94 HGB-12.6* HCT-39.7* MCV-80*#
MCH-25.5*# MCHC-31.7 RDW-17.8*
[**2118-12-12**] 11:02PM NEUTS-75* BANDS-1 LYMPHS-17* MONOS-5 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2118-12-12**] 11:02PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TEARDROP-OCCASIONAL ENVELOP-1+
[**2118-12-12**] 11:02PM PLT COUNT-174
[**2118-12-12**] 11:02PM PT-11.7 PTT-24.4 INR(PT)-1.0
Labs on dicharge:
[**2118-12-14**]: GLUCOSE-102 UREA N-24 CREAT-1.0 SODIUM-142 POTASSIUM-4.3
CHLORIDE-108 TOTAL CO2-26 ANION GAP-12
[**2118-12-14**]: CA-8.9 MG-1.7 PHOS-3.4
[**2118-12-14**]: WBC-3.8 RBC-4.01 HGB-10.3 HCT-32.4 MCV-81 MCH-25.7
MCHC-31.9 RDW-17.2
[**2118-12-14**]: ALT-337 AST-530 T bili-2.3 AP-607 Alb-3.4
[**2118-12-14**]: CK-3073
IMAGING:
[**2118-12-12**] LIVER ULTRASOUND WITH DOPPLERS.
COMPARISON: CTA abdomen [**2116-5-20**], MRI abdomen [**2118-5-21**].
FINDINGS: The liver is coarse in echotexture. There is
intrahepatic biliary ductal dilatation, stable. There are
multiple hypodense regions within the liver, consistent with
bile lakes, also apparently stable. The CBD measures 3.8mm.
There is normal flow and waveforms seen within the left hepatic
vein, right hepatic vein, and middle hepatic vein. Normal flow
and waveforms are seen within the left portal vein, main portal
vein, and anterior and posterior branches of the right portal
vein. Normal flow and waveforms were seen within the main
hepatic artery. There was slight diminished flow in the left
hepatic artery. The right hepatic artery was not visualized.
IMPRESSION:
1. Normal flow and waveforms seen in all vessels except for
diminished flow in the left hepatic artery. The right hepatic
artery was not visualized.
2. Intrahepatic biliary ductal dilatation with bile lakes,
appears similar to the previous study.
[**2118-12-12**] CT scan abdomen
COMPARISON: MRI dated [**2118-5-21**] and CT torso dated [**2117-2-17**].
TECHNIQUE: Contiguous helical acquisition through the abdomen
and upper pelvis was performed according to the liver CTA
protocol. Images were acquired with and without intravenous
contrast. Arterial, venous, and delayed phase imaging was
obtained. Coronal, sagittal, and MIP images of the hepatic
vasculature were created.
FINDINGS: The heart is stable in size. There is atherosclerotic
calcification involving the coronary arteries. Atelectasis is
noted at the lung bases bilaterally. Multiple low-density
lesions are again identified throughout the liver which are
unchanged in size and appearance compared to most recent MRI of
[**2118-5-9**] and thought to represent bilomas with internal debris
related to hepatic artery occlusion. No new bilomas are
identified. There is moderate intrahepatic biliary dilatation
which is more prominent when compared to the prior MRI. No
enhancing liver masses are identified. The portal and hepatic
veins are patent. The celiac trunk, splenic artery, and
gastroduodenal artery are widely patent. There is near-complete
occlusion of the hepatic artery with minimal flow identified
within it. The portal vein, superior mesenteric artery and vein
are widely patent. No perihepatic fluid collections are
identified. There is no free fluid in the abdomen. The spleen is
stably enlarged. Several low-density lesions are noted in the
right kidney which are too small to characterize but most likely
represent tiny renal cysts. The left kidney is normal in
appearance. There is no hydronephrosis or perinephric fluid
collection. The kidneys enhance normally. The pancreas is
unremarkable in appearance. The visualized bowel is normal.
There is mild atherosclerotic disease of the aorta. No
suspicious lytic or sclerotic lesions are noted within the
osseous structures. Degenerative changes noted, most prominent
within the thoracic spine.
IMPRESSION:
1. Intrahepatic biliary dilatation which is more prominent when
compared to the prior MRI of [**2118-5-9**].
2. Near-complete hepatic artery occlusion with minimal residual
flow and multiple bile lakes noted throughout the liver, stable
in size and distribution compared to most recent MRI of [**Month (only) **]
[**2117**].
3. Stable splenomegaly.
ERCP [**2118-12-14**]: Report not yet available at the time of discharge.
Brief Hospital Course:
Mr. [**Known lastname **] is a 61 year old man with a history of EtOH cirrhosis
& HCC s/p OLTx [**2114**] c/b multiple episodes of acute cellular
rejection, multiple episodes of biliary sludge / stones
requiring repeat ERCPs, and delayed arterial thrombosis
resulting in ischemic cholangiopathy and bile lakes, who is
directly admitted from home for elevated transaminases on
outpatient labwork, but also with biliary obstructive symptoms.
1. Biliary obstruction. Mr. [**Known lastname **] was admitted with clinical and
laboratory findings consistent with biliary obstruction, but
concerning for possible [**Known lastname **] rejection. He was started on
levofloxacin and flagyl on [**2118-12-13**] for possible cholangitis. He
was taken for ERCP on [**2118-12-14**] to evaluate his biliary tree - the
results are as above. This represents another incidence of
obstruction comparable to prior episodes. As the findings of
stricture and stones were likely the cause of his symptoms, he
was monitored overnight and discharged the next morning without
liver biopsy to investigate organ rejection. Mr. [**Known lastname 63532**]
transaminases, bilirubin and alkaline phosphatase improved on
their own prior to ERCP, with reduction in total bilirubin from
7.9 to 2.8. This resulted in improvement of both his jaundice
and pruritis. Cholestyramine was held, and hydroxyzine was
prescribed PRN for itch. Following ERCP, his labs trended upward
again likely due to mechanical manipulation of the structures
around the biliary tree, and then trended downward again the day
following admission. He received levo/flagyl during this
admission for possible cholangitis (no evidence of this on ERCP)
which were stopped the day of discharge. He was resumed on his
Bactrim ppx at discharge.
2. Myalgias. Mr. [**Known lastname **] presented with a complaint of myalgias in
his anterior thighs. His neurological exam was fully intact with
no focal deficits. His serum CK was > 13,000 on admission, and
trended consistently downward with IV fluids and cessation of
gemfibrozil and simvastatin. Biliary obstruction may have
predisposed to a statin-induced rhabdomyolysis. However, urine
myoglobin screening (conducted when CK was ~8,000) returned
"presumptively negative." A decision was made not to restart
these medications at discharge.
3. Acute renal failure. Creatinine at admission was elevated to
1.4 on admission from a baseline of 1.0, but trended down to 1.2
and then 1.0 at discharge with IVF. This may have been due to
transient myoglobinuria from a possible mild rhabdo (as above)
vs. dehydration. Furosemide and lisinopril were held in the
setting of ARF but resumed on discharge.
4. Alcoholic cirrhosis s/p [**Known lastname **]. Mr. [**Known lastname **] was continued
on his home medications of CellCept and rapamycin. His rapamycin
level on admission was elevated for this stage post-[**Known lastname **]
to > 9. His dose was therefore reduced to 2 mg daily (from 3
mg). He was continued on ursodiol. During this admission, he was
re-evaluated by the [**Known lastname **] team for possible future
re-[**Known lastname **], as complications from continued biliary
obstruction are likely to occur. Peak MELD during this admission
was 14.
5. Other home medications were continued during this admission.
Medications on Admission:
- Cholestyramine-Aspartame [Cholestyramine Light] 4gram Packet
by mouth twice a day, started Thursday [**2118-12-8**] by Dr. [**Last Name (STitle) 497**],
increased to three times a day by patient today [**2118-12-12**]
- ALENDRONATE 70 mg Tablet by mouth once weekly, every Thursday
- ALPRAZOLAM 1 mg Tablet by mouth x1 PRN for MRI
- ATENOLOL 25 mg Tablet by mouth once a day
- FUROSEMIDE 20 mg Tablet by mouth once a day
- GEMFIBROZIL [LOPID] 600 mg by mouth twice a day
- LISINOPRIL 5 mg Tablet by mouth daily
- MYCOPHENOLATE MOFETIL 250 mg Capsule by mouth twice a day,
changed to generic formulation produced by Mylan [**2118-10-10**]
- OMEPRAZOLE [PRILOSEC] 20 mg Capsule, Delayed Release(E.C.) by
mouth at bedtime
- SIMVASTATIN 80 mg Tablet by mouth at bedtime
- SIROLIMUS [RAPAMUNE] 3 mg Tablet by mouth once a day
- TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM] 400 mg-80 mg Tablet by
mouth once a day
- URSODIOL 600 mg Capsule by mouth once a day in the morning,
300mg Capsule by mouth once a day in the evening
- ZOLPIDEM 10 mg Tablet by mouth at bedtime PRN
- ASPIRIN 325 mg Tablet by mouth once a day
- CALCIUM CARBONATE-VIT D3-MIN [CALTRATE 600+D PLUS MINERALS]
600 mg-400 unit Tablet by mouth twice a day
- FERROUS SULFATE 325 mg (65 mg Iron) Tablet by mouth three
times a day
- MULTIVITAMIN Tablet one by mouth daily
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO HS (at bedtime).
7. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
13. Caltrate 600+D Plus Minerals 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Biliary obstruction
- Jaundice/itching
- Myalgias (possibly secondary to mild rhabdomyolysis)
Secondary:
- s/p OLT in [**2114**]
- Coronary artery disease
- Hypertension
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital1 69**] with
complaints of itching skin, thigh pain, and jaundice. An
ultrasound and CTA scan of your abdomen showed widening of the
biliary ducts within the liver and impaired blood flow through
the hepatic artery. ERCP showed some strictures of the biliary
tree as well as the presence of gallstones with some leaking of
bile into the adjacent areas of liver. This obstruction of the
bile duct is most likely what caused your symptoms of itching
and jaundice. Your muscle aches may have been caused by your
cholesterol medications in the setting of this obstruction. You
should stop taking these medications until instructed to resume
by your physician.
We have made the following changes to your medication regimen:
- STOP TAKING gemfibrozil
- STOP TAKING simvastatin
- REDUCE DOSE of sirolimus to 2 mg by mouth daily
Please keep your follow up appointments as instructed before.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2119-1-11**]
9:30
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2119-1-11**] 10:40
- You may wish to call the clinic to move this appointment
earlier at the request of Dr. [**Last Name (STitle) 497**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2118-12-16**] Admission Date: [**2118-12-16**] Discharge Date: [**2118-12-21**]
Date of Birth: [**2057-7-20**] Sex: M
Service: MEDICINE
Allergies:
Meperidine
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Fevers/cholangitis
Major Surgical or Invasive Procedure:
Right IJ placement
History of Present Illness:
Mr. [**Name13 (STitle) **] is a 61 year-old man with alcoholic cirrhosis and HCC
s/p OLTx [**2115-2-21**], multiple episodes of biliary sludge/stones
requiring ERCP, delayed hepatic arterial thrombosis [**10/2115**] with
resultant ischemic cholangiopathy and bile lakes, who presents
with fevers and abdominal pain after undergoing ERCP on [**2118-12-14**]
with extention of pre-existing sphincterotomy which was
stenosed. Biliary debris was expressed. There were also
multiple stones in the biliary tree.
He is being transferred to the [**Hospital Ward Name 516**] [**Hospital Unit Name 153**] from MICU 7 as a
precaution in case he needs emergent ERCP. Full HPI is
available in the MICU 7 admission note.
Briefly, he initially underwent ERCP with extension of existing
sphincterotomy on [**2118-12-12**] for jaundice and pruritis. His bili
fell from 7.9 to 2.8 post-procedure. He received levo/flagyl
initially but was discharged from the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service off
antibiotics on the morning of admission reportedly looking well.
However, when he returned home, he developed rigors, a fever of
103.5, and RUQ pain, so he represented to the [**Hospital1 18**] ED on the
evening of [**2118-12-16**]. There, he had a fever to 105F and his SBPs
fell to the 80s. A CVL was placed and he was bolused 6L NS;
levophed was also started. ERCP was consulted and he went to
MICU7 because of lack of bed availability in the [**Hospital Unit Name 153**].
In MICU 7, his levophed, initially at 0.08 mcg/kg/hr was weaned
and off by noon. His systolic blood pressure ranged from 97 to
121 since admission, his HR 90-115, and he has been afebrile.
He was continued on zosyn and is now growing GNRs on [**1-10**] BCx,
resistant to cipro and gent, but sensitivie to cefepime, ceftaz,
and CTX. His tbili which was initially going up from 2.3 to 2.9
while discharged, trended down to 2.2 this AM. His LFTs are
trending down as well. His Cr increased from nl baseline and
1.0 upon discharge to 1.5 overnight and 1.6 this AM. He was
given dilaudid for pain.
He was seen by ERCP who wanted to watch him clinically for now,
and feels he likely has an area of edema causing mild
obstruction versus biloma in rt lobe or retained stone fragment.
Hepatology saw him as well and recommended a diagnostic para.
Currently upon arrival, he feels much better and no longer with
rigors. He reports increased LE edema and abdominal distension
beginning today. Other than one dose at home, he has been
without his diuretics since his last admission. He has
continued mild RUQ pain, but no other abdominal pain.
REVIEW OF SYSTEMS:
(+)ve: as per HPI
(-)ve: night sweats, loss of appetite, fatigue, chest pain,
palpitations, rhinorrhea, nasal congestion, cough, sputum
production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia,
melena, dysuria, urinary frequency, urinary urgency, focal
numbness, focal weakness, myalgias, arthralgias
Past Medical History:
1. h/o EtOH cirrhosis:
-- c/b HCC, diuretic-resistant ascites, left hepatic
hydrothorax, variceal hemorrhage s/p banding, encephalopathy,
anemia
-- s/p OLTx [**2115-2-21**]
-- c/b renal failure [**1-10**] calcineurin toxicity, multiple episodes
of biliary sludge & stones s/p repeat ERCPs (most recent
[**2117-5-27**]), multiple episodes of acute cellular rejection ([**5-/2115**],
[**8-/2115**], [**11/2115**]), delayed hepatic arterial thrombosis [**2115-10-9**]
and resultant ischemic cholangiopathy and bile lakes
2. s/p Roux-en-Y hepaticojejunostomy [**2115-2-21**] at time of OLTx
3. CAD w/ MI s/p PTCA [**2099**]
4. hypertension
5. dyslipidemia
6. osteoporosis
7. s/p bilateral inguinal hernia repairs
8. s/p umbilical hernia repair
9. s/p lipoma removal from left posterior neck
Social History:
Remote history of alcohol and tobacco, none for years. Lives
with his wife. Two children. Retired police officer. Denies
illicit drugs.
Family History:
No family history of hereditary hemochromatosis, colon cancer or
diabetes. Otherwise noncontributory.
Physical Exam:
VS: 98.9 HR 96 127/64 93%2L
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: JVD 12 cm, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST: mild bibasilar rales, o/w ctab no w/r.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: obese and distended, TTP RUQ. No shifting dullness.
NABS. No rebound or guarding.
EXTREMITIES: 2+ LE pedal edema, extremities warm without
cyanosis. 2+ distal pulses.
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact.
Strenght and sensation grossly intact.
Pertinent Results:
Hematology:
[**2118-12-16**] 08:10PM WBC-2.9* RBC-4.62 HGB-11.8* HCT-38.2* MCV-83
MCH-25.6* MCHC-31.0 RDW-17.4*
[**2118-12-16**] 08:10PM NEUTS-80* BANDS-3 LYMPHS-9* MONOS-2 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-3*
[**2118-12-16**] 08:10PM PLT COUNT-133*
[**2118-12-16**] 08:10PM PT-12.6 PTT-23.6 INR(PT)-1.1
.
Chemistries:
[**2118-12-16**] 08:10PM GLUCOSE-136* UREA N-27* CREAT-1.0 SODIUM-142
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-17
[**2118-12-16**] 08:10PM ALT(SGPT)-444* AST(SGOT)-552* ALK PHOS-715*
TOT BILI-2.9*
[**2118-12-16**] 08:10PM LIPASE-43
.
Urinalysis:
[**2118-12-16**] 11:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2118-12-16**] 11:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2118-12-16**] 11:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
.
Imaging:
CXR Portable [**2118-12-16**]: Upright AP view of the chest is obtained.
Low lung volumes limit evaluation. No free air is seen below the
right hemidiaphragm. Double density of the right hemidiaphragm
is compatible with known eventration better seen on the prior
CT. There is no evidence of pneumonia or CHF. Linear densities
in the lower lungs are most compatible with atelectasis. Heart
size is grossly within normal limits allowing for technique.
Bony structures are intact.
.
RUQ Ultrasound (wet read): [**2118-12-16**]:
Stable size to right lower liver lobe bile [**Doctor Last Name **], but with new
echogenic
debris. may be related to recent ERCP, but infection cannot be
excluded.
stable bile duct dilation. normal portal vein flow.
.
Microbiology:
Blood cultures x 2 [**2118-12-16**]:
[**2118-12-16**] 8:20 pm BLOOD CULTURE
**FINAL REPORT [**2118-12-19**]**
Blood Culture, Routine (Final [**2118-12-19**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Blood cultures x 2 [**2118-12-17**]: NGTD at time of discharge
Brief Hospital Course:
Mr. [**Name13 (STitle) **] is a 61 year-old man with alcoholic cirrhosis and HCC
s/p OLTx [**2115-2-21**], multiple episodes of biliary sludge/stones
requiring ERCP presenting with sepsis/cholangitis.
.
Sepsis/cholangitis/E. coli bacteremia: Multiple episodes of
biliary obstruction previously thought to be secondary to
hepatic artery insufficiency and presenting with fevers, rising
bilirubin, RUQ pain after ERCP on [**2117-12-14**]. GNRs growing in both
BCx from ED with sensitivities as above, most likely source from
biliary source. His hypotension responded to fluid and his
levophed was weaned off with hemodynamic stabilization. He had
been on zosyn initially with clinical improvement. Bedside U/S
shows no obvious pocket for ascites. He was evaluated by the
ERCP team who did not feel that repeat ERCP was warrented at
this time given clinical improvement. His bilirubin and LFTs
trended down. His bacteremia resulted to E. coli sensitive to
ceftriaxone, for which he was switched to complete a 10 day
total course through [**2118-12-25**]. A PICC line was placed prior to
discharge.
.
Alcoholic cirrhosis s/p [**Month/Day/Year **]: Thought to be a possible
candidate for re-[**Month/Day/Year **] given complications. Rapamycin dose
recently reduced for supratherapeutic level. He was continued
on mycophenolate and sirolimus for his immunosuppresive. He was
also continued on his home ursodiol and bactrim. His lasix was
initially held given hemodynamic instability but was restarted
on [**2118-12-18**]. He will follow up closely with his hepatologist.
His lasix was restarted and dose increased at discharge given
edema.
.
Acute Renal Failure: Felt to be secondary to hypoperfusion in
the setting of sepsis. He was fluid resuscitated and his
antihypertensives and lasix were held. His creatinine peaked at
1.6 and trended down to 1.2. His lasix was restarted at the
time of floor transfer and upon discharge.
.
Abdominal distension and LE edema: Worsening abdominal
distension and LE edema likely related to underlying liver
disease and being without his diuretics. Abdominal ultrasound
was performed but did not show any evidence of ascites. His
diuretics were held in the setting of acute renal failure and
hemodynamic instability but were felt safe to resume at the time
of floor transfer and at discharge. His lasix was restarted and
dose increased at discharge given edema. His discharge weight
was 208 lbs.
.
Thrombocytopenia: near baseline, cont to follow.
.
Coronary Artery Disease, native: Stable. Held atenolol and asa
initially. Gemfibrozil and statin were held at last admission
[**1-10**] elevated ck and myalgias. Last ECHO normal 7/[**2116**]. These
medications were held at discharge
.
Hypertension, benign: held antihypertensives initially.
Restarted prior to discharge
.
CODE STATUS: full
.
EMERGENCY CONTACT: Ms. [**Name13 (STitle) **], Home Phone: [**Telephone/Fax (1) 63533**] Work
Phone: [**Telephone/Fax (1) 63534**]
Medications on Admission:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One
(1)capsule, Delayed Release(E.C.) PO HS (at bedtime).
7. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day
8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
13. Caltrate 600+D Plus Minerals 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
15. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) GRAM Intravenous Q24H (every 24 hours) for 6 days.
Disp:*6 injections* Refills:*0*
2. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
3. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
7. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Atenolol 25 mg Tablet Sig: .5 Tablet PO once a day.
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day.
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
home solutions
Discharge Diagnosis:
E. coli bacteremia
Cholangitis
Alcoholic cirrhosis, liver [**Telephone/Fax (1) **]
Coronary artery disease, native
Hypertension, benign
Biliary sludge
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted with infection of your biliary system
(cholangitis). You were very sick and spent some time in the
ICU. You were treated with IV antibiotics. You were found to
have bacteria in the blood which was treated. You will need to
complete a full course of IV antibiotics through your PICC line.
.
Please weight yourself when you get home. If your weight does
not decrease over the next 2 days-OR- it goes up at anytime,
please call your doctor. It means your lasix dose will need to
be adjusted.
.
Please continue all previous medications as before, except for
your lasix. Your lasix dose was increased to 20mg 2x/day.
Please follow up with your PCP and hepatologist as soon as
possible. You will have blood work checked on [**Telephone/Fax (1) 766**] and this
will be faxed to your PCP.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name (STitle) **] [**Name (STitle) 10755**]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: [**Last Name (LF) 766**], [**1-2**] at 11:00am
Location: [**Location (un) 46471**], [**Location (un) **],[**Numeric Identifier 46472**]
Phone number: [**Telephone/Fax (1) 46461**]
.
Appointment #2
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2118-12-28**] 3:20
|
[
"576.1",
"414.01",
"584.9",
"733.00",
"V42.7",
"038.42",
"272.4",
"V45.82",
"995.92",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
29270, 29315
|
23830, 26808
|
16443, 16463
|
29510, 29510
|
21262, 23807
|
30483, 30937
|
20506, 20612
|
28036, 29247
|
29336, 29489
|
26834, 28013
|
29655, 30460
|
20627, 21243
|
19147, 19522
|
16385, 16405
|
16491, 19128
|
3612, 8344
|
29524, 29631
|
19544, 20333
|
20349, 20490
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,745
| 111,795
|
50938
|
Discharge summary
|
report
|
Admission Date: [**2170-6-30**] Discharge Date: [**2170-7-12**]
Date of Birth: [**2115-2-16**] Sex: F
Service: SURGERY
Allergies:
Tylenol
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
HCV cirrhosis
Major Surgical or Invasive Procedure:
[**2170-7-1**] liver transplant
[**2170-7-6**] ERCP with placement of PD & CBD stent
[**2170-7-12**] Pancreatic stent removal
Past Medical History:
1. HCV cirrhosis.
2. Portal hypertension.
3. Ascites.
4. Hepatopulmonary syndrome.
Pertinent Results:
[**2170-6-30**] 02:10PM WBC-5.4 RBC-2.96* HGB-10.8* HCT-32.5*
MCV-110* MCH-36.6* MCHC-33.2 RDW-15.9*
[**2170-6-30**] 02:10PM GLUCOSE-75 UREA N-13 CREAT-0.8 SODIUM-134
POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-18* ANION GAP-12
[**2170-7-12**] 05:00AM BLOOD WBC-12.0* RBC-3.44* Hgb-10.6* Hct-32.4*
MCV-94 MCH-30.8 MCHC-32.7 RDW-16.9* Plt Ct-167
[**2170-7-11**] 04:55AM BLOOD WBC-13.9* RBC-3.42* Hgb-10.4* Hct-31.3*
MCV-91 MCH-30.3 MCHC-33.2 RDW-17.2* Plt Ct-140*
[**2170-7-12**] 08:35AM BLOOD PT-12.3 PTT-22.0 INR(PT)-1.0
[**2170-7-12**] 05:00AM BLOOD Glucose-95 UreaN-29* Creat-1.2* Na-138
K-3.6 Cl-102 HCO3-27 AnGap-13
[**2170-7-11**] 04:55AM BLOOD Glucose-74 UreaN-26* Creat-1.0 Na-137
K-3.7 Cl-103 HCO3-26 AnGap-12
[**2170-7-12**] 05:00AM BLOOD ALT-35 AST-14 AlkPhos-66 TotBili-0.4
[**2170-7-12**] 05:00AM BLOOD Albumin-2.4* Calcium-8.2* Phos-3.4 Mg-1.6
[**2170-7-11**] 04:55AM BLOOD tacroFK-12.9
Brief Hospital Course:
On [**2170-7-1**] she underwent Orthotopic deceased donor liver
transplant (piggyback) with portal vein-portal vein anastomosis,
common bile duct to common bile duct anastomosis without a T
tube and celiac axis patch (donor) to branch patch (recipient).
Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please refer to operative note
for complete details. Two JPs were placed. She received standard
induction immunosuppresion consisting of solumedrol and
cellcept. Postop, she went directly to the SICU intubated where
she did well. LFTS trended down and an u/s of the liver was
performed on pod 1 showing patent hepatic vasculature with
appropriate waveforms and no biliary dilatation or collection
seen. A cxr was also done showing a small right pneumothorax. A
chest CT confirmed this. Subsequently a chest tube was placed.
She was extubated on pod1. PRBC and plt were given to keep hct
greater than 30. An insulin drip was used for hyperglycemia.
She continued to do well, but required O2 3-4 liters to keep
sats in the 90-95 range. Standing IV lasix was started. She was
transfered to the medical surgical floor where her diet was
advanced and tolerated. PT followed, but activity was limited
given O2 needs (please see PT notes)given hepatopulmonary
syndrome. She was able to transfer to the commode with assist of
one, wearing O2 continuous. The Chest tube remained in placed
until [**6-10**] when non-bilious output decreased to less than 200ml.
Post removal, his O2 desat'd to 79% when attempting to ambulate.
Breath sounds remained clear with faint decrease in the right
LLL. A cxr showed a tiny right apical pneumothorax. A repeat CXR
was done on [**6-11**] showing near resolution of the pneumothorax.
JP output was noted to be bilious therefore on [**7-6**] an ERCP was
performed demonstrating a biliary leak at the anastomosis.
Extravasation was noted at the middle third of the common bile
duct. A sphincterotomy was performed and a stent was placed
successfully after a pancreatic duct stent was placed. She
tolerated the procedure well. Amylase and lipase remained
normal. The JP drainage became non-bilious. LFTs continued to
be normal. Unasyn was given for 6 days following the ERCP. On
[**6-12**], the pancreatic duct stent was removed without incident.
Post, procedure she was stable and diet was resumed. On [**6-12**], the
remaining JP was removed and the site sutured. Oxycodone was
given for incisional pain with good relief.
Immunosuppression: Solumedrol was tapered per protocol down to
20mg qd starting on [**7-7**]. Cellcept 1 gram [**Hospital1 **] continued and
prograf was started on pod 1. Daily dosing occurred based on
daily trough levels. Dose was decreased to 1mg [**Hospital1 **] on [**7-12**] for a
level of 15.2.
Social work followed for emotional support. PT evaluated and
recommended rehab given significant hepatopulmonary syndrome.
She was only partially able to participate in PT eval given
decreased O2 with exertion. O2 sat decreases into the mid 80's
off O2. She continued to require 3liter of O2. IV lasix 40mg had
been given [**Hospital1 **] until day of discharge when this was stopped when
her weight decreased to her admission weight.
Incision appeared clean, dry and intact with staples.
She was accepted by [**Hospital **] Rehab Hospital and transferred
there via ambulance on [**6-12**] in stable condition.
Medications on Admission:
Spironolactone 50 qd, Clotrimazole 10 5x a day, Boniva, Calcium
Carbonate-Vit D3-Min, B12, Folic Acid
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q12H (every 12 hours).
2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection ASDIR (AS DIRECTED): see printed scale.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
10. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
12. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
HCV cirrhosis
hepatopulmonary syndrome
right pneumothorax, resolved
s/p liver transplant
bile leak, s/p biliary stent placement
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
shortness of breath, chest pain, nausea, vomoiting, jaundice,
abdominal pain, incision redness/bleeding/drainage.
Labs every Monday and Thursday for cbc, chem10, LFTs, and trough
prograf level. Results need to be fax'd to the Transplant office
[**Telephone/Fax (1) 697**] [**Name8 (MD) 5035**] RN coordinator
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2170-7-19**]
9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2170-7-26**] 9:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2170-8-1**]
9:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2170-7-12**]
|
[
"525.8",
"070.54",
"575.11",
"996.82",
"789.59",
"155.0",
"512.1",
"571.5",
"250.00",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"52.93",
"51.87",
"50.59",
"51.10",
"97.56",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
6315, 6394
|
1457, 4897
|
280, 408
|
6566, 6573
|
533, 1434
|
7011, 7605
|
5049, 6292
|
6415, 6545
|
4923, 5026
|
6597, 6988
|
227, 242
|
430, 514
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,382
| 148,630
|
49439
|
Discharge summary
|
report
|
Admission Date: [**2189-3-31**] Discharge Date: [**2189-4-7**]
Date of Birth: [**2138-6-4**] Sex: M
Service: MEDICINE
Allergies:
Roxicet / Penicillins / Aspirin
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
lethargy and hypotension
Major Surgical or Invasive Procedure:
trach change
History of Present Illness:
50 y/o male with a h/o squamous cell cancer of vallecula s/p XRT
and tonsillar cancer w/ recent initiation of XRT and
chemo,history of cirrohsis,history of seizure disorder on meds,
history of trach and PEG, who is transferred from [**Hospital **] Rehab
with lethargy and hypotension. He had recent admission [**Date range (1) 103489**]
for 2nd cycle of chemo/XRT which involved continued treatment of
a pneumonia that had been diagnosed at [**Hospital 100**] Rehab. His sputum
grew multidrug resistant Klebsiella so abx were changed to
meropenem and discharged to [**Hospital 100**] Rehab and completed course on
[**2189-3-25**].
.
Prior to this admission, per family and ED records pt has been
noted to have lethargy and over the past few days with sBP's in
the 80's. This time she states he finished the meropenem on [**3-25**]
and on [**3-27**] he became more lethargic and then [**3-28**] began bringing
up more sputum from his trach. She states he has not been
tolerating tube feeds for the few days PTA(was having nausea and
vomiting) and so these have been held for most of the weekend.
IVF were also held over the past few days.
.
She states at baseline (when he is on abx) he is up and walking
around and able to care for his G tube on his own. He used to be
able to talk with a passey muir valve, but last week his trach
was downsized to a smaller one that does not allow him to talk.
This has been very frustrating to him.
.
On arrival to the ED BP was 90/58 but then dropped to 74/41. 4L
of NS were hung but the patient only received approx 1L NS
before being transferred to the MICU. On arrival to the MICU BP
was 135/75. In the ED he received cefepime 1g IV, Vancomycin 1gm
IV. Wife states pt has had difficulty with edema in his legs in
the past, and thus NS boluses were stopped and pt was placed on
D5NS at 75 hour x 1L.
.
He is now stabilized in the MICU and transferred to the floor.
.
MICU course:
-ID- His was found to have MRSA and resistent Klebsiella on
sputum. ID was also consulted. His abx was changed to meropenem
and vancomycin. This was c/b leukopenia likely [**1-23**] to meropenem.
His WBC has been decreasing from 4K to 1.6K today.
-Pulm- Given his sputum and [**Month/Day (2) 65**] sputum and infection, his trach
was upsized to facilitate suction.
-Heme- His was found to have clot in left subclavin during
flouro for PICC. This was c/b low plt ? HIT. THis returned neg
and was started lovenox as a bridge to coumadin.
Past Medical History:
-Squamous cell cancer of the vallecula that was diagnosed in
[**2181**]
(T2N0M0). He was initially treated with radiation. Pt later
presented with dysphagia and CT of his neck revealed that he had
a 2.8 x2.1 x 4.5 cm right tonisillar mass, unresectable tonsil
cancer, which could be palliated with systemic chemotherapy
and/or XRT or a combination of both. XRT and chemo (Taxol/CDDP)
initiated in [**1-28**].
-Alcoholic cirrhosis
-Seizure d/o - last sz > 2y ago
-Psoriasis
-G tube placed [**10-27**] [**1-23**] failure of swallow test
-Pancreatitis secondary to ETOH
-Hepatic encephalopathy
-Bleeding esophageal varices
-Portal vein thrombosis
Social History:
Lives with his wife, although he has been in [**Name (NI) **] [**Hospital1 1501**] and
more recently in acute rehab at [**Hospital 100**] Rehab for the past [**1-24**]
months. Former ETOH. Former smoking.
Family History:
Brother died of CAD at age 34.
Physical Exam:
Vitals: 99.3, 80, 135/75, 18, 93% on 6L trach mask, increased to
97% s/p suctioning and placement on 35% O2 via trach mask.
General: 50M in NAD, appears older than stated age
HEENT: NC/AT. PERRLA. EOMI. MMM.
Neck: Trach collar in place with beige secretions.
CV: Normal S1, S2 without m/r/g.
Pulm: coarse breath sounds B/L, otw CTAB.
Abd: Soft, NT/ND with normoactive BS. PEG tube in place, c/d/i.
Ext: no c/c/e. psoriasis on B/L UE and LE.
Neuro: pt not talking, but nodding head appropriately.
Pertinent Results:
Head CT without contrast: There is no intra- or extra-axial
hemorrhage, mass effect, shift of normally midline structures,
or hydrocephalus. There is no major or minor vascular
territorial infarction. The differentiation of the [**Doctor Last Name 352**]-white
matter is preserved. Density values of brain parenchyma are
within normal limits. The surrounding soft tissues and osseous
structures are unremarkable.
IMPRESSION: No evidence of acute intra- or extra-axial
hemorrhage. No change compared to [**2184-7-22**]
Portable AP chest dated [**2189-3-30**] is compared to the prior PA and
lateral from [**2189-3-9**]. Tracheostomy tube is seen terminating in
the mid trachea, good and stable position. A right PICC line
terminates in the mid axillary line. The heart size is normal.
The pulmonary vasculature is normal. The hilar contours are
stable. The lungs are clear. There is no pleural effusion or
pneumothorax
IMPRESSION: No evidence for infiltrate.
Brief Hospital Course:
50 y/o male with a h/o squamous cell cancer of vallecula s/p
XRT and tonsillar cancer s/p recent chemo/XRT and recent
klebsiella pna admitted with recurrent lethargy and increased
sputum:
.
# Lethargy and increased sputum: likely [**1-23**] recurrent
tracheo-bronchitis, treated with antibiotics initially given
poor baseline. Resp therapist noted that trach plug smelled like
pseudomonas. Pt has been in rehabs/hospitals for last several
months and has been exposed to many drug-resistant organisms.
However, positive cultures (MRSA, ESBL Klebsiella) may represent
colonization rather than true infection. Abx stopped on [**4-4**] and
clinically well-appearing, with no fevers.
-WBC continues to be low, possibly from meropenem; trending up
off [**Last Name (un) 2830**] and received dose of neupogen yesterday
-trach changed [**4-1**], still with thick secretions but strong
cough
-continue airway humidification as much as possible to help
break up secretions
-pt should NOT have his trach downsized in the near future, even
at rehab due to problems with secretions accumulating and
infections
-PICC changed and replaced (see below)
.
# Hypotension: likely from dehydration given that wife reports
tube feeds and IVF have been held x 4 days. Pt responded quickly
to 1L NS and now is normotensive. Initially gave D5NS at 75 per
hour until TF restarted. (family gives history of extensive LE
edema which is now not present but do not wish to overload with
fluids).
-continues to be normotensive, no further IVF needed for now
-should have airway humidification as much as possible to avoid
dehydration through trach
.
# left subclavian vein DVT: detected under fluoro for PICC
placement; not started on heparin overnight due to concern for
HIT; however, on discussion with heme/onc, pt previously worked
up for HIT and has intermittent thrombocytopenia
- bridge to coumadin with lovenox (coumadin started [**4-3**])
.
# Elevated Cr: only slightly elevated to 1.2 (baseline 0.7) on
admission. Likely from dehydration. Creat down with hydration.
.
# Onc: 2 primary head and neck cancers.
-plan per oncology team
.
# Psoriasis - cont on clobetasol cream.
.
# Cirrhosis - cont lactulose and nadolol. LFT's at baseline.
.
# Seizure disorder - cont Keppra and Dilantin. Dilantin level
15.9 in ED. (therapeutic is [**10-10**]). Check Dilantin level as may
be interfering with WBC.
.
# FEN - tube feeds, will change to bolus. Cont reglan and use
ativan and compazine prn nausea.
.
# Access: has PICC (needs TPA) and peripherals.
.
# Code: Full, discussed with patient
Medications on Admission:
-Dilantin 100mg per GT q8am and qnoon, 200mg per GT q8pm
-methadone 10mg per GT tid
-compazine 10mg per GT q8
-reglan 10mg per GT q6
-atrovent nebs q6
-albuterol nebs q6
-nadolol 20mg daily
-scopolamine patch 1.5 TD q3 days
-lactulose 30mg tid
-mucomyst into trach [**Hospital1 **]
-chlorhexidine 15ml swish and spit tid
-clobetasol 0.05% cream [**Hospital1 **] apply to upper arms
-clonidine 0.1mg per GT qhs
-gabapentin 300mg po q8am and q2pm, 600mg qhs
-simethicone 80mg qid
-omeprazole 20mg daily
-tylenol prn
-dilaudid 4mg q4 prn
-ambien 5mg qhs prn
-ativan 1mg q6 prn
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please follow up with the doctor at your facility. He will need
to check your blood to determine when you can stop the lovenox
shots. Please continue the full course of antibiotc Meropenem
as prescribed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2189-4-14**] 2:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2189-4-14**] 2:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2189-5-14**] 11:45
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
|
[
"466.0",
"V44.1",
"345.90",
"276.51",
"284.1",
"453.40",
"572.2",
"V10.02",
"571.2",
"V55.0",
"696.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8462, 8514
|
5274, 7837
|
314, 329
|
8568, 8577
|
4290, 5251
|
8831, 9342
|
3724, 3757
|
8535, 8547
|
7863, 8439
|
8601, 8808
|
3772, 4271
|
250, 276
|
357, 2814
|
2836, 3484
|
3500, 3708
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,964
| 145,114
|
34747
|
Discharge summary
|
report
|
Admission Date: [**2149-5-21**] Discharge Date: [**2149-6-4**]
Date of Birth: [**2071-10-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
75 YOF s/p MVC with multiple fractures
Major Surgical or Invasive Procedure:
1.)Tracheostomy [**2149-5-27**]
2.)[**Year (4 digits) 282**] [**2149-5-27**]
3.)IVC filter [**2149-5-27**]
4.)Ex fix R lower extremity [**2149-5-23**]
5.) ORIF L ankle [**2149-5-23**]
6.)Conversion of Ex Fix to ORIF R lower extremity [**2149-6-2**]
7.) s/p L subclavian central venous catheter
8.) R subclavian central venous catheter
History of Present Illness:
77 YOF with emphysema, COPD, HTN s/p restrained driver in MVC,
struck at 45mph on Left front side of vehicle. No LOC.
Injuries: open left ankle fx, right tibial plateu fx, R patellar
fx open right wrist fx, closed left wrist fracture
Past Medical History:
HTN
Emphysema
COPD
Hypercholesterolemia
Social History:
Widowed, lives alone, active prior to hospital admission. Denies
EtOH, denies current tobacco use per chart.
Family History:
Non contributory
Physical Exam:
HR 93 BP 118/x RR 25 T 37 SpO2 95 RA GCS 15
HEENT: NC, abrasion present on L forehead, PERRL, EOMI
CV: RRR, normal to palpation
Resp: CTA B, normal effort
Ab: Soft, NT, ND
Ext: Dislocation of R knee, Open R wrist, abrasion on Right
upper arm, Open L ankle-DP/PT not palpable, but identified on
doppler, palpable post reduction
Neuro: CN 2-12 intact
Pertinent Results:
[**2149-5-21**] 05:45PM LACTATE-2.4*
[**2149-5-21**] 05:35PM UREA N-18 CREAT-1.3*
[**2149-5-21**] 05:35PM estGFR-Using this
[**2149-5-21**] 05:35PM AMYLASE-112*
[**2149-5-21**] 05:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-9.7
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2149-5-21**] 05:35PM WBC-10.2 RBC-4.79 HGB-11.9* HCT-36.3 MCV-76*
MCH-24.9* MCHC-32.8 RDW-16.4*
[**2149-5-21**] 05:35PM PLT COUNT-236
[**2149-5-21**] 05:35PM PT-13.6* PTT-30.7 INR(PT)-1.2*
[**2149-5-21**] 05:35PM FIBRINOGE-298
Brief Hospital Course:
Patient was brought to the ED at [**Hospital1 18**] on [**2149-5-21**]. She had been
in an MVC when she was driving away from [**Hospital6 2561**] -
she had been there for suspicion of a Left wrist fracture, which
was found to not be fractured. Upon arrival in the ED, her GCS
was 15. Injuries upon examination included a left open ankle
fracture, right tibial plateau fracture, shattered right
patella, and right open wrist fracture. Head CT, C-spine CT,
and Torso CT showed no other injuries. The only other finding
on the CT torso was an infrarenal AAA measuring 3.8 cm x 3.4 cm.
The patient was taken to the OR the same night of admission.
The orthopedics team repaired her left ankle fracture, placed an
external fixation device on her right leg, and repaired her
right wrist fracture. When the patient returned to the T-SICU,
she became hypotensive and tachypneic. ABGs revealed her pO2s
in the 40s. Given her recent trauma and orthopedic injuries,
suspicion was raised that the patient had a pulmonary embolus.
A bedside ECHO was performed, which showed Right atrium
diliation. Patient was intubated and sent down for a CT scan of
her chest - CT showed no PE. Patient was brought back to the
ICU and was kept intubated. A right popliteal artery duplex was
also obtained for the right tibial posterior dislocation - the
duplex was negative for any injury of her her right leg
arteries. Because the chest CT revealed no PE, it was thought
that the patient's desaturation episode was secondary to fat
embolism.
During the patient's period on the vent, she developed a
respiratory alkalosis. However, whe was extubated on [**2149-5-24**] and
remained off the vent until she tired out and was reintubated on
[**2149-5-26**]. The patient's reintubation was also due to blood and
sputum cultures that were obtained on the [**2149-5-25**], and were now
growing pseudomonas - thus the patient had developed a
pneumonia. Because the patient had failed extubation, and
because of her poor underlying pulmonary function, the patient
underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 79622**], [**First Name3 (LF) 282**], and IVC filter placement on
[**2149-5-27**]. She received double coverage antibiotics for the
pseudomonas, consisting of a regimen of Zosyn and tobramycin.
The patient progressed on tube feeds from [**2149-5-28**] through
[**2149-6-2**]. On [**6-2**], the patient was taken back to the OR with
orthopedics for conversion of her right leg external fixation to
an ORIF. The patient tolerated the procedure well, however her
HCT level fell to 18 on the morning of [**2149-6-3**]. She was
transfused 2 units of pRBCs. At this point in her
hospitalization, her vent settings were weanted to CPAP with
PEEP 5 and PS5. However, patient could not tolerate being on
trach mask for extended periods.
Of note patient's albulmin level was 1.7, and her pre-albumin
level is pending at the time of discharge.
Medications on Admission:
Flovent
Asacol
Prilosec
Pravastatin
Serevent
Spiriva
Lopressor
ASA
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: 650 mg PO Q6H (every
6 hours) as needed.
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: 100 mg PO BID (2
times a day).
5. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
8. Bisacodyl 10 mg Suppository Sig: 10 mg Suppositorys Rectal
DAILY (Daily) as needed for Constipation.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H () as needed for Pain.
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours).
14. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
19. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours).
20. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
Intravenous Q12H (every 12 hours): Last dose 7/21.
21. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours): Last dose 7/21.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1.) open left ankle fx,
2.) right tibial plateu fx
3.) open right wrist fx
4.) closed left wrist fracture
5.) Closed R patellar fx
6.) R knee dislocation s/p reduction
6.) Pseudomonas bacteremia
7.) RUL pneumonia-Cx+ for pseudomonas
8.) b/l pleural effusion
9.) infrarenal AAA 3.8 x 3.4cm
10.) Pulmonary nodules
11.)Tracheostomy
12.)[**Hospital1 282**]
13.)IVC filter
[**Hospital **] Hospital:
1.) Emphysema/COPD
2.) HTN
3.) Hyperlipidemia
Discharge Condition:
Hemodynamically stable, tolerating tube feeds, pain controlled,
stable on trach mask.
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
You are also being discharged on IV antibiotics. Please call
your doctor if you develop a rash or any of the other symptoms
described below. You antibiotics are scheduled to stop on
[**2149-6-9**].
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.
Activity:
Please follow the orthopedic recommendations for your activity
in regards to your extremities, but you may get out of bed with
assistance.
Wound Care:
No tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Followup Instructions:
-Ortho- You should follow up in [**Hospital 5498**] clinic with [**First Name11 (Name Pattern1) 2191**]
[**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2149-6-17**] 9:00
-Trauma-You should follow up with Dr. [**Last Name (STitle) **] on [**2149-6-17**] at
1:30 with Dr. [**Last Name (STitle) **]. Please call [**Telephone/Fax (1) 68386**] if you have
questions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"823.00",
"416.8",
"822.0",
"E812.0",
"824.5",
"813.44",
"958.4",
"813.54",
"482.1",
"401.9",
"276.2",
"038.43",
"496",
"518.5",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"84.72",
"96.71",
"79.36",
"79.66",
"79.32",
"31.1",
"38.93",
"38.91",
"96.72",
"78.17",
"96.6",
"78.67",
"79.06",
"43.11",
"79.02"
] |
icd9pcs
|
[
[
[]
]
] |
7041, 7120
|
2093, 5051
|
352, 689
|
7605, 7693
|
1562, 2070
|
9182, 9732
|
1159, 1177
|
5168, 7018
|
7141, 7584
|
5077, 5145
|
7717, 9042
|
1192, 1543
|
274, 314
|
9054, 9159
|
717, 954
|
976, 1017
|
1033, 1143
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,803
| 140,133
|
18765
|
Discharge summary
|
report
|
Admission Date: [**2184-10-14**] Discharge Date: [**2184-10-24**]
Date of Birth: [**2111-3-21**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
Latino male with a history of myocardial infarction
approximately ten years ago who awoke in the AM of [**2184-10-14**] at 3 o'clock with left-sided chest pain. He stated
that the pain was just like his pain with his myocardial
infarction in the past. He presented to the Emergency
Department at [**Hospital3 417**] Hospital. There he was given
nitroglycerin sublingually times three, Lopressor 5 mg
intravenous push and Morphine. He became hypotensive and was
given intravenous bolus. His blood pressure recovered and
the patient was transferred to the [**Hospital6 649**] for cardiac catheterization. His
catheterization showed an ejection fraction of 50% with mild
inferoapical hypokinesis, LM-diffuse 30% disease, left
anterior descending-50% proximal, 50% mid, TO-mid after
septal takeoff, left circumflex-mid 70%, TO-after obtuse
marginal, obtuse marginal 1-90%; right coronary artery, NO;
LPDA-TO. The patient was assessed and was deemed appropriate
for coronary artery bypass graft on [**2184-10-15**] by Dr.
[**Last Name (STitle) 70**].
PAST MEDICAL HISTORY: Status post myocardial infarction ten
years ago, hypercholesterolemia, status post appendectomy,
status post cholecystectomy.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] smoked
tobacco one pack per day for 60 years and drank 3 to 4 drinks
per day beer with one glass of brandy or alcohol.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: The patient was only on Aspirin.
REVIEW OF SYSTEMS: On admission his review of systems was
negative for visual changes, shortness of breath,
palpitations or fluttering, hematemesis or gastroesophageal
reflux disease. The patient had no dysuria, pain on
urination, musculoskeletal examination which showed positive
upper extremity numbness with position and neurological
history of had no transient ischemic attacks or
cerebrovascular accident.
PHYSICAL EXAMINATION: On physical examination the patient
was afebrile and his heartrate was 89, blood pressure 144/92,
respiratory rate 18, sating 95% on 2 liters of nasal cannula.
Generally, he was pleasant male in no acute distress. Head,
eyes, ears, nose and throat, pupils equal, round and reactive
to light, extraocular movements intact, pharynx was clear.
Neck was supple without lymphadenopathy, bruits or
jugulovenous distension. Lungs were clear to auscultation,
bilaterally. Heart was regular rate and rhythm without
murmurs, rubs or gallops. Abdomen, positive bowel sounds.
Soft, nontender, nondistended, well healed right upper
quadrant and right lower quadrant incisions. Extremities
were without cyanosis, clubbing or edema. The patient was
right hand dominant. Neurological examination, alert and
oriented times three, grossly intact. Pulses, left carotids
2+, right carotids 2+, radial arteries were 2+ bilaterally,
posterior tibial 2+ bilaterally, dorsalis pedis 2+
bilaterally.
ASSESSMENT: Assessment at that time showed a 73 year old
male with multi-vessel disease who was preopped for coronary
artery bypass graft on the morning of [**2184-10-15**].
HOSPITAL COURSE: The patient underwent two-vessel coronary
artery bypass graft on [**2184-10-15**] without incident and
on postoperative day #1 was started on alcohol drip for
history of alcohol and was started on low dose Lopressor at
12.5 twice a day. The patient was on a Neo-Synephrine drip
at 1.5 and insulin drip 3, as well as alcohol drip. On
postoperative day #2, the mediastinal chest tube was
discontinued. However, the left pleural chest tube was kept
in place. The Lopressor was increased to 50 b.i.d. for
increasing heartrate to 90s. Physical therapy began seeing
the patient on postoperative day #2, and continued to see the
patient throughout the hospital course. By postoperative day
#3, the patient was given Amiodarone bolus and Lopressor was
increased to 75 b.i.d. for rapid atrial fibrillation to a
heartrate of 125, and the patient was off of the alcohol drip
at this point and continued on p.o. alcohol one q.d. which
was then supplemented with Thiamine and Folate. On
postoperative day #4 the patient remained in atrial
fibrillation at a rate of 112 and Electrophysiology and the
Division of Cardiology was consulted and recommended
continuation of the Amiodarone and recommended changing to
oral dose of 400 mg p.o. b.i.d. times one week and then 400
mg q.d. times two weeks and then 200 mg p.o. q.d.
Electrophysiology also recommended direct current
cardioversion for conversion to normal sinus rhythm once the
patient was adequately anticoagulated with intravenous
heparin with PTT of between 50 and 80, and then initiation of
Coumadin.
On postoperative day #5 the Neo-Synephrine drip began to be
weaned and between postoperative day #5 and 7, Neo-Synephrine
drip continued to be weaned and was off on postoperative day
#7. The patient was on Aspirin and Plavix therapy by
postoperative day #8 and was then on 400 mg of Amiodarone
q.d. for control of atrial fibrillation. By postoperative
day #9 the patient was doing extremely well and was
discharged home without event.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o. b.i.d.
2. Potassium 20 mEq p.o. b.i.d. times one week
3. Colace 100 b.i.d.
4. Zantac 150 mg p.o. b.i.d.
5. Aspirin 325 one tablet p.o. q.d.
6. Percocet 5/325 one to two tablets p.o. q. 4 hours for
pain
7. Plavix 75 p.o. q.d.
8. Multivitamins
9. Albuterol 1 to 2 puffs inhalation q. 6 hours
10. Folate 1 q.d.
11. Thiamine 100 q.d.
12. Amiodarone 400 q.d.
13. Lasix 40 mg p.o. q.d. times one week
FOLLOW UP: The patient was instructed to follow up with
primary care physician in one week, follow up with his
cardiologist in two to three weeks and follow up with Dr.
[**Last Name (STitle) 70**] in four weeks.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft
2. Status post alcohol and tobacco abuse
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 10197**]
MEDQUIST36
D: [**2184-10-24**] 18:17
T: [**2184-10-24**] 18:49
JOB#: [**Job Number 51398**]
|
[
"305.00",
"272.0",
"410.71",
"429.9",
"305.1",
"427.31",
"414.01",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.12",
"88.56",
"88.53",
"39.61",
"94.62",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6135, 6477
|
5336, 5765
|
6000, 6113
|
1672, 1706
|
3321, 5313
|
5777, 5979
|
2143, 3303
|
1726, 2120
|
186, 1269
|
1292, 1419
|
1436, 1645
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,241
| 188,085
|
50845
|
Discharge summary
|
report
|
Admission Date: [**2109-8-25**] Discharge Date: [**2109-9-19**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2109-9-9**] Aortic Valve Replacement(23mm [**Company 1543**] Mosaic Porcine
Valve), and Two Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to left anterior descending, vein graft
to obtuse marginal).
History of Present Illness:
Mrs. [**Known lastname 2405**] is an 80 year old female with history of
paroxsymal atrial fibrillation(PAF) who presented with fatigue
and shortness of breath for approximately one week. She has PAF
diagnosed 7 years ago and follows Dr. [**Last Name (STitle) **]. She manages her PAF
with Sotolol and Coumadin and has been largely asymptomatic
since her diagnosis. She does not have palpitations or SOB and
she does not know when she is in sinus or afib. About a week
ago, she noticed easy fatigue and dyspnea on exertion. She
works 4 days a week as a salesperson and normal walks up and
down the stairs multiple times without difficulty. Over the
past week, she gets SOB with exertion and on Saturday, she felt
dramatically weak while doing up the stairs and had to pause in
the middle. She denies chest pain. Seeing that her symtoms did
not resolve, she presented to [**Hospital1 18**] ED.
Past Medical History:
Congestive Heart Failure
Aortic Valve Stenosis, Aortic Valve Insufficiency
Coronary Artery Disease
Hypertension
History of Paroxysmal Atrial Fibrillation
s/p Polypectomy
s/p Cataract Surgery
s/p Hernia Repair
Social History:
Widowed, lives alone, very independent. Has children nearby.
Denies alcohol, tobacco and/or IVDU.
Family History:
Denies premature coronary artery disease
Physical Exam:
Vitals: T 98.1, HR 114, BP 112/66, RR 16
General: Elderly female in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, JVP approx 8cm
Lungs: CTA bilaterally, bibasilar crackles noted
Heart: Regular rate and rhythm, [**3-19**] holosystolic murmur noted
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, trace edema
Pulses: 1+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2109-8-25**] 09:15PM BLOOD WBC-6.8 RBC-3.73* Hgb-12.0 Hct-35.2*
MCV-94 MCH-32.1* MCHC-34.0 RDW-14.0 Plt Ct-202
[**2109-8-25**] 09:15PM BLOOD PT-25.3* PTT-33.6 INR(PT)-2.6*
[**2109-8-25**] 09:15PM BLOOD Glucose-106* UreaN-33* Creat-0.8 Na-133
K-4.9 Cl-100 HCO3-20* AnGap-18
[**2109-8-25**] 09:15PM BLOOD CK-MB-9
[**2109-8-25**] 09:15PM BLOOD cTropnT-0.06*
[**2109-8-26**] Cardiac Echocardiogram: The left atrium is moderately
dilated. The estimated right atrial pressure is 11-15mmHg. There
is mild symmetric left ventricular hypertrophy with normal
cavity size. There is moderate to severe global left ventricular
hypokinesis (LVEF = 30-35% %). Right ventricular chamber size is
normal. Right ventricular systolic function appears depressed.
The aortic arch is mildly dilated. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area =0.7cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
severe mitral annular calcification. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
[**2109-8-29**] Carotid Ultrasound: Less than 40% stenosis of the
bilateral internal carotid arteries.
[**2109-9-2**] Chest CT Scan: 1. Dense calcifications in the aortic
valve, mitral annulus and coronary arteries. Ascending aorta
measuring up to 41 mm. Moderate cardiomegaly. 2. Mild pulmonary
edema. Bilateral pleural effusions with associated adjacent
relaxation atelectasis. 3. Dense atherosclerotic calcification
of the abdominal aorta, proximal bilateral renal arteries and
celiac trunk. 4. Bilateral non-obstructing kidney stones. 5.
Hypodense lesions in the liver, too small to be characterized,
likely cysts. 6. Mildly enlarged pulmonary arteries, consistent
but no diagnostic of pulmonary hypertension.
[**2109-9-2**] Cardiac Cath: 1. Coronary angiography in this right
dominant system revealed 2 vessel disease. THe LMCA had a
discrete 30% lesion at the origin. The LAD had a discrete 70%
distal lesion. The LCX had a 60% lesion. The RCA was occluded
and filled by collaterals. 2. Resting hemodynamics revealed
elevated right and left sided filling pressures with RVEDP of 20
mmHg and LVEDP of 35 mmHg. There was moderate pulmonary artery
systolic hypertension with a PASP of 50 mmHg. The cardiac index
was slightly decreased at 2.3 L/min/m2. 3. There was severe
aortic stenosis with a peak to peak gradient of 50 mmHg and a
calculated [**Location (un) 109**] of 0.45 cm2. 4. Left ventriculography revealed 1+
mitral regurgitation. The LVEF was calculated to be 34%. 5. The
ascending aorta was extensively calcified.
[**2109-9-3**] Myocardial Viability Stud: The LV cavity is not dilated.
There is a moderate to severe defect in the MIBI portion of the
study in the mid to basilar inferior wall; it is unclear if this
is a true perfusion defect or an attenuation artifact. No
correlative defect is seen on the FDG portion of the study. The
FDG was overall not optimally taken up by the myocardium,
however, given this limitation, the walls appear symmetric and
all demonstrate glucose metabolism. IMPRESSION: Moderate to
severe defect in the inferior wall on the MIBI portion of the
study, but normal metabolism in this region on FDG. The defect
may be attenuation related, but this may also represent a region
of hibernating myocardium.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2109-9-11**] 4:03 PM
CHEST (PORTABLE AP)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman s/p AVR/cabg and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
INDICATION: Rule out pneumothorax after chest tube removal.
COMPARISON: [**2109-9-9**].
PORTABLE UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY 4:30 P.M:
There has been interval removal of all tubes except the right IJ
introducer catheter. There is no pneumothorax. Hazy opacity in
the left lower lobe indicates pleural effusion with associated
atelectasis. Equivocal underlying consolidation.
IMPRESSION: No pneumothorax after interval removal of tubes and
catheters. New left pleural effusion with associated
atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 2671**] [**Doctor Last Name **]
Brief Hospital Course:
Mrs. [**Known lastname 2405**] was admitted to the medicine service with
congestive heart failure and atrial fibrillation. She ruled out
for myocardial infarction. The EP and cardiac surgical services
were consulted and further evaluation was performed.
Cardioversion was initially performed on [**8-26**], and again
on [**8-29**] for recurrent atrial fibrillation. Amiodarone was
initiated at that time. Additional cardiac surgical workup
included echocardiogram, cardiac catheteterization, chest CT
scan, carotid ultrasound and viability study - please see result
section for details. Given her aortic valve disease, she was
cleared by the dental service after clinical and radiographic
examinations found no evidence of infection. She otherwise
remained stable on intravenous Heparin and was eventually
cleared for surgery. On [**9-9**], Dr. [**Last Name (STitle) 1290**] performed an
aortic valve replacement and coronary artery bypass grafting.
For surgical details, please see seperate dictated operative
note. In summary the patient had AVR(#23 [**Company 1543**] Mosaic
Porcine)CABGx2(LIMA-LAD,SVG-OM),bypass time was 93 minwith
crossclamp 67 min. She tolerated the surgery well and was
transferred to the ICU in stable condition. Ms [**Known lastname 2405**] was kept
sedated on the day of surgery, on POD1 her sedation was
discontinued she was weaned from the ventilator and extubated.
She was noted to have afib and was therefore started on
Amiodarone, and over the next few days she was cardioverted
temporarily to SR, following which the EP service was consulted.
Additionally she was noted to have left sided weakness and a
slight facial droop, these findings resolved over the next
several days. Because the patient was felt to be somewhat
fragile she spent several additional days in the ICU. On POD5
she was transferred to the step down floor for continued cardiac
rehabilitation and post-op care. Over the next several days the
nurses and PT advanced her activity level and on POD 10 it was
decide she was ready for discharge to rehab.
Medications on Admission:
Coumadin, Sotalol, Lisinopril
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
10. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Check INR [**9-20**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Congestive Heart Failure(Systolic)
Aortic Valve Stenosis, Aortic Valve Insufficiency
Coronary Artery Disease
Hypertension
History of Paroxysmal Atrial Fibrillation, Postop Atrial
Fibrillation
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1290**] in [**4-18**] weeks, call for appt
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-16**] weeks, call for appt
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] in [**2-16**] weeks, call for appt
Completed by:[**2109-9-19**]
|
[
"427.31",
"780.52",
"401.9",
"276.51",
"414.01",
"782.1",
"244.9",
"428.0",
"424.1",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.53",
"99.04",
"88.56",
"35.21",
"37.23",
"36.11",
"36.15",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
9922, 9988
|
6764, 8819
|
289, 515
|
10224, 10231
|
2326, 5971
|
10567, 10921
|
1810, 1852
|
8899, 9899
|
6008, 6054
|
10009, 10203
|
8845, 8876
|
10255, 10544
|
1867, 2307
|
229, 251
|
6083, 6741
|
543, 1445
|
1467, 1677
|
1693, 1794
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,055
| 162,552
|
16603+16604
|
Discharge summary
|
report+report
|
Admission Date: [**2125-9-4**] Discharge Date: [**2125-9-14**]
Date of Birth: [**2067-12-28**] Sex: F
Service: [**Hospital1 **] & MEDICAL ICU GREEN TEAM
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 54-year-old female,
with relapsing polychondritis, who presents for evaluation of
possible treatment of shortness of breath due to severe
subglottic stenosis. The patient reports that her illness
began approximately four years ago, at which time she moved
to [**State 108**] and began to have "sinus problems." The patient
was initially treated with three course of antibiotics
without improvement. The patient also began to have severe
daily left-sided headaches. At this time, the patient's
primary care physician recommended sinus surgery. Following
surgery, the patient was stable for a few months, until
[**3-/2124**] or [**4-/2124**], at which time she lost her voice acutely.
The patient reports that her voice was very quiet and
extremely hoarse. The patient also began to have joint and
muscle pain around this time. On [**2124-10-5**], the patient
abruptly developed marked stridor and shortness of breath.
CT and bronchoscopy showed subglottic stenosis that was
moderately severe. The patient was placed on prednisone 60
mg po qd with some improvement in her shortness of breath.
When the medication was decreased to 40 mg po qd, severe
shortness of breath recurred. At this time, the patient was
diagnosed with polychondritis. Labs on diagnosis showed an
ANCA which was negative, ESR 42 and 55, low positive
rheumatoid factor, and negative [**Doctor First Name **].
At this time, the patient came to [**Location (un) 86**] for a second opinion
from Dr. [**Last Name (STitle) 6426**]. Her polychondritis has been treated by
him since that time. On [**2125-2-15**], CT of the trachea was
obtained to further evaluate her shortness of breath. This
showed focal subglottic stenosis and minimal luminal airway
diameter of 5 mm x 6 mm. The patient was admitted today for
repeat evaluation of her tracheomalacia and consideration of
treatment options.
PAST MEDICAL HISTORY:
1. Relapsing polychondritis per HPI.
2. Right ovary cyst removal.
ALLERGIES: Nitrous oxide.
MEDICATIONS:
1. Remicade.
2. CellCept [**Pager number **] mg po bid.
3. Prednisone 35 mg po qd.
4. Albuterol nebs tid.
5. Effexor 37.5 qd.
6. Equate nasal spray.
SOCIAL HISTORY: The patient is divorced and lives in
[**State 108**]. Before she became ill, she worked in real estate
sales. Smoked 30 years but quit 1 year ago. Rare social
alcohol use. Denies drug abuse.
PHYSICAL EXAM ON ADMISSION: Temperature 97.1, blood pressure
138/80, heart rate 76, respiratory rate 24.
GENERAL: Pleasant lady in no acute distress. Alert and
oriented x 3. Must pause after 2 or 3 sentences for a deep
breath.
CARDIAC: Regular rate and rhythm.
PULMONARY: Diffuse inspiratory and expiratory wheezes
throughout all lung fields. Bibasilar crackles.
ABDOMEN: Soft, nontender, nondistended. Positive bowel
sounds.
EXTREMITIES: No clubbing or cyanosis. 1+ lower extremity
edema bilaterally, most severe around the ankles. 2+
dorsalis pedis pulses.
NEURO: Cranial nerves II through XII intact.
STUDIES ON ADMISSION: CT of the trachea [**2125-9-4**]:
Persistent subglottic stenosis with luminal narrowing to
approximately 5 mm in diameter. Improved caliber of airways
in lower cervical trachea and intrathoracic trachea.
Persistent anterior wall thickening of the lower cervical and
intrathoracic trachea. Extensive air-trapping.
SUMMARY OF HOSPITAL COURSE - 1) TRACHEOMALACIA WITH
SUBGLOTTIC STENOSIS: This was due to the patient's relapsing
polychondritis. On admission, it was evaluated by CT of the
trachea with results as above. In addition, the patient
underwent bronchoscopy which showed her trachea to be
narrowed to 4 mm at the cricoid. ENT and interventional
pulmonology consulted together to consider multidisciplinary
treatment approaches for her tracheomalacia and subglottic
stenosis.
On [**2125-9-5**], the patient underwent dilatation of her
trachea. The patient initially tolerated the procedure well,
and her trachea was dilated to 12 mm. However, following the
procedure, the patient developed stridor, and her oxygen
saturations dropped to 85% on room air. At that time, the
patient required elective intubation. It was determined that
the patient's respiratory distress was most likely due to
edema from the trauma of the procedure. She was began on
stress dose steroids and ceftriaxone.
On [**2125-9-12**], the patient had a cuffless tracheostomy
placed. She still had evidence of subglottic stenosis at
that time. She will be continued on a slow dexamethasone
taper. The ceftriaxone was discontinued on [**2125-9-13**]. The
patient has been oxygenating well with a trach mask since
that time.
2) DEPRESSION: The patient with strong family support.
Support from nursing and medical team. She was continued on
Effexor throughout admission.
3) RELAPSING POLYCHONDRITIS: The patient was continued on
mycophenolate 100 mg po bid throughout the admission. She
will receive a Remicade treatment on [**2125-9-14**] to maintain
her schedule. Her PPI, diphosphonate and Vitamin D were all
continued throughout the admission, as the patient is on
chronic steroids.
4) ENDOCRINE: The patient had fingersticks checked qid, and
sliding scale Insulin, for her steroid-induced hyperglycemia,
throughout the admission.
5) FLUIDS, ELECTROLYTE AND NUTRITION: The patient underwent
a swallowing study, following placement of tracheostomy, on
[**2125-9-13**]. This showed that the patient had mildly reduced
bolus control resulting in premature spillover of liquids and
puree into the valleculae. This material then spilled into
the laryngeal vestibule just as swallow was starting and
during the swallow. However, the patient kept her vocal
cords closed and was able to strip the penetrating material
out of her laryngeal vestibule. Aspiration never occurred.
The patient's diet has been advanced as tolerated, and she is
tolerating the diet at this time. Electrolytes were replaced
as needed throughout the admission.
6) REHABILITATION: The patient has been evaluated by
physical therapy. She will be continued to be followed by
them throughout the rest of her hospitalization. She will
benefit from outpatient rehabilitation stay in a physical and
pulmonary rehabilitation center.
7) PROPHYLAXIS: The patient was continued on a proton pump
inhibitor, subcu heparin, and sliding scale Insulin
throughout the admission.
8) CODE STATUS: The patient is full code.
CONDITION ON DISCHARGE: Stable using a tracheostomy mask
with oxygen. The patient will be discharged to a
rehabilitation center for physical and pulmonary
rehabilitation.
DISCHARGE DIAGNOSES:
1. Tracheomalacia with subglottic stenosis.
2. Acute respiratory failure.
3. Relapsing polychondritis.
4. Depression.
5. Steroid-induced hyperglycemia.
DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg 1-2 tabs po q 4-6 h prn.
2. Ambien 5 mg 1 tab po q hs prn for sleeplessness.
3. Mycophenolate 1,000 mg po bid.
4. Albuterol nebs q 8 h.
5. Sodium chloride nasal spray [**11-23**] sprays tid prn.
6. Venlafaxine XR 112.5 mg po qd.
7. Risedronate 35 mg 1 tab po q Sunday.
8. Albuterol MDI 1-2 puffs inhaled q 4 h prn.
9. Ipratropium bromide 118 mcg 2 puffs inhaled q 4-6 h prn.
10.Calcium carbonate 500 mg 1 tab po tid.
11.Vitamin D 400 U po qd.
12.Milk of magnesia prn.
13.Lansoprazole 30 mg po qd.
14.Sliding scale Insulin.
15.Percocet 1-2 tabs po q 4-6 h prn pain for tracheostomy
site.
16.Ativan 0.5, 2 mg po q 4-6 h prn for anxiety.
17.Dexamethasone taper.
FOLLOW-UP PLANS:
1. The patient will follow-up with Dr. [**Last Name (STitle) 6426**] as needed at
her convenience.
2. The patient will follow-up with Dr. [**Last Name (STitle) **] per his
recommendations which will be determined prior to discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 315**]
MEDQUIST36
D: [**2125-9-14**] 12:11
T: [**2125-9-14**] 12:17
JOB#: [**Job Number 47066**]
UPDATE PENDING [**2125-9-17**]
Admission Date: [**2125-9-4**] Discharge Date: [**2125-9-24**]
Date of Birth: [**2067-12-28**] Sex: F
Service: BLOOMGARD
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female with a four year history of relapsing polychondritis
complicated by subglottic stenosis managed with steroids
prior to admission. The patient presented on [**9-4**] with
complaints of shortness of breath and she was admitted for
evaluation for tracheomalacia and consideration of further
treatment options.
PAST MEDICAL HISTORY:
1. Relapsing polychondritis times four years managed with
prednisone 60 mg q. day, Remicade, CellCept and albuterol
p.r.n.
2. Right ovary removed.
3. Depression managed with Effexor.
SOCIAL HISTORY: The patient is divorced. Lives in [**State 108**].
Worked in real estate. She smoked for 30 years but quit one
year ago.
ALLERGIES: Allergic to nitrous oxide which gives her a rash.
MEDICATIONS: Include:
1. Acetylcysteine 20%, 10 mL q. 4-6h.
2. Ibuprofen 600 mg p.o. q. 8h. p.r.n.
3. Prednisone 30 mg p.o. q. day.
4. Cephalexin 500 mg p.o. q. 6h.
5. Lorazepam 0.5 to 2 mg IV q. 4h. p.r.n. anxiety.
6. Albuterol one to two puffs IH q. 4h. p.r.n.
7. Ipratropium bromide MDI two puffs IH q. 4-6h.
8. Mycophenolate mofetil 1000 mg p.o. b.i.d.
9. Venlafaxine XR 112.5 mg p.o. q. day.
10. Calcium carbonate 500 mg p.o. t.i.d.
11. Vitamin D 400 units p.o. q. day.
12. Lansoprazole 30 mg p.o. q. day.
13. Milk of magnesia 30 mL p.o. q. 6h.
14. Alendronate sodium 35 mg p.o. every Sunday.
15. Aluminum magnesium hydroxide 15-30 mL p.o. q.i.d. p.r.n.
16. Acyclovir ointment 5% one application t.p. q.i.d.
17. Zolpidem tartrate 5 mg p.o. q. hs. p.r.n.
PHYSICAL EXAMINATION ON ADMISSION: Examination on admission
[**9-4**] was significant for a respiratory rate of 24. She
was in no apparent distress but required a pause between
sentences to take a breath. Respiratory examination was
significant for diffuse inspiratory and expiratory wheezes
through all lung fields. She had bibasilar crackles. Her
extremities showed 1+ edema in the lower extremities with 2+
pulses.
LABORATORY ON ADMISSION: Normal.
RADIOLOGY: CT trachea showed persistent subglottic stenosis
with luminal narrowing to 5 mm diameter with extensive air
trapping.
HOSPITAL COURSE:
1. Respiratory/subglottic stenosis: Description of the
patient's course from [**9-5**] to [**9-14**] is described
in the discharge note by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47067**]. Briefly, on
[**9-5**] patient underwent subglottic dilation to 12 mm.
This was complicated by severe airway edema requiring
emergent intubation. In Medical Intensive Care Unit she was
placed on stress dose steroids 60 mg q. 4h. with sedation,
nebs and ceftriaxone prophylaxis. On [**9-12**] she had a
cuffless trach placed and was transferred to the Medical
floor on [**9-14**] stable with mild throat pain, 98% with
trach mask. Ambulating and tolerating p.o.'s.
On [**9-16**] the patient began complaining of shortness of
breath even with nebulizers. She was seen by Cardiothoracic
Surgery for evaluation of subcutaneous air. Cardiothoracic
Surgery removed the deep suture around her trach to allow for
air removal and her shortness of breath was treated with
racemic epinephrine with some improvement. On [**9-17**] at
6:00 a.m. the patient in acute respiratory distress with
hypoxia in the 60's secondary to trach dislodgement. A
respiratory code was called for acute respiratory failure.
The patient received nasotracheal tube with improvement of
sats to the mid 90's. She was transferred back to the
Medical Intensive Care Unit. On [**9-17**] the patient went
back to the Operating Room to have her trach replaced.
Cefazolin was started due to mild erythema around the stoma.
On [**9-18**] she was transferred back to the floor stable on
trach mask, 94% on room air. The patient was ambulating,
tolerating p.o.'s. On [**9-21**] the patient went back to
the Operating Room to have a custom made #7 Portex cuffless
trach with extra long arm placement. This was done without
complications. She has remained stable since this procedure
satting 98% on room air. She received nebulizers and
Mucomyst for increased pulmonary secretions on [**9-24**].
She is to return to the hospital on [**10-1**] to have her
trach downsized.
2. Relapsing polychondritis: The patient was continued on
mycophenolate 1000 mg b.i.d. and Remicade 100 mg once which
was received on [**2125-9-14**]. Steroids were tapered from
dexamethasone 4 mg q. 4h. to prednisone 7.5 mg q. day. Two
days after the taper patient began complaining of paratibial
pain and some calf pain similar to previous RPC flare-ups.
Her prednisone was increased to 30 mg q. day with resolution
of symptoms. She continued to receive proton pump
inhibitors, diphosphate and vitamin B for prophylaxis.
3. Endocrine: The patient has steroid-induced diabetes.
She received q.i.d. fingersticks with sliding scale insulin.
DISCHARGE MEDICATIONS:
1. Acetylcysteine [**12-1**] mL nebulizer q. 4-6h. p.r.n.
2. Ibuprofen 600 mg p.o. q. 8h. p.r.n.
3. Prednisone 30 mg p.o. q. day.
4. Cephalexin 500 mg p.o. q. 6h.
5. Lorazepam 0.5 to 2 mg IV q. 4h. p.r.n. anxiety.
6. Albuterol one to two puffs IH q. 4h. p.r.n. wheezing.
7. Ipratropium bromide MDI two puffs IH q. 4-6h. p.r.n.
wheezing.
8. Insulin sliding scale as described.
9. Epinephrine inhalation 0.5 mL IH q. 6h. p.r.n. shortness
of breath.
10. Mycophenolate mofetil 1000 mg p.o. b.i.d.
11. Venlafaxine XR 112.5 mg p.o. q.i.d.
12. Calcium carbonate 500 mg p.o. t.i.d.
13. Vitamin D 400 units p.o. q. day.
14. Alenzoprazole 30 mg p.o. q. day.
15. Milk of magnesia30 mL p.o. q. 6h. p.r.n. for
gastrointestinal upset.
16. Alendronate sodium 35 mg p.o. every Sunday.
17. Acyclovir ointment 5% one application topical q.i.d.
18. Zolpidem tartrate 5 mg p.o.
CODE STATUS: Full code.
DISPOSITION: To pulmonary rehabilitation.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Relapsing polychondritis with subglottic stenosis.
2. Acute renal failure.
FOLLOW-UP INSTRUCTIONS:
1. Patient to follow up with Dr. [**Last Name (STitle) **] on [**10-1**] for
downsizing of trach.
2. Should not use Muir valve until 24 hours after refitting.
3. Follow up with Dr. [**Last Name (STitle) 47068**] as necessary.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-986
Dictated By:[**Last Name (NamePattern1) 47069**]
MEDQUIST36
D: [**2125-9-25**] 13:52
T: [**2125-9-25**] 14:18
JOB#: [**Job Number 47070**]
|
[
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"E849.7",
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"518.81",
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"519.02",
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] |
icd9cm
|
[
[
[]
]
] |
[
"32.01",
"99.15",
"33.22",
"97.23",
"31.1",
"96.04",
"96.72",
"33.21",
"31.99",
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icd9pcs
|
[
[
[]
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] |
14280, 14361
|
13287, 14235
|
10555, 13264
|
14250, 14259
|
7723, 8391
|
192, 214
|
8420, 8765
|
10398, 10538
|
14385, 14846
|
8787, 8974
|
8991, 9969
|
6676, 6825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,640
| 139,701
|
34535
|
Discharge summary
|
report
|
Admission Date: [**2119-3-16**] Discharge Date: [**2119-3-23**]
Date of Birth: [**2054-8-21**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 65686**]
Chief Complaint:
new left hemianopsia with cerbral hemorrheage and edema admitted
to ICU for medical management
Major Surgical or Invasive Procedure:
IVC filter
History of Present Illness:
64 year old male with metastatic renal cell to brain, spine,
larynx, liver and lung, s/p avastin, recurrent pulmonary emboli
on lovenox, presented to the ED with worsening right sided
visual field loss. He reports intermittant blurry vision and
flashes of light accompanied by headaches x 2 1/2 weeks with
worsening symptoms over the past 6 days. Three days ago he had
severe bitemporal headache which he describes as [**5-12**] and
throbbing. Around the same time, he noted right sided
hemianopsia with "psychadelic" flashes of light and colors. On
the day of admission, he presented to an opthalmologist who
performed a dialated exam and determined that his vision loss
was not related to a primary occular lesion and recommended
presentation to the ED.
.
.
In the ED, initial vs were: 97.3 71 143/102 22 99%. He was
AAOx3, exam notible for right hemianopsia. CT head showed
progression of known left occipital/parietal mass with worsening
hemorrheage and edema (compared with MRI [**12-13**]. labs notible for
Na 129, Cr 1.4 (baseline 1.3), WBC 5.6 75% PMN, INR 1.1.
Neurosurgery was consulted who recommended blood pressure
control and FFP but did not recommend surgery or seizure
prophylaxis. Patient was given dexamethasone 10mg IV and 2 units
FFP and furosemide 20mg IV. 2 PIV. Vitals on transfer p68
bp136/88 sao2 96% on RA.
.
Upon arrival to ICU, patient reported [**2-9**] bifrontal headache
and continued right hemianopsia. He reported word finding
difficulites and short term memory loss over the past weeks to
months.
.
Review of sytems:
(+) increased hemoptysis in last week, and increased respiratory
secretions
(-) Denies numbness/tingling in his extremities, denies gait
instability, muscle weakness.Denies fever, chills, rhinorrhea or
congestion. Denied shortness of breath. Denied chest pain.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits.
Past Medical History:
Bilateral pulmonary emboli [**2094**] and [**2112**]
Bilateral pulmonary embolism in [**2104**], [**8-/2113**], on long term
warfarin
Left lower pulmonary artery PE [**2119-2-20**] --> changed from warfarin
to lovenox
Resection of pulmonary metastasis [**2112**]
Resection of a subglottic metastasis requiring tracheotomy [**6-10**]
Hypertension since [**2112**]
BPH since [**2107**],
History of colonic adenomas [**2105**] and [**2110**], stable
Hx of pancreatic cyst [**2107**], stable
Stress fracture of right fibula [**2081**]
Left eye epithelial retina membrane [**1-/2118**] (slight distortion
of
lines of vision)
Umbilical hernia since [**2115**]
Depression since [**2115**]
Left forearm lipoma since [**2099**]
Diverticulosis since unknown
.
Oncology History:
- [**2111-11-2**], left lower lobe nodule found on routine scan.
- [**2111-12-3**], VATS procedure with resection of the lesion.
- [**2113-6-2**], pulmonary recurrence.
- [**2113-7-3**], pulmonary resection.
- [**2116-5-3**], multiple new lung nodules as well as bony sclerotic
lesions and liver lesion.
- [**2116-10-3**], one cycle of interleukin-2 therapy.
- [**2117-6-2**], removal of excess subglottic tissue and pathology
was consistent with metastatic renal carcinoma, larynx and
subglottic metastasis resection with a permanent tracheostomy.
- [**2117-11-14**], staging MRI mass in the posterior right
temporal lobe.
- [**2117-10-26**], CyberKnife radiosurgery to the left
posterior temporal lobe lesion.
- [**2117-11-2**], Sutent therapy, progressed on Sutent last dose
in [**2118-4-2**].
- [**2118-3-3**], gadolinium-enhanced lumbosacral spine MRI showed
left posterior vertebral body L1 metastasis.
- [**2118-5-23**], began Avastin, temsirolimus trial [**Numeric Identifier **].
- [**2118-9-2**], taken off the trial due to progression of
disease. New nodule seen on CT scan of torso.
- [**2118-9-26**], started Avastin monotherapy.
- [**2118-11-2**]: Worsening back pain. MRI lumbar spine [**2118-11-7**]
showed epidural disease at L1.
- Last dose avastin [**2119-3-3**]
Social History:
Lives at home with wife in [**Name (NI) 13040**], two daughters. Retired
neuroscience researcher. Ambulates with a cane.
Family History:
Father: congestive heart failure, Mother: leukemia.
Physical Exam:
Admission Physical Exam:
Vitals: T:99.2 BP:161/91 P:67 R: 18 O2:97 RA
General: Middle aged male appearing comfortable, occasional word
finding difficulty.
HEENT: EOMI PEERLA, MMM, oropharynx clear
Neck: trach collar in place, 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: Obese soft, non-tender, non-distended, bowel sounds
normoactive no hepatospleenomegaly.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
.
Mental status: Awake and alert, cooperative with exam, normal
affect. Poor short term memory ([**12-5**] recall at 5 min) Poor
concentration (unable to perform serial 7??????s)
Orientation: oriented to person, hospital, year:[**2088**],Oriented to
person, place, and date.
Language: occasional word finding difficulty.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 4 mm
bilaterally. Right homonymous hemianopsia is noted.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-6**] throughout. No pronator drift
.
Cerebellum: intact heel to shin, no dysdiadokinesia
.
Sensation: Intact to light touch,
DTRs: 3+ Bilaterally in patella and biceps tendons.
Babinski downgoing bilaterally
.
On Discharge:
Vitals: 96.3 BP: 148/71, HR: 50, RR: 18, O2 93% RA
General: NAD,
HEENT: EOMI PEERLA, MMM, oropharynx clear, right temporal visual
field hemianopsia (stable)
Neck: 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: Obese soft, non-tender, non-distended, bowel sounds
normoactive no hepatosplenomegaly.
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: CN II-XII intact, Normal tone bilaterally. No abnormal
movements, tremors. Strength full power [**4-6**] throughout. No
pronator drift
Pertinent Results:
Admission labs ([**2119-3-16**]):
-WBC-5.3 RBC-4.42* Hgb-14.7 Hct-41.2 MCV-93 MCH-33.3* MCHC-35.7*
RDW-14.9 Plt Ct-180 Neuts-75.5* Lymphs-16.8* Monos-6.3 Eos-0.3
Baso-1.1
-PT-13.0 PTT-27.0 INR(PT)-1.1
-Fibrino-560*
-LMWH-1.16
-Glucose-117* UreaN-18 Creat-1.4* Na-129* K-4.5 Cl-98 HCO3-21*
AnGap-15
-Calcium-9.8 Phos-1.3* Mg-2.0
-Osmolal-276
-TSH-3.7
-Cortisol-15.6
.
Discharge Labs:
- WBC-8.4 RBC-4.55* Hgb-14.9 Hct-42.8 MCV-94 MCH-32.7* MCHC-34.7
RDW-14.5 Plt Ct-197
- Glucose-100 UreaN-21* Creat-1.0 Na-136 K-4.4 Cl-104 HCO3-22
AnGap-14
- Calcium-8.8 Phos-2.6* Mg-2.4
.
[**3-16**] CXR: Innumerable pulmonary nodules, relatively stable
compared to next preceding CT, compatible with metastases. No
focal opacification concerning for pneumonia.
.
[**3-16**] Admission CT Head: New intraparenchymal hemorrhage with
surrounding edema and mass effect centered on previous left
median occipital lobe metastasis.
.
[**3-16**] Repeat CT Head: 1. Stable left occipital intraparenchymal
hemorrhage with stable edema and mass effect.
.
[**2119-3-17**]: Duplex U/S bilaterally: No evidence of DVT in the right
or left lower extremity.
.
[**2119-3-20**]: MR HEAD: IMPRESSION: The left parietooccipital
hemorrhage is grossly similar in size compared with the CT of
the head performed [**2119-3-16**]. The surrounding mass effect
is not significantly changed. The ventricles are stable in size
and are not enlarged. The post-contrast sequence does not
demonstrate other foci of post-contrast T1 hyperintensity within
the brain parenchyma to suggest other lesion. The hemorrhage
produces intrinsic T1 hyperintensity which could mask underlying
enhancing lesion as seen on the prior MRI in [**Month (only) 404**] of this
year.
Brief Hospital Course:
64 year old man with metastatic renal cell carcinoma admitted
with progressive headaches and right hemanopsia and found to
have worsening hemorrhagic mass in the left parietal/occipital
region and admitted to the ICU for medical management.
.
# Hemorrhagic brain metastasis: Patient with renal cell
carcinoma, known brain metastasis, and currently on Lovenox for
anticoagulation. Head CT on admission was remarkable for an
enlarged edematous and hemorrhagic mass extending into the
occipital and parietal lobes, which explained right homonymous
hemianopsia. Anticoagulation was stopped and Neurosurgery was
was consulted, who recommended no intervention until greater
than 2 weeks after his last dose of Avastin. He was admitted to
the [**Hospital Unit Name 153**] and monitored with serial neuro checks. Head CT was
repeated which showed no progression for hemorrheage/edema. His
blood pressure was initially controlled with a Nicardipine gtt
(goal sBP 120-140) and his head of bed was maintained >30
degrees. Repeat CT head imaging was stable. Per Neuro-Oncology
he was started on Nimodipine for prevention of vasospasm, Keppra
for seizure prophylaxis, and his Dexamethasone was decreased
from 6 mg to 4 mg q6h. He remained stable and was transferred to
the OMED service for further management. His Dexamethasone was
tapered and he was discharged on Dexamethasone 4mg Daily.
Repeat MRI on [**2119-3-20**] showed stable intracranial process. On
[**2119-3-22**] he had an episode of hypertension and was otherwise
asymptomatic. He was restarted on his home medications -
hydrochlorothiazide 25mg PO daily and metoprolol tartrate 50mg
PO BID. His nimodipine was changed to PRN, but he did not
require any doses and was not continued at the time of
discharge. His Right Homonymous hemianopsia persisted and is
not expected to resolve.
.
# Increased intracranial pressure: Patient complained of
worsening headache on admission and was bradycardic and
hypertensive ([**1-5**] components of [**Location (un) **] triad). HOB was
maintained >30. Headache improved and experienced no change in
neurologic examination to suggest herniation or increased ICP.
Bradycardia and hypertension resolved.
.
# Hypertension: Given concern for acute hemorrheage we aimed to
maintain SBP 120-140. This was initially achieved with a
Nicardipine gtt, which was turned off on hospital day 2. He was
also initially continued on his outpatient Metoprolol Tartrate
50 [**Hospital1 **], which was held in the setting of starting Nimodipine for
vasospasm to prevent relative hypotension. On [**2119-3-22**] he had an
episode of hypertension and was otherwise asymptomatic. He was
restarted on his home medications - hydrochlorothiazide 25mg PO
daily and metoprolol tartrate 50mg PO BID. His nimodipine was
changed to PRN, but he did not require any doses and was not
continued at the time of discharge.
.
# Pulmonary embolisms: Patient has a history of recurrent
pulmonary emboli, and was previously anticoagulated with
warfarin and then changed to Lovenox 3/[**2118**]. Given hemorrhagic
brain mets, future anticoagulation is contraindicated. Bilateral
lower extremity ultrasounds were negative for DVT. He underwent
placement of an IVC filter on [**3-17**] by Interventional Radiology
to prevent future clot propogation.
.
# Hemoptysis: Possibly related to multiple pulmonary metastasis
in the setting of anitcoagulation. New pulmonary embolism is
unlikely given absence of tachycardia or hypoxia. He was
provided with humidified oxygen. His O2 saturations remained
adequate on room air.
.
# Acute on Chronic Kidney disease: Baseline Cr appears to be
1.3-1.4. The patient's Cr was at baseline on admission, and
increased in the setting of diuresis. He was bolused 500 cc of
NS and repeat electrolytes revealed improvement in creatinine.
His creatinine remained stable for the rest of his hospital
stay.
.
# Hyponatremia: Thought to be secondary to SIADH given
underlying intracranial and pulmonary disease. Serum cortisol
was normal. Urine lytes revealed sodium avidity with a highly
concentrated urine, likely a mixed picture (dehydration with
underlying SIADH). He was given IVFs with subsequent improvment
in sodium. At the time of discharge his Na was 136.
.
# Metastatic Renal Cell Carcinoma: Patient diagnosed with RCC
after biopsy of metastatic pulmonary lesion. He has metastatic
involvment of brain, spinal cord, lungs and larynx. In [**2116**] he
was treated with tracheostomy for laryngeal mass. Admission
chest xray showed worsening of pulmonary metastatic disease.
His hemorrhagic brain mass has been well controlled with steroid
therapy. He has stabilized since admission and is doing well.
He will continue to receive dexamethasone in the outpatient
setting and follow up with his outpatient oncologists.
.
# Chronic low back pain with neuropathy: Patient is on
gabapentin and oxydonone for chronic low back pain and
neuropathy. Gabapentin was initially held on admission to avoid
sedating medications and pain was controled with oxycodone +
oxycontin at home dose. His pain was relatively well controlled
and his gabapentin was restarted at the time of discharge.
.
Code: Full confirmed
Communication: Patient, Wife [**Telephone/Fax (2) 79328**]h [**Telephone/Fax (2) 79329**]c
Medications on Admission:
Belacizumab - 25mg/mL Solution - 10 mg/kg every 2 weeks
Diphenhydramine - 25 mg [**12-4**] Capsule(s) by mouth at bedtime as
needed
ENOXAPARIN 120mg Q12Hours
Fenofibrate 200mg Daily
Finsasteride 5 mg Daily
Gabapentin 300 mg Capsule [**Hospital1 **]
Gabapentin 500 mg Capsule QHS
Hydrochlorothiazide 25 mg QAM
Terazosin 5 mg daily
Metoprolol tartarate 50 mg [**Hospital1 **]
Omeprazole 20 mg [**Hospital1 **]
Oxycodone 5 mg 1-2 Tabs Q4h PRN
Oxycodone SR 10 mg Tablet 1 tab Q8H
Trazodone 50 mg Tablet QHS
Aacetaminophen 500mg-1000mg Q6-8 Hours PRN pain
Calcium carbonate Dosage uncertain
Calcium citrate Vitamin D3 315 mg-200 unit 2tabs daily
Ergocalciferol 1000 unit Capsule daiy
Fiber 4 tabs per day
Multivitamin daily
OMEGA-3 FATTY ACIDS 1,200 mg-144 mg daily
Senossides/docusate 8.6 mg/50 mg Tablet - 2 Tablet(s) by mouth
TID
Discharge Medications:
1. AVASTIN 25 mg/mL Solution Sig: Ten (10) mg/kg Intravenous
Q2week.
2. Benadryl 25 mg Capsule Sig: [**12-4**] Capsules PO at bedtime as
needed for insomnia.
3. fenofibrate 50 mg Capsule Sig: Four (4) Capsule PO once a
day.
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
6. gabapentin 100 mg Capsule Sig: Five (5) Capsule PO at
bedtime.
7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO
every 6-8 hours as needed for pain.
14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 days.
15. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
19. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: Two (2)
Tablet PO once a day.
20. ergocalciferol (vitamin D2) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
21. Fiber-Tabs 625 mg Tablet Sig: Four (4) Tablet PO once a day.
22. multivitamin Tablet Sig: One (1) Tablet PO once a day.
23. Omega 3-6-9 1,200 mg Capsule Sig: One (1) Capsule PO once a
day.
24. terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day.
25. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Primary Diagnosis:
Hemorrhagic lesion in the brain
.
Secondary Diagnosis:
metastatic Renal Cell Cancer
Hypertension
Bradycardia
Pulmonary embolus
Hemoptysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were
admitted to the hospital because of increasing headache and loss
of vision on the right side. We found that the lesion in your
brain was hemorrhaging and your lovenox was stopped and you were
started on IV steroids and medications to control your blood
pressure. You were initially admitted to the intensive care
unit for monitoring. Your blood pressure remained well
controlled and you were transferred to the regular floor. We
are tapering your steroids and have switched you back to your
home blood pressure medications. Repeat MRI on [**2119-3-20**] showed
that the bleeding in the brain has remained stable and is not
getting worse. You were seen by physical therapy and it was
felt you would be safest and best if you were discharged to
Rehab for strength and gait training. You will follow up with
your outpatient oncologists for further care.
.
The following medications were STARTED:
Dexamethasone 4mg by mouth Daily
Keppra 500mg by mouth twice a day
Miralax 17gm by mouth Daily if you are not having bowel
movements
.
The following medication was STOPPED:
Lovenox 120mg two times a day
.
Please continue your other medications as prescribed.
Followup Instructions:
Department: BMT/ONCOLOGY UNIT
When: MONDAY [**2119-3-27**] at 10:30 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: RADIOLOGY
When: SUNDAY [**2119-4-2**] at 1:15 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2119-4-3**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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15,503
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19935
|
Discharge summary
|
report
|
Admission Date: [**2200-9-17**] Discharge Date: [**2200-9-24**]
Date of Birth: [**2131-4-24**] Sex: M
Service: MED
Allergies:
Iodine / Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
69M w/ hx pancreatic CA dx [**12-12**] s/p multiple CBD stent
placements was admitted on [**2200-9-17**] with acute cholangitis.
Major Surgical or Invasive Procedure:
ERCP
7 cm 10 French stent placement
History of Present Illness:
Mr. [**Known firstname 53773**] is a 69 year old Italian speaking gentleman
diagnosed with pancreatic CA in [**12-12**], s/p multiple CBD stent
placements, who presented to an OSH on [**2200-9-15**] with severe
abdominal pain and jaundice. He had been feeling well since
removal of his last stent in [**7-13**] until [**2200-9-10**], when he told
his family that he wasn't feeling well, with decreased appetite
and malaise that progressed during the next several days. On
[**2200-9-15**] he experienced onset of severe abdominal pain in the
RUQ and epigastric region with radiation to his back, and was
admitted to [**Hospital3 417**] Hospital.
At the time of admission, Mr. [**Known lastname 7996**] complained of abdominal
pain, anorexia, malaise, weakness, and nausea. He denied fevers
or chills. He was afebrile, hemodynamically stable, with no
leukocytosis, so was given IV hydration and analgesia. During
the first 24 hours of admission, however, he began to look more
toxic and spike low-grade fevers. He was transferred to the ICU
and started on gentamycin and imipenem, and given one dose of
levofloxacin. He required oxygen (50% on venting mask) to
maintain sats of 90-94%, but required neither intubation nor
pressors. Per his niece, the GSH did not have ERCP capabilities
available and he was transferred to the [**Hospital1 18**] MICU for ERCP on
the evening of [**2200-9-17**]. At the time of transfer, his labs were
notable for Na 134, Mg 1.6, TBili 19.8, DBili 15.4, and alk phos
of 411, WBC 10.3, and Hct 36.9. Blood cultures were negative at
the time of transfer.
On his arrival in the [**Hospital1 18**] MICU, Mr. [**Known lastname 7996**] was febrile to
100.6, satting 90-93% on 50% O2 face mask. He complained of
severe abdominal pain radiating to his back. He was noted to be
jaundiced and disoriented. He was started on meropenam and
vancomycin, administered 1 mg Ativan and 5 mg Zydis for anxiety,
and given a total of 6 mg Dilaudid for pain. His DBili
increased to 27.9, with Dbili 20.0 and Alk [**Doctor Last Name **] 354. AST was 72,
ALT 40, [**Doctor First Name **] 16, lip 7, albumin 3.1. Digoxin, initiated in [**5-13**]
following an episode of pulmonary edema, was discontinued as
thought to be contributing to 1st degree heart block noted on
EKG.
ERCP was performed on [**9-18**], and the patient was noted to have a
10 mm long irregular stricture of the lower [**1-11**] CBD. A 7 cm 10
French stent was placed successfully. The patient noted
resolution of pain following ERCP. He was transferred to the
floor on the morning of [**2200-9-20**] for monitoring and evaluation.
The history of Mr. [**Known lastname 53774**] pancreatic cancer is as follows.
He had been in his usual state of good health until [**Month (only) 359**] of
[**2199**], when he began experiencing abdominal pain and anorexia.
He was treated with antibiotics with initial resolution of
symptoms, but through [**Month (only) **] and [**Month (only) 1096**] noted increasing
anorexia. In the last week of [**Month (only) 1096**] he was admitted to Good
[**Hospital 53775**] Hospital with malaise, RUQ and LUQ post-prandial pain,
and 10 lbs weight loss. Non-contrast CT at that time showed an
abnormal pancreatic duct with ductal dilation, a cystic lesion
measuring 8 mm in the pancreatic body and a cystic structure in
the tail measuring 1.3 cm. His common bile duct and his liver
function tests were normal. ERCP showed stricture of both the
pancreatic duct and intra-pancreatic portion of the CBD, and a
plastic stent was placed in the CBD. Cytology was negative for
malignant cells. The patient continued to experience nausea,
vomiting, and abdominal pain, without fever or jaundice. His
weight had at this time decreased from 120 lbs to 80 lbs. EUS
with FNA of the pancreatic cystic lesions (head and body) on
[**2200-2-6**] revealed atypical cells and CEA of 416. His stent was
replaced on [**2200-2-27**]. Based on cytology, the patient was
thought to have either IPMT or mucinous ductal ectasia, and a
Whipple procedure was contemplated for [**2200-6-4**]. TPN was
initiated in preparation for surgery, and the patient gained
back 42 lbs. An echo showed EF of 65% and an exercise stress
test showed no evidence of ischemia. However, just before the
procedure, the patient was hospitalized for SOB and was found to
be in pulmonary edema. Per his niece, plans for surgery in the
immediate future were discontinued secondary to concerns for his
perioperative pulmonary status. The patient was begun on home
O2 when VNA noted sats in the 80s on room air, asymptomatic from
the patient's perspective. On repeat ERCP, the CBD stent was
removed on [**2200-7-10**] and not replaced when it was found that a 12
mm balloon could be passed through the stricture. He did well
at home on solid POs and 3L O2, with good mobility and mental
function, until the symptoms prompting the current admission.
The patient's translator and health-care proxy is his niece,
[**Name (NI) **] [**Name (NI) **], who can be reached at ([**Telephone/Fax (1) 53776**].
Past Medical History:
1. Pancreatic CA, as above
2. PUD
3. Ventricular ectopy, possibly secondary to small MI at age 40
4. Osteoarthritis
5. Emphysmea
6. Anxiety
PSH:
- s/p laminectomy in 30s, for back pain following a car
accident.
- appendectomy in youth
- vein ligation for vericosities
Social History:
Italian-speaking. History of heavy smoking, currently several
cigarettes per day. [**1-10**] glasses wine per day, no hx heavy EtOH.
Lives with sister and her husband in [**Name (NI) 1475**]. Single,
without children. Retired shoe-factory worker.
Family History:
CAD in mother, father, and sister.
Cerebral aneurysms in sister.
Negative for pancreatic, colorectal, or any other CAD.
Physical Exam:
VS: Tmax 99.5, Tcurr 98.9, pulse 93, BP 110/72, RR 22, sats 95%
6L.
GEN: The patient is a cachectic, jaundiced gentleman in NAD,
appearing older than his stated age.
HEENT: Icterus noted in eyes and buccal mucosa. Oropharynx
non-injected. Upper teeth, lower molars missing.
NECK: supple, no LAD. No Virchow's node appreciated.
PULM: Reduced breath sounds bilaterally. Tympanitic. Very
light crackles at bases. End expiratory wheezes throughout.
CV: NSR, no MRG.
ABD: soft, non-distended, tender to palpation in RUQ, no rebound
or guarding. No masses appreciated. Liver span 9 cm in
mid-clavicular line. No periumbilical nodes appreciated.
EXT: warm, 2+ pulses B at radius and DP. Varicosity noted on
anterior aspect of R crus.
NEURO: via translation, patient appeared alert. Oriented to
self and year, but not to which hospital he was in. Could not
recall why he is in hospital. Answered questions appropriately.
CN II-XII intact. Sensation intact to distal extremities.
Strength 5/5 in upper and lower limbs. Patellar reflexes 2+.
No clonus; Babinski downgoing.
Pertinent Results:
[**2200-9-20**]:
Na 131
K 3.9
Cl 98
Bicarb 19
BUN 6
Cr <0.3
Glu 174
WBC 10.4 (62% polys)
Crit 33.6
Platelets 531
ALT 40
AST 30
LDH 151
Alk Phos 290 (from peak 396 on [**9-17**])
TBili 23.8 (from peak 27.9 on [**9-18**])
DBili 17.4 (from peak 20.0 on [**9-18**])
CXR [**2200-9-17**]:
PORTABLE AP CHEST X-RAY: Comparison is made to studies from
1/--/02. An area
of lucency representing a bulla is seen in the right lower lobe,
and a smaller
than was seen on the previous exam. Diffuse linear opacities are
noted, likely
representing parenchymal scarring and fibrosis are seen
diffusely bilaterally.
No pneumothorax is seen. No infiltrate is identified. Heart size
is normal.
Mediastinal and hilar contours are within normal limits. No
osseous
abnormalities are identified.
IMPRESSION: No evidence of pneumonia. Right lower lobe bulla is
smaller in
comparison to previous exam. Diffuse interstitial scar is seen.
ERCP [**2200-9-18**]:
- A single irregular stricture that was 10 mm long was seen at
the lower third of the common bile duct and it could represent
malignant versus inflammatory stricture.
- Cytology samples were obtained for histology using a brush in
the lower third of the common bile duct.
- A 7 cm by 10 fr Tannenbaun stent biliary stent was placed
successfully in the common bile duct.
Echo [**2200-9-19**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal (LVEF
70%). Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
A/P: 69M with hx pancreatic cancer since [**12-12**], s/p multiple CBD
stents, presents to OSH with abdominal pain and jaundice.
Transferred to the [**Hospital1 18**], ERCP performed, and stent placed
[**2200-9-18**], with resolution of pain and disorientation. Patient
transferred from MICU [**2200-9-20**] for monitoring and evaluation.
1. GI
History and labs consistent with ascending cholangitis [**2-10**] CBD
stricture. S/p ERCP with stent placement on [**2200-9-18**], with
resolution of pain and disorientation. TBili (today 15.4 from
peak 27.9 on [**9-18**]). Pain free since [**2200-9-19**].
-Will have LFTs checked qwk at rehab. If increases, may need
change of stent. Will f/u with ERCP in [**1-10**] months for metallic
stent.
2. Pancreatic CA
Whipple procedure considered in [**5-13**] but aborted due to episode
of pulmonary edema and concern for pulmonary status. Cytology
from biliary washing now suggestive of adenoCA. Will likely
require metal stent eventually.
- Follow up as outpatient with surgery and GI. Will need f/u
with Heme-Onc per PCP.
3. Pulmonary
Etiology of oxygen requirement uncertain. Per niece, patient
had not needed oxygen prior to [**Month (only) 116**] episode of pulmonary edema;
has been on 3L home O2 requirement since to maintain sats in low
90s. CTs have shown emphysema, consistent with heavy smoking
history. Pulmonary edema episode may have been caused by volume
overload [**2-10**] TPN, transient cardiac ischemia, or less likely PE.
- Satting 95% on 3L this AM (at baseline from home).
- LENIs negative, no right heart strain per TTE.
- Continue pulmonary regimen: Advair diskus 250/50 2 puffs [**Hospital1 **];
Ipratropium bromide 1 neb Q6; Albuterol 1 neb Q4
4. ID
Begun on merepenam and vancomycin (due to PCN allergy) on
[**2200-9-18**].
- WBC stable. Afebrile. Has not spiked fever since [**2200-9-18**].
Follow.
- Continue Abx for 10 day course.
- C. diff antigen from [**9-20**] negative.
5. Cardiac:
- Pump: BP stable. No evidence of volume overload by lung, neck,
or extremities exam. Digitoxin started during pulmonary edema
episode d/ced in MICU due to suggestion of first degree heart
block. With EF of 70% and no evidence of failure, no current
indication to resume digitoxin.
- Ischemia: no evidence of current ischemia.
- Rhythm: borderline first degree heart block noted on EKG, Dig
discontinued.
- Consider ASA for outpatient regimen. However, benefits may be
outweighed by risk of exacerbating PUD.
6. Renal: BUN, Cr reassuring. No active issues.
- Continued good urine output following Foley removal [**2200-9-20**].
7. Heme: stable Hct.
8. FEN:
-Pancrease and Megace added. Tolerating diet.
9. Endocrine:
- Improved sugars with increased SS Insulin. Requirement may
increase as acute episode resolves. Alternatively, could be new
onset diabetes [**2-10**] pancreatic process.
10. Pain: well controlled. Has not requested pain meds since
[**9-20**]. PO Morphine IR for breakthrough pain.
11: Prophylaxis:
- Heparin SC
- PPI
- Vit D, Ca.
12. Anxiety and Depression
- However, patient is still sad and periodically anxious.
Reassurance seems to help; continue checking in on patient
frequently.
- Continue home Xanax, Remeron regimens.
13. Code: full
14. Dispo: To rehab, will f/u with ERCP, GI, and PCP
Medications on Admission:
Home meds:
Combivent MDI 2 puffs QID
Advair MDI 250/50 2 puffs [**Hospital1 **]
Megace 400 mg QD
Pancrease 900 units TID
Remeron 15 mg QHS
Xanex 0.25 mg QID
Carafate 1 gram QID
Protonix 40 mg QD
Digoxin 0.25 mg QD
Morphine Sulfate 60 mg [**Hospital1 **], 5 mg Q2 hrs PRN breakthrough pain.
Meds on transfer to MICU:
Dilaudid 1.2 mg IV Q6 PRN pain
Digoxin 0.25 mg PO QD
Xanex 0.25 mg PO QD
Remeron 15 mg PO QHs
Vancomycin 1000 mg IV Q12
Meropenam 1000 mg IV Q8
Advair diskus 250/50 2 puffs [**Hospital1 **]
Ipratropium bromide 1 neb Q6
Albuterol 1 neb Q4
Protonix 40 mg IV QD
Carafate 1 gm PO QID
Heparin 5000 units SQ TID
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
neb Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
9. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO QD (once a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
13. Multivitamin Capsule Sig: One (1) Cap PO QD (once a
day).
14. Megestrol Acetate 40 mg/mL Suspension Sig: Four Hundred
(400) mg PO QD (once a day).
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for GERD.
16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
17. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed for insomnia.
18. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous
three times a day for 4 days.
19. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous twice a day for 4 days.
20. Insulin Regular Human 300 unit/3 mL Syringe Sig: per sliding
scale units Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Cholangitis s/p ERCP and stent placement
Discharge Condition:
stable
Discharge Instructions:
Please call your primary care physician if you are having
temperatures > 101.5, severe chest pain, shortness of breath, or
abdominal pain.
Followup Instructions:
Follow up with ERCP in [**1-10**] months for metallic stent. The ERCP
fellow will call you to set up an appointment.
Follow up with Dr. [**Last Name (STitle) **], your PCP [**Last Name (NamePattern4) **] [**2-11**] weeks. Please call his
office for an appointment.
Follow up with Dr. [**Last Name (STitle) **] in [**2-11**] weeks.
Completed by:[**2200-9-24**]
|
[
"576.2",
"276.5",
"576.1",
"261",
"426.11",
"157.8",
"300.4",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.14",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
15503, 15574
|
9473, 12779
|
432, 469
|
15659, 15667
|
7399, 9450
|
15854, 16218
|
6164, 6285
|
13452, 15480
|
15595, 15638
|
12805, 13429
|
15691, 15831
|
6300, 7380
|
264, 394
|
497, 5587
|
5609, 5879
|
5895, 6148
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,098
| 125,050
|
12008
|
Discharge summary
|
report
|
Admission Date: [**2111-6-1**] Discharge Date: [**2111-6-5**]
Date of Birth: [**2067-3-18**] Sex: F
Service: SURGERY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy and lysis of adhesions.
History of Present Illness:
The patient is a 44 year old woman with a history of open
roux-en y gastric bypass in [**2102**], s/p ex-lap, LOA, and
omentectomy [**2110-4-20**] who is seen in surgery consultation with ?
SBO.
The patient states that she developed abdominal pain
approximately 72 hours ago, which she describes as diffuse and
cramping in nature. She has had multiple episodes of
non-bloody,
non-bilious emesis since the onset of her symptoms (~8X/day).
She denies fevers/chills and sick contacts. She has not been
eating or drinking much in the past 3 days. Her last BM was on
Thursday (4 days ago) and she has not passed flatus in at least
24 hours. She states that her abdomen has become progressively
distended.
Past Medical History:
PMH:
HTN
History of narcotic abuse (on Suboxone)
Chronic back pain
PSH:
s/p ex-lap, LOA, omentectomy [**2110-4-20**]
s/p Roux-en-Y gastric bypass [**2102**]
s/p Panniculectomy [**2106**]
s/p Ventral hernia repair
s/p Lumbar spine surgery
s/p LUE forearm tendon surgery
Social History:
Does office work. Lives with husband, children. Denies tobacco,
EtOH, or illicit drug use. Prior narcotic addition for chronic
lower back pain, weaning off Suboxone.
Family History:
Non-contributory
Physical Exam:
Temp 98.9 HR 79 BP 148/70 100% RA
- NAD, appears somewhat ill
- RRR
- lungs clear
- abdomen soft, distended, tender to palpation diffusely across
abdomen most significant at umbilicus; + mild tap tenderness;
mild voluntary guarding; no frank peritoneal signs
- rectal exam (already performed by ED resident, not repeated):
normal tone, guaiac negative
Pertinent Results:
[**2111-6-1**] 12:55PM WBC-8.7 RBC-3.17* HGB-6.3*# HCT-21.4*#
MCV-68*# MCH-19.8*# MCHC-29.2* RDW-16.7*
[**2111-6-1**] 12:55PM NEUTS-89.8* LYMPHS-7.0* MONOS-2.9 EOS-0.1
BASOS-0.2
[**2111-6-1**] 12:55PM PLT COUNT-254
[**2111-6-1**] 01:00PM GLUCOSE-99 UREA N-14 CREAT-0.6 SODIUM-139
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-18* ANION GAP-13
[**2111-6-1**] Abd CT : 1. Diffuse dilation of afferent and efferent
limbs of the small bowel consistent with small-bowel obstruction
with two transition points in the mid abdomen which are
concerning for closed loop obstruction. No evidence of free air.
Perihepatic fluid noted.
2. Nasogastric tube is within the esophagus and should be
repositioned.
3. 4 cm low density in the left adnexa. Recommend 6-week
followup pelvic
ultrasound.
4. Subcentimeter hypodensities in the right kidney are too small
to
characterize but likely represent simple cysts.
[**2111-6-1**] 11:52PM WBC-13.3*# RBC-4.27# HGB-9.1*# HCT-30.3*#
MCV-71* MCH-21.2* MCHC-29.9* RDW-17.9*
[**2111-6-4**] HCT 26.6
Brief Hospital Course:
Mrs. [**Known lastname 37721**] was admitted to the hospital, made NPO and taken
urgently to the Operating Room for an exploratory laparotomy.
Her hematocrit on admission was 21 and she was transferred with
2 units of PRBC's. She underwent lysis of adhesions and her
total small bowel obstruction was relieved. She tolerated the
procedure well and returned to the ICU for further management.
Her hematocrit was stable post transfusion in the 26-27 range.
She maintained stable hemodynamics and her pain was controlled
with high doses of a Dilaudid PCA. Her needs were great
secondary to her prior history of narcotic abuse. Prior to
admission she was on Suboxone.
Her nasogastric tube was left in place for 3 days until she had
some return of bowel function. Subsequently she was transferred
out of the unit to the Surgical floor where she progressed well.
She began a Bariatric stage 1 diet which was advanced over 48
hours to stage 3. she tolerated this well without any evidence
of nausea or vomiting. Her Dilaudid PCA ended on [**2111-6-5**] and
she tolerated oral medication without difficulty.
She was up and walking without difficulty and her abdominal
wound was healing well. After an uncomplicated recovery she was
discharged to home on [**2111-6-5**] and will follow up with Dr. [**Last Name (STitle) **]
next week for staple removal.
Medications on Admission:
Atenolol 100mg daily
Norvasc 10mg daily
Suboxone 2mg QOD
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Hydromorphone 4 mg Tablet Sig: 1 [**12-27**] -2 Tablets PO Q3H (every
3 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
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 [**10-9**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your staples will be removed in the office next week.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2111-6-10**] 3:30
Call your doctor to help wean the Dilaudid and restart your
Suboxone
Completed by:[**2111-6-5**]
|
[
"305.51",
"V45.86",
"276.2",
"560.81",
"285.1",
"401.9",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04",
"96.07",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
5093, 5099
|
3023, 4378
|
282, 331
|
5191, 5191
|
1969, 3000
|
6858, 7108
|
1560, 1578
|
4486, 5070
|
5120, 5170
|
4404, 4463
|
5342, 6541
|
1593, 1950
|
228, 244
|
6553, 6835
|
359, 1066
|
5206, 5318
|
1088, 1360
|
1376, 1544
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,019
| 171,445
|
10706
|
Discharge summary
|
report
|
Admission Date: [**2112-2-5**] Discharge Date: [**2112-2-12**]
Date of Birth: [**2042-7-19**] Sex: M
Service: SURGERY
Allergies:
Reglan
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
The patient presented electively for resection of a carcinoma of
the esophagogastric junction.
Major Surgical or Invasive Procedure:
s/p trans-hiatial esophagojejunostomy, total gastrectomy
History of Present Illness:
This gentleman has cancer of the gastroesophageal junction which
appeared to mostly involve the stomach originally. He had been
treated with neoadjuvant
treatment. He had a large peri portal lymph node which made him
unresectable essentially for cure prior to treatment but this
was negative on PET CT after his treatment and therefore he
became an operative candidate. He was counseled as to his
options and wished to proceed with surgery. Surgery was planned
to provide the operation which would provide the least morbidity
but also provide resection of the area. It was thought that he
may have enough residual disease in his stomach, as noted by PET
CT that he may need much more extensive dissection of the
stomach and that a minimally invasive esophagogastrectomy may
not be feasible. Therefore, an open approach was planned with
the plan for an extensive lymph node dissection in the area of
the old lymph nodes as
well as the ability to decide between a total gastrectomy or an
Ivor-[**Doctor Last Name **] esophagogastrectomy.
Past Medical History:
1. GERD.
2. Prostate cancer diagnosed in [**2106**] status post brachytherapy,
most recent PSA [**8-/2111**] 0.1.
3. Low back pain with history of L4-L5 disk herniation
Social History:
He lives with his wife. [**Name (NI) **] has no children, but does have a
stepdaughter. He is currently on disability retirement; he is a
former school custodian.
Tobacco: History of three packs per day for 42 years, quit 20
years ago.
Alcohol: History of abuse, now drinks one to two times per
year.
Family History:
His brother died of lung cancer at 63 and a second brother died
of COPD at 65. There may have been lung cancer as well. His
mother died at 81 of cardiovascular disease and his father died
at 61 of cardiovascular disease.
Physical Exam:
On day of discharge
T 98.6 Pulse 86 BP 130/84 RR 18 O2 sats 98%RA
Gen - NAD, alert and oriented
Card - Regular rate and rythmn
Pulm - Clear to auscultation bilaterally
Abd - soft, non distended, appropriately tender
Wounds - dressings dry
Pertinent Results:
UGI SGL CONTRAST W/ KUB
Reason: ?leak, swallow, regurgitation
Contrast: CONRAY
[**Hospital 93**] MEDICAL CONDITION:
69 year old man s/p esophagojejunostomy, total gastrectomy
REASON FOR THIS EXAMINATION:
?leak, swallow, regurgitation
STUDY: Barium upper GI small bowel follow-through.
INDICATION: 69-year-old male status post esophagojejunostomy and
total gastrectomy. Assess for leak.
COMPARISONS: [**2112-2-9**].
FINDINGS: An initial scout image demonstrates removal of the
previously placed nasogastric tube. A drain terminates within
the left upper quadrant of the abdomen. There are several
air-fluid levels present throughout the large bowel. A few
surgical clips project over the left mid abdomen. Multiple
staples overlie the midline of the abdomen. Thin barium was
administered orally to the patient, and fluoroscopic spot images
of the esophageal-jejunal anastomosis obtained. Interrogation of
the anastomosis in multiple planes demonstrates no evidence of
leak. A side-to-end anastomosis is noted with a small residual
cavity comprised of jejunum. Contrast is noted to pass freely
distally throughout the remaining jejunum.
IMPRESSION: Status post esophagojejunostomy and total
gastrectomy, without evidence of leak at the esophageal-jejunal
anastomosis. Free passage of contrast noted distally.
Pathology
SPECIMEN SUBMITTED: ESOPHAGECTOMY, PERIESOPHAGEAL TISSUE,
STOMACH, STOMACH DONUT, ESOPHAGEAL DONUT.
Procedure date Tissue received Report Date Diagnosed
by
[**2112-2-5**] [**2112-2-5**] [**2112-2-9**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mb????????????
DIAGNOSIS:
I. Esophagectomy (A-S):
1. No carcinoma seen (Prior biopsy is not available for
review).
2. Inflammatory polyp just below the gastroesophageal junction.
3. Expansion of the submucosa by necrosis, abundant macrophages
and chronic inflammation consistent with treatment effect.
4. Active esophagitis with ulceration and chronic active
gastritis.
5. Paraesophageal tissues with;
a) Eighteen nodes, no malignancy identified (0/18), many show
necrotizing granulomas.
b) Hyalinized nodules, possibly thrombosed vessels or treated
nodules.
II. Paraesophageal tissue (T):
Adipose tissue, no malignancy identified.
III. Stomach (V-AA):
1. Chronic active gastritis with loose non-necrotizing
granulomas in the lamina propria and submucosa.
2. One lymph node, no malignancy identified (0/1).
IV. Stomach donut (AB):
Small bowel within normal limits.
V. Esophageal donut (AC):
No malignancy identified.
Brief Hospital Course:
The patient was admitted for resection of a mass at the
gastro-esophageal junction. Following the procedure the patient
was transferred to the ICU for close monitoring. He had an NG
tube placed, IVF, made NPO, pain controlled via an epidural and
PCA pump, foley catheter to gravity, j tube to gravity. His
blood pressure in the ICU required fluid bolus and
norepinephrine.
POD 1 - the patient remained in the ICU with IVF, NGT, foley,
epidural but norepinephrine was discontinued and his blood
pressure remained stable. A line discontinued
POD 2 - Tube feeds via J tube were started at 10 cc/hr and
increased by 10 cc q8hrs as tolerated. The patient was
transferred to the floor.
POD 3 - Epidural catheter removed, foley catheter removed. The
patient was started on lasix IV and continued this once per day
for three days to remove excess fluid.
POD 4 - Barium swallow performed, limited study showed no leak
at the anastamosis site. NG tube discontinued. Physical
therapy commenced.
POD 5 - Repeat swallow study showed free passage of fluid and no
leak. Tube feeds at goal of 90/hr. initiate PO diet - clears.
POD 6 - advanced to regular diet - no breads, bulky, sharp or
tough foods, no carbonated beverages. Tube feeds cycled at
night for 12 hours.
POD 7 - Nutrition shakes added to diet, physical therapy
continued with the patient. He will be discharged today,
tolerating PO, pain well controlled and ambulating.
Medications on Admission:
ATIVAN 1 mg--1 tablet(s) by mouth three times a day as needed
for nausea/vomiting
COLACE 100 mg--1 (one) capsule(s) by mouth twice a day as needed
COMPAZINE 10 mg--1 tablet(s) by mouth q 6 hours as needed for
nausea/vomiting
LACTULOSE 10 gram/15 mL--15-30ml solution(s) by mouth q3-4 hours
as needed for constipation. take until bowel movement happens.
Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 400 mg-400 mg-40 mg-25 mg-200
mg/30 mL--1 tablespoon swish and swallow 15 minutes before meals
and at bedtime as needed for sore throat
OMEPRAZOLE 20 mg--1 capsule(s) by mouth twice a day
REPLETE/FIBER --60 ml/hour per tube at night (60ml/hour)
SENOKOT 8.6 mg--1 to 2 tablet(s) by mouth twice a day as needed
TIMOPTIC 0.5 %--Ou at bedtime
Tylenol PM Extra Strength 500 mg-25 mg--1 (one) tablet(s) by
mouth at bedtime
XALATAN 0.005 %--Ou at bedtime
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for puritis.
2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension Sig: One
(1) PO BID (2 times a day).
5. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray
Mucous membrane PRN (as needed).
6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
per JTUBE.
7. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed.
Disp:*750 ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
Primary:
esophageal tumor-adneoncarcinoma
.
Secondary:
GERN, Anxiety, Prostate cancer
Discharge Condition:
Stable
Tolerating regular, soft foods, and tube feedings via JTUBE.
Adequate pain control via JTUBE.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid 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.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
JTUBE Care:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Be sure to cleanse around insertion site daily
-Flush daily with 50cc of water.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
Followup Instructions:
1. Please make a follow-up appointment with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) **] in [**2-14**] weeks.
2. Make a follow-up appointment with your primary care provider,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] [**Telephone/Fax (1) **] in 1 week or as needed.
|
[
"535.50",
"338.18",
"724.2",
"530.81",
"V10.46",
"V15.82",
"530.10",
"151.0",
"V17.3",
"458.9",
"V16.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"40.3",
"44.13",
"43.99",
"46.41"
] |
icd9pcs
|
[
[
[]
]
] |
8109, 8189
|
5076, 6514
|
361, 420
|
8319, 8422
|
2516, 2597
|
10316, 10656
|
2018, 2242
|
7440, 8086
|
2634, 2693
|
8210, 8298
|
6540, 7417
|
8446, 9507
|
9522, 10293
|
2257, 2497
|
226, 323
|
2722, 5053
|
448, 1485
|
1507, 1680
|
1696, 2002
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,009
| 125,425
|
22253
|
Discharge summary
|
report
|
Admission Date: [**2160-7-9**] Discharge Date: [**2160-8-2**]
Date of Birth: [**2119-6-10**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
liver failure, encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
41 yr old female w/ PMH of ETOH-induced cirrhosis ([**2157**]) +
pancreatitis, admitted to [**Hospital 17436**] hospital in mid-[**Month (only) 205**] with 3 day
hx of RUQ pain, increasing abdominal girth, N/V, jaundice and
one-month history of anorexia. She reports that she stopped
drinking 2 weeks prior to admission. Her admission labs were as
follows: Na 140, K 3, Cl 92, CO2 29, BUN 6, Cr 0.7, Gluc 93, AG
19, Ca 8.1, TP 8.1, Alb 4.0, Bilitot 17.3, AST 165, ALT 36, AP
390, amylase 52, lipase 422, ammonia 67, ETOH <0.01, WBC 5.3,
Hct 33.5, Plt 38, NEU 75.8%, MCV 95.2, PT 17.8, INR 1.8, PTT 43.
Abd U/S and CT showed a cirrhotic liver w/ possible liver mass
in right lobe, fluid in the right and left gutters, ascites.
Paracenteses were performed on [**2160-6-30**] (1L) and [**2160-7-2**] (3L)
without evidence of spontaneous bacterial peritonitis (clear,
yellow, WBC 35, RBC few, NEU 12, LYMPH 16, MESOS 2, Alb <0.4, TP
<1.0, gram stain polys, no organisms, no growth), but Pt was
started empirically on ceftriaxone. ABG [**2160-7-3**] 7.34/32/64.
During the course of her hospitalization she went from being
able to answer questions to being confused/agitated, at first
thought to be secondary to ETOH and benzo withdrawal and treated
using sedatives, however she progressed to her current state of
being confused/somnolent. Transferred to [**Hospital1 18**] for further
evaluation. The day before transfer labs were as follows: BUN
24, Cr 1.0, AG 9, Alb 2.6, AST 159, ALT47, AP 245, Bilitot 34,
INR rose to 2.1 and is now 1.8 after vitamin K tx, PT 17.9, WBC
13.7, Hct 27.9, Plt 134.
Past Medical History:
ETOH abuse
benzodiazapine abuse
ETOH-induced cirrhosis ([**2157**])
ETOH-induced pancreatitis
GERD
ovarian cysts
c-section x2
appendectomy
tubal ligation
Social History:
Lives with husband and 16 y/o daughter in [**Name (NI) **] ME. Limited
employment secondary to health. 12 pack-year smoking history,
currently [**12-7**] ppd. ETOH abuse. benzodiazapine abuse.
Family History:
mother 64 died of emphysema
father 67 died of ETOH related dz
Physical Exam:
On admission:
T95.8-96.4, BP120-122/60-74, HR82-84, RR18, O2sat99%RA
HEENT: sceral icterus, EOMI, PERRL, MM dry, poor dentition, no
lad, NC/AT
CV: RRR, NL S1/S2
PULMO: CTAB
ABD: BS+, distended, mildly tender to palpation, hyperresonant,
+fluid shift, shifting dullness
EXT: warm, no C/C/E,
SKIN: jaundice, spider angiomata, prominent superficial venous
markings on abd
NEURO: AxOx0, difficult to assess asterixis given pts
agitation.
Pertinent Results:
[**2160-7-9**] 08:42PM PT-22.3* PTT-48.7* INR(PT)-3.3
[**2160-7-9**] 08:42PM PLT COUNT-94*
[**2160-7-9**] 08:42PM WBC-9.4 RBC-2.46* HGB-8.0* HCT-26.9*
MCV-LABEL VERI MCH-32.5*
MCHC-29.7* RDW-15.8*
[**2160-7-9**] 08:42PM HCV Ab-NEGATIVE
[**2160-7-9**] 08:42PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2160-7-9**] 08:42PM AMMONIA-39
[**2160-7-9**] 08:42PM ALBUMIN-2.5* CALCIUM-7.9* PHOSPHATE-4.6*
MAGNESIUM-2.5
[**2160-7-9**] 08:42PM LIPASE-91*
[**2160-7-9**] 08:42PM ALT(SGPT)-45* AST(SGOT)-141* LD(LDH)-145 ALK
PHOS-238* AMYLASE- 82 TOT BILI-30.2*
[**2160-7-9**] 10:18PM GLUCOSE-131* UREA N-48* CREAT-0.5 SODIUM-132*
POTASSIUM-4.0
CHLORIDE-103 TOTAL CO2-15* ANION GAP-18
[**2160-7-10**]
ABG 7.38/21/102, ALT 52, AST 154, LDH 181, AP 272, amylase 82,
Tbili 33.7, dbili 22.4, ibili 11.3, lipase 96, alb 2.8, Ca 9.0,
Phos 5.1, Mg 2.8, NH4 39, Fe 21, TIBC 217, TRF 167, ferritin 32,
vitB12 >200, folate > 20, AFP 5.4, urine Na < 10, urine Cl 23,
urine creatinine 42, urine osm 447, urine TP 37, ascites LDH 33,
ascites TP 0.6, ascites alb < 1.0, ascites glucose 162, ascites
creatinine 1.1, ascites WBC 175, RBC 675, polys 8%, lymph 2%,
monos 89%.
##HEMOCHROMATOSIS ANALYSIS: COPPER, SERUM 1354 (wnl [**Telephone/Fax (1) 58023**]
UG/L); HEREDITARY HEMOCHROMATOSIS GENE ANALYSIS: Negative for
C282Y mutation. Negative for H63D mutation; CERULOPLASMIN 37
(wnl 18 -53 MG/DL)
##[**Doctor First Name **] negative
##ABXR [**2160-7-9**]:IMPRESSION: NGT seen entering stomach before
passing out of view of image.
##CXR [**2160-7-9**]:IMPRESSION: Appropriate positioning of PICC line
with tip in the distal SVC. No acute cardiopulmonary process
observed.
##CXR [**2160-7-11**]:IMPRESSION: Nasogastric tube terminates in the
distal stomach. Paucity of gas within imaged portion of the
abdomen. This raises the possibility of ascites.
##CT ABD [**2160-7-11**]: IMPRESSION:
1) Shrunken and nodular liver parenchyma with heterogeneous
enhancement, consistent with cirrhosis. Portal hypertension,
gastroesophageal varices and a splenorenal shunt are also
present.
2) No evidence of a focal hepatoma.
3) Patent hepatic arteries, portal vein, and hepatic veins.
4) Diffuse abdominal ascites.
5) Crossed and fused ectopia of the kidneys, as discussed above.
6) Diffuse wall thickening of the colon and rectum, likely
secondary to the patient's low albumin state and liver failure.
Clinical correlation is recommended to help exclude an
infectious/inflammatory etiology.
##CT HEAD [**2160-7-11**]: There is no shift of normally midline
structures. The visualized paranasal sinuses and mastoids are
normally aerated. There are no lytic or destructive changes of
the skull. Please note that the examination is limited and that
the most superior aspect of the brain is not included in the
area examined.
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect
##U/S ABD [**2160-7-29**]: 1) Cirrhosis, with changes of portal
hypertension and reversal of blood flow. 2) Mild gallbladder
wall thickening, probably related to the patient's cirrhotic
state.
##CXR [**2160-7-13**]:IMPRESSION:1. Recent intubation. 2. Right upper
lobe infiltrate with left lower lobe atelectatic changes.
##[**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO)[**2160-7-16**]:IMPRESSION:
Successful placement of postpyloric feeding tube. Tip is in the
first portion of the duodenum.
##CXR [**2160-7-29**]: PICC tip in proximal right atrium. No evidence of
pneumonia
##BLOOD CX: 8/21-23-24/04: all no growth
##URINE CULTURE (Final [**2160-7-27**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH
SKIN
AND/OR GENITAL CONTAMINATION.
FUNGAL CULTURE (Final [**2160-7-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
##STOOL CULTURE: 8/21-23-24/04: no C. Diff, Campylobacter,
Shigella, Salmonella
##CMV Viral Load (Final [**2160-7-31**]): CMV DNA not detected.
##[**2160-7-28**] 7:02 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE: NO FUNGUS ISOLATED. BLOOD/AFB CULTURE: NO
MYCOBACTERIA ISOLATED.
Brief Hospital Course:
At arrival Pt's affect ranged from somnolent to aggitated and
confused, requiring that she be placed in restraints. She was
given haldol 2.5 mg q4h prn for aggitation. She was immediately
put on lactulose q1h and was transitioned to NGT administration
of all food and meds. Ceftriaxone 1 g Q24h for empiric coverage
of possible sbp, but was stopped after one day secondary to
paracentesis (~200cc) results (LDH 33, TP 0.6, alb < 1.0,
glucose 162, creatinine 1.1, WBC 175, RBC 675, polys 8%, lymph
2%, monos 89%, 1+ <1 per 1000X FIELD POLYMORPHONUCLEAR
LEUKOCYTES. NO MICROORGANISMS) indicating no sbp. CT of head
ruled-out cranial bleed. Liver mass characterized on CT was
found to be negative for malignant cells on cytology. Pt was in
wards [**7-9**] - [**7-12**], MICU [**7-12**] - [**7-17**], wards [**7-17**] - [**8-1**]. Hospital
care by problem was as follows:
####################################
Hepatic Encephalopathy:
Pt maintained on Folic Acid 1mg PO QD and Thiamine 100mg PO QD
for EtOH withdrawel since admit.
AOx0 [**2160-7-9**] - [**2160-7-15**]
AOx0 or 1? (self) but responds to commands (squeeze fingers,
open mouth) [**Date range (3) 58024**]
AOx2 (self and place). Responsive, holds some discussion.
[**2160-7-21**]
AOx3. Fully talkative, anxious to recover. [**2160-7-22**]-present
No asterixis as of [**2160-7-19**] but continues to have persistent
tremors.
haldol 2.5mg q4h [**Date range (1) 47643**]
Lactulose 30ml Q1H [**7-11**]
Lactulose 30ml QID [**7-12**]
Lactulose 30ml QD [**7-14**] - present
Flagyl 500mg Q8 [**2160-7-14**] - [**2160-7-28**], 250mg [**Hospital1 **] [**2160-7-29**]-present
*** Pt [**Name (NI) **]3, fully responsive and conversant, some tremors in
arms, continue Lactulose 30ml PO QID, Metronidazole 250mg PO
BID, Thiamine HCl 100mg PO QD, Folic Acid 1mg PO QD
####################################
Hepatic Cirrhosis and ascites: Paracentesis were performed on
[**2160-6-30**] (1L), [**2160-7-2**] (3L), [**2160-7-10**] (200ml), [**2160-7-13**] (2L), [**2160-7-19**]
(1L), [**2160-7-25**] (1.5L), [**2160-7-31**] (2.5L). All taps were followed
with 10g Albumin / L removed except last which was followed with
transfusion of 1U of blood post tap. All were negative for
SBP. SAAG > 1.1 -> portal hypertension/transudate. Patient
liver enzymes were monitored and AST stayed in the 130-150 range
but has recently declined down to 80. ALT has remained mostly
in the 40-60 range. The lesion found in the liver by CT was
found to be benign by cytology of a biopsy. Pt was worked up
for Wilsons but was found to be negative based on ceruplasmin
and blood copper with only questionable slightly high urine
copper concentration of 59.6 UG/L for 24 collection (normal
[**1-/2086**]). Pt was negative for hemachromatosis. HAV, HBV, HCV
negative. [**Doctor First Name **] negative. Pt was kept on Ursodiol (starting
[**7-11**]-present @ 300mp PO TID) for prevention of gallstones.
Ceftriaxone 1g Q24 and Vanc 1g Q24 ([**2160-7-14**] [**2160-7-17**]) for SBP
prophylaxis. Placed on 750mg QWeek Cipro for SBP prophylaxis.
*** Continue Ciprofoxacin 750mg PO QWeek for SBP prophylaxis,
monitor LFT's for liver function, Ursodiol 300mg PO TID. Pt
seems to need therapeutic taps every 5-7 days.
####################################
Anemia: Fairly steady Hct with some fluctiations and declines,
may be due to iatrogenic due to frequent testing, no other
source for blood loss found, transfusions on [**2160-7-11**] 1 unit
[**2160-7-17**] 1 unit [**2160-7-31**] 1 unit, Hct generally ketp in the
25-30% range.
*** Maintain Hct > 25
####################################
Respiratory distress: Pt transferred to MICU [**2160-7-12**] for
respiratory distress secondary likely to gap and non-gap
metabolic acidosis (? d/t diarrhea) with respiratory
compensation with labs:
154 | 129 | 40 /
--------------- 197 AG = 16 7.39/16/84
4.7 | 9 |0.8 \
T99.1 P125 BP114/62 RR32 PO295RA
A line was placed for frequent BP and ABG monitoring. Was
intubated [**2160-7-13**]. Was given D5W to correct hypernatremia. HCO3
was given to correct acidemia. Had ? Pneumonia (RUL infiltrate)
and was treated Ceftriaxone 1g Q24 (co-coverage with UTI).
Extubated on [**2160-7-15**] and transferred to wards [**7-17**].
***No followup other than to be aware of potential of
respiratory distress in face of metabolic acidosis secondary to
diarrhea.
####################################
Hypotention: Pt repeatedly became intravascularly dry. Was
given NS and 50g albumin bolus as needed to maintain BP > 80.
***Monitor BP, give fluids and albumin as needed, pt tends to be
intravascularly dry and needs constant albumin to avoid
hepatorenal syndrome exacerbation.
####################################
Metabolic Acidosis: Pt was constantly acidotic early in hospital
course possibly leading to respiratory distress secondary
possibly to persistent diarrhea. Pt was repeatedly given HCO3
to correct acidosis up to [**2160-7-24**], placed on NaHCO3 tabs,
3x650mg tabs [**Hospital1 **] [**2160-7-24**] - [**2160-7-26**], and now Sodium Citrate, 30ml
QID which seems to have maintained a good HCO3 / pH range.
*** Continue Sodium Citrate 30ml PO QID
####################################
Renal Failure:
Pentoxyfylline 400mg PO TID starting [**7-11**]
Cr began to increase on [**2160-7-15**]. Was worked up ? ARF, RTA, HRS.
Urine Na < 10 and other tests made HRS most likely, pt treated
on octreotide (200 mcg SC Q8H [**7-17**]-present) and midodrine (7.5
mg PO TID [**Date range (1) 58025**], 10 mg PO TID ([**2160-7-19**] - [**2160-7-29**]), 15
mg PO TID ([**2160-7-30**]-present). Creatine continued to increase as
did BUN and hemodialysis was being considered for some time but
was not yet warranted. Both Cr and BUN have recently begun to
decrease
*** Monitor Creatinine, continue midodrine 15mg PO TID,
Octreotide 200mcg SC Q8H, Pentoxifylline 400mg PO TID
####################################
Leukocytosis: Pt had 2 episodes of leukocytosis, first in the
MICU ([**2160-7-12**] - [**2160-7-15**]) where the WBC went up to 29 with 80%PMN.
Pt was worked up for SBP, C. Difficile, blood infection, urine
infection, all negative, but was regardless emperically treated
with Flagyl 500mg Q8, Vancomycin 1gQ24 C. Diff and SBP
prophylaxis. Leukocytosis resolved without determination of
cause. Second episode of leukocytosis occured [**Date range (3) 58026**]
where WBC max = 30, 85% Neutriphils with toxic granulations.
Was worked up for renal and liver abscess, SBP, blood infection
(bacterial and fungal), GI infection (cdiff toxin A and B, O&P,
and cultures), GU infection, CXR, all with negative results
except persistent yeast infection in urine. Changed foley
catheter [**7-30**] and saw some decrease in yeast. Leukocytosis
seemed to self resolve by around [**2160-8-1**].
***Monitor WBC, UA, and blood cultures for possible infections,
pt likely to be somewhat immunocompromised.
####################################
UTI: Pt had foley catheter since admit. Enteroccocus UTI on
[**2160-7-15**]. Treated w/ Ceftriaxone 1g Q24H for 2 days ([**2160-7-15**] -
[**2160-7-17**]) and Ciprofloxacin PO Q24 (500mg [**2160-7-17**] - [**2160-7-21**],
250mg [**2160-7-21**] - [**2160-7-28**]). Persistant yeast found in urine to
date. Foley changed [**2160-7-30**].
*** Continue to follow for yeast and new bacterial infections.
####################################
Gluteal Sore: Gluteal sore secondary to repeated exposure to
fecal and urine materials. Recommendations include:
*** Apply Miconazole Powder 2% Applied TP TID ([**2160-7-9**]-present),
frequent cleaning of area with each bowel movement, encourage
use of bed pan if rectal tube falls out, encourage pt to turn
Q2hrs, clean perianal area, apply powder and Bard Double Guard
Moisture barrier ointment.
####################################
Activity: [**Date range (1) 32318**] - in restraints, secondary to encephalopathic
uncontrolled actions
[**Date range (1) 19818**] - bed
[**7-22**]. Pt began to be mobile with assistance. Would sit in
chair each day and could walk small steps with walker.
**Continues PT therapy as tolerated
####################################
Nutrition: Switch TPN to NGT, post-pyloric tube placed [**7-11**].
Deiner -> Probalance @ 55cc/hour ([**Date range (1) 20176**]) and 45cc/hr
([**Date range (1) 58027**]) -> Criticare at 60cc/hr ([**2160-7-29**]-present). Pt
began PO [**2160-7-21**] but has low intake to date and requires
supplemental TF.Pt has had incontinence tube and diarrhea since
admit.
***Diarrhea has been becoming worse recently (1-2L/day). [**Month (only) 116**] be
due to intestinal wall edema malabsorbtion, less likely
infectious etiology. [**Month (only) 116**] need to consider TPN if diarrhea can
not be improved. Otherwise follow attached nutritional
recommendations
####################################
Electrolytes: Corrected as needed (especially K+).
***Pt currently on CaCO3 500mg PO/NG TID, monitor K+ [**Hospital1 **], Pt has
needed upwards of 80-120meq K+ recently.
####################################
***Pneumoboots and Pantoprazole 40mg PO Q24H for DVT and GI
ulcer prophylaxis
####################################
Access: PICC Line right antecub
####################################
Communication: Husband [**Name (NI) **] [**Name (NI) 58028**] (H) [**Telephone/Fax (1) 58029**] (W)
[**Telephone/Fax (1) 58030**]
Medications on Admission:
MEDS AT HOME:
protonix 40 QD
propranolol 10 mg QD
dexapro 40 QD
oxycodone prn
MEDS ON TRANSFER FROM ME:
TPN
calcium carbonate 500 mg TID
folic acid 1 mg QD
lactulose two teaspoons [**Hospital1 **]
MVI 1 tab QD
pantoprazole 40 mg QD
pentoxifylline 400 mg TID
KCl 20 mEq QD
thiamine 100 mg QD
estradiol 300 mg TID
morphine sulfate 2-4 mg IV q2h prn
lorazepam 0.5 mg q6h prn
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection sliding scale.
4. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
8. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous
membrane TID (3 times a day).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QD (once a
day).
10. Octreotide Acetate 20 mg Kit Sig: Two Hundred (200) mcg
Intramuscular Q8H (every 8 hours): SC.
11. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
12. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO QID (4 times a day).
13. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
14. Midodrine HCl 5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
15. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
17. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO 1X/WEEK
(MO).
18. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Liver cirrhosis, Liver failure, Hepato-renal syndrome, Hepatic
encephalopathy
Discharge Condition:
Pt is stable for transfer, but with clinically poor prognosis.
Discharge Instructions:
Continue Pt on current medication regimen. Monitor serum
potassium levels, as they have been fluctuating with diarrhea.
Nutritional-I/O needs need to be assessed daily given diarrhea,
recommendations attached. Monitor BUN/Cr as Pt has hepato-renal
syndrome. See Discharge summary for further information and
instructions.
Followup Instructions:
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] [**Telephone/Fax (1) 58031**] [**Hospital **] HOSPITAL
|
[
"276.2",
"276.0",
"572.2",
"112.2",
"486",
"707.0",
"571.2",
"599.0",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.71",
"54.91",
"99.07",
"96.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
18610, 18625
|
7130, 16530
|
337, 343
|
18747, 18811
|
2919, 7107
|
19184, 19301
|
2380, 2443
|
16954, 18587
|
18646, 18726
|
16556, 16931
|
18835, 19161
|
2458, 2458
|
268, 299
|
371, 1974
|
2472, 2900
|
1996, 2151
|
2167, 2364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,359
| 183,649
|
47223
|
Discharge summary
|
report
|
Admission Date: [**2194-11-25**] Discharge Date: [**2194-12-1**]
Date of Birth: [**2131-8-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Shortness of Breath
Fatigue
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
63 year-old man with a history of obesity, longstanding
hypertension, diastolic heart failure with preserved LVEF,
anemia, mild chronic kidney disease, hyperparathyroidism, and
MGUS who has felt sick for 1 week with shortness of breath. He
states that over the past week he has been increasingly dyspneic
and fatigued. He also was experiencing dyspnea on exertion,
paroxysmal nocturnal dyspnea and orthopnea. He also noted chills
and cough productive of white yellow sputum and decreased
energy. He denied fever. He was unable to assess his ankle
swelling and does not check his weight. He also stated that he
had been eating a diet of "junk food" which is baseline for him.
He had been admitted for CHF in [**2190**], otherwise his CHF had been
relatively well controlled on his home medication.
.
On presentation to the ED his vitals were T 98.2, HR 65, BP
97/62, RR 20, Sat 92% RA. He denied CP, numbness, tingling. He
appeared fluid overloaded but had SBP 90-100, so the ED gave 500
cc bolus and then Lasix 60mg IV. He was also given an ASA 81mg.
He had a CXR which showed no acute process. D dimer was
negative. BNP 5088.
.
Initially on the floor his vital signs were T 96.9, BP 148/97,
HR 71, RR 22, SpO2 93% 3L NC, 152.9kg (335 lbs). Over the next
several hours he became progressively more lethargic, and was
found to have an oxygen saturation of 80% on 3L. On a NRB his
oxygen saturation improved to 91%. He was given an additional
40mg of IV lasix with minimal improvement. His ABG revealed a pH
of 7.21 and a pCO2 of 111
.
On review of systems, he has had a history fo bleeding at time
of surgery, but denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, 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 were negative.
.
Cardiac review of systems is notable for absence of chest pain,
orthopnea, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Rt heart failure with diastolic dysfunction
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
MGUS
Acquired [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Disease
H/O RESPIRATORY FAILURE
H/O RT HEART FAILURE
Diastolic dysfunction.
H/O MORBID OBESITY
RENAL INSUFFICIENCY
FACTOR VIII DEFICIENCY
ERECTILE DIFFICULTY
MONOCLONAL GAMMOPATHY
HYPERTENSION
IRON DEFICIENCY ANEMIA
h/o ugi bleed from AV malformation seen on endoscopy 08.
PROBLEMS WITH BALANCE
SECONDARY HYPERPARATHYROIDISM
+Lupus anticoagulant
Social History:
Quit smoking in [**2190**] (20 pack year history of smoking), denies
alcohol or drug abuse.
Family History:
Significant for cancer and sickle cell trait
Physical Exam:
VS: 100.2 96/55 70 20 92/RA
GENERAL: Obese man, mildly uncomfortable. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVP hard to assess
CARDIAC: Distant heart sounds. PMI located in 5th intercostal
space, midclavicular line. RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Shallow breaths, minimal breath sounds. No crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Dry lower extremities.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
[**2194-11-25**] 10:10AM BLOOD WBC-4.2 RBC-5.12 Hgb-13.4* Hct-41.4
MCV-81* MCH-26.2* MCHC-32.3 RDW-15.6* Plt Ct-206
[**2194-11-25**] 10:10AM BLOOD proBNP-5088*
[**2194-11-25**] 10:10AM BLOOD cTropnT-<0.01
[**2194-11-26**] 02:36AM BLOOD CK-MB-4 cTropnT-<0.01
[**2194-11-25**] 10:07PM BLOOD Type-ART pO2-81* pCO2-111* pH-7.21*
calTCO2-47* Base XS-11
[**2194-11-26**] 03:07AM BLOOD Type-ART pO2-68* pCO2-65* pH-7.38
calTCO2-40* Base XS-9
[**2194-11-26**] 11:45AM BLOOD Type-ART pO2-80* pCO2-89* pH-7.28*
calTCO2-44* Base XS-11
[**2194-11-26**] 01:20PM BLOOD Type-ART FiO2-45 pO2-69* pCO2-92*
pH-7.28* calTCO2-45* Base XS-12 Intubat-INTUBATED
Vent-SPONTANEOU
[**2194-11-26**] 05:07PM BLOOD Type-ART Temp-38.4 pO2-123* pCO2-57*
pH-7.42 calTCO2-38* Base XS-10 Intubat-INTUBATED
[**2194-11-26**] 06:54PM BLOOD Type-ART Temp-38.3 pO2-65* pCO2-52*
pH-7.44 calTCO2-36* Base XS-9
[**2194-11-26**] 08:36PM BLOOD Type-ART Temp-38.5 Rates-22/ Tidal V-550
PEEP-5 FiO2-35 pO2-72* pCO2-53* pH-7.42 calTCO2-36* Base XS-7
-ASSIST/CON Intubat-INTUBATED
CXR admission: FINDINGS: A portable upright AP view of the chest
was obtained. There are low lung volumes resulting in vascular
crowding. There is no focal consolidation, effusion, or
pneumothorax. The heart is slightly enlarged. Osseous structures
are intact. No free air is seen below the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
CXR [**11-25**]
ET tube in standard placement, tip no less than 4 cm from the
carina. Heart is moderately enlarged. Heterogeneous
opacification in the left lower lung could be pneumonia. Right
lung is clear. There is no pulmonary edema. Pleural effusion on
the left is likely, small-to-moderate. None on the right.
Nasogastric tube passes below the diaphragm and out of view. No
pneumothorax.
CXR [**11-30**]
Cardiomegaly is stable. There is mild vascular congestion. There
is no
pneumothorax or pleural effusion. Atelectasis in the right upper
lobe and
left lower lobe has resolved.
Brief Hospital Course:
Mr. [**Known lastname 99999**] was a 63 year-old man with multiple medical problems
including obesity, diastolic congestive heart failure, CRI, vWD
([**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] disease) who presented after a week of increased
fatigue and shrotness of breath.
.
# Dyspnea: Mr. [**Known lastname 99999**] was admitted to the cardiology service
for presumed decompensated congestive heart failure. Soon after
admission, he became obtunded and was found to be in hypercarbic
respiratory failure with a pCO2 of 111. He was intubated and
transfered to the CCU. There, he was diuresed with minimal
improvement in his symptoms. A chest X-ray obtained post
intubation was concerning for pneumonia and he was started on
ceftriaxone and azithromycin on hospital day 2 ([**11-26**].) Attempts
to wean him from the ventilator initially failed secondary to
hypoventilation. He was transfered to the MICU where he
recovered well and was successfully extubated. He was
subsequently transfered to the general medicine floor where he
did well though he continued to have desaturations. On the 5th
hospital day, his antibiotic regimen was expanded to include
vancomycin for the treatment of VAP and levofloxacin, which
replaced ceftiaxone and azithromycin. He was also provided a
trial of CPAP overnight to treat his suspected obstructive sleep
apnea. He reported that he tolerated the CPAP well and felt that
he experienced longer sleep intervals. In review of his medical
record on the 6th hospital day, it was determined that Mr.
[**Known lastname 99999**] had evidence of pneumonia prior to intubation and
therefore did not need continued treatment with vancomycin and
it was discontinued. In addition, the sputum culture obtained by
endotracheal sampling in the ICU revealed polymicrobial gram
stain but only rare gram negative rod growth.
He remained afebrile on the medicine floor and was evaluated
by the physical therapy service. He was observed to desaturate
to 85% on ambulation, and it was determined that he would
benefit from home oxygen therapy. He was discharged with oxygen
therapy for home and a prescription of levofloxacin to complete
a 7 day course of therapy.
# Acute on chronic renal failure: Mr. [**Known lastname 99999**] had a baseline
creatinine of 1.6. After diuresis his creatinine rose to 3.0 and
gradually returned to baseline. Upon discharge his creatinine
was 1.5.
# Obesity Hypoventilation: Mr. [**Known lastname 99999**] was morbidly obese with
chest wall compliance limited secondary to body habitus.
# Chronic Diastolic Heart Failure: His right sided heart failure
likely contributes to his respiratory dysfunction. He has mild
pulmonary hypertension on echocardiogram from 3/[**2194**].
# HTN: He was continued on carvedilolol throughout his
admission. Lasix and lisinopril were held while his creatinine
was elevated.
# VWD: Continued on home dose of aminocaproic acid
Medications on Admission:
aminocaproic acid [AMICAR]as needed for uncontrolled bleeding
carvedilol 25 mg Tablet [**Hospital1 **]
furosemide 40 mg Tablet daily
lisinopril 10 mg Tablet daily
sildenafil 100 mg Tablet 1/4-1 tab daily as needed
B complex vitamins [B Complex] 1 capsule daily
Calcium 600 + D(3) 600 mg (1,500 mg)-200 unit [**Unit Number **] tab daily.
Discharge Medications:
1. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
2. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. aminocaproic acid Oral
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. sildenafil Oral
7. B Complex Oral
8. Calcium 500 + D (D3) Oral
9. Home Oxygen
Please start at 1L O2 at rest and 3L O2 with activity adjusting.
Please evaluate for a pulse dose. Target SpO2 above 90%
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Pneumonia
Hypercarbic Respiratory Failure
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 shortness of breath and
fatigue. You were evaluated and treated by the medicine service.
You were given medications to help your breathing and you
required the aid of a breathing machine for one day. You were
found to have a pneumonia and received antibiotics that helped
your breathing.
The following changes have been made to your medications:
1. You have been STARTED on Levofloxacin 500mg daily for 3 days
(7 total days of treatment)
No other changes have made to your home medications.
Please take your medications as prescribed and keep your
outpatient appointments.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2194-12-4**] at 4:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2194-12-4**] at 4:30 PM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2194-12-4**] at 4:30 PM
With: DR. [**Last Name (STitle) 4013**]/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: [**Hospital1 7975**] INTERNAL MEDICINE
When: FRIDAY [**2194-12-5**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"428.0",
"585.2",
"518.81",
"278.01",
"272.4",
"286.4",
"403.90",
"428.33",
"584.9",
"486",
"416.8",
"278.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9895, 9952
|
6008, 8936
|
343, 369
|
10038, 10038
|
4005, 5985
|
10827, 11792
|
3187, 3233
|
9323, 9872
|
9973, 10017
|
8962, 9300
|
10189, 10804
|
3248, 3986
|
2485, 2603
|
276, 305
|
397, 2391
|
10053, 10165
|
2634, 3061
|
2413, 2465
|
3077, 3171
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,459
| 119,685
|
49604
|
Discharge summary
|
report
|
Admission Date: [**2197-5-4**] Discharge Date: [**2197-5-9**]
Date of Birth: [**2113-9-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Hydralazine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
VF arrest after hemodialysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname 1826**] is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 664**] 83 yo who
is s/p bioprosthetic AVR [**4-11**] who was readmitted post op with
rapid atrial fibrillation. She was seen by EP due to
tachy/brady
syndrome and started on norpace for control of afib. She was
discharged back to rehab and has been progressing well. Today
she was at dialysis and was waiting for transportation after
completion of her session when she developed cardiac arrest.
Her
rhythm was VF and recieved CPR and 1 shock from an AED with
return to SR. She was transported to an outside hospital where
her K was 3.2, she was hemodynamically stable with no further
arrhythmias, she was started on amiodarone and was transferred
to
[**Hospital1 18**].
Past Medical History:
Aortic Stenosis, s/p AVR [**2197-4-11**]
readmitted with dysrhythmias
PMH:
ESRD secondary to Pauci-immune Crescentric Glomerulonephritis
from hydralazine, on HD since [**Month (only) 205**] (Tu, Th, Sa)
Paroxysmal AFib/Aflutter in [**8-6**] during acute renal failure,
loculated pericardial effusion
Steal Syndrome from AV fistula
Hypertension
Dyslipidemia
GERD
Gout
Age-related Macula Degeneration
Social History:
-Lives alone, independent in most ADLs, but daughter assists
with shopping and some meals
-Tobacco: none
-Alcohol: none
-Illicits: none
Family History:
-Father: died at 80 of "[**Last Name **] problem"
-Mother: died at 89 of "something with her heart"
-No history of rheumatologic illness, prostate, breast, ovarian,
or colon cancer.
Physical Exam:
Pulse:56 Resp:18 O2 sat:94 on 50% FM
B/P Right:146/52 Left:
Height: Weight:
General:
Skin: Dry [x] diffuse ecchymosis, intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs coarse rhonchi bilat[]
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact[x]
Pulses:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Pertinent Results:
[**2197-5-9**] 04:20AM BLOOD WBC-5.2 RBC-3.43* Hgb-10.4* Hct-32.5*
MCV-95 MCH-30.2 MCHC-31.8 RDW-19.2* Plt Ct-157
[**2197-5-8**] 05:40AM BLOOD WBC-5.3 RBC-3.37* Hgb-10.3* Hct-31.9*
MCV-95 MCH-30.5 MCHC-32.2 RDW-19.5* Plt Ct-148*
[**2197-5-9**] 04:20AM BLOOD Glucose-119* UreaN-50* Creat-3.0* Na-133
K-4.4 Cl-98 HCO3-24 AnGap-15
[**2197-5-8**] 05:40AM BLOOD UreaN-41* Creat-3.0* Na-135 K-4.3 Cl-98
[**2197-5-7**] 06:10AM BLOOD Glucose-115* UreaN-21* Creat-2.3* Na-136
K-4.5 Cl-98 HCO3-30 AnGap-13
[**2197-5-6**] 04:12AM BLOOD Glucose-116* UreaN-26* Creat-2.4* Na-135
K-4.3 Cl-101 HCO3-30 AnGap-8
[**2197-5-8**] 05:40AM BLOOD ALT-35 AST-25 LD(LDH)-231 AlkPhos-132*
TotBili-0.3
[**2197-5-5**] 04:10AM BLOOD ALT-101* AST-155* AlkPhos-168* Amylase-55
TotBili-0.4
[**2197-5-9**] 04:20AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.3
[**2197-5-8**] 05:40AM BLOOD Albumin-3.1* Mg-1.8
[**2197-5-7**] 06:10AM BLOOD Mg-2.1
Brief Hospital Course:
EP consulted and determined that the most likely explanation is
a Torsade arrest precipitated by electrolyte shifts and
bradycardia in the setting of disopyramide therapy. Amiodarone
was discontinued and electrolytes were monitored and optimized.
Norpace was allowed to "washout" and no further nodal agents
were administered.
Renal was consulted for management of hemodialysis.
She remained hemodynamically stable and was discharged back to
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Rehab on hospital day 6.
Medications on Admission:
colace 100mg twice daily
simvastatin 10mg daily
aspirin 81mg daily
amlodipine 10mg daily
prilosec 20mg twice daily
nephrocaps 1 cap daily
clonidine 0.1 mg three times daily
disopyramide 150mg twice daily
tylenol as needed
coumadin for afib
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: [**1-29**]
Tablet, Chewables PO QID (4 times a day) as needed for
heartburn.
8. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis, s/p AVR [**2197-4-11**]
readmitted with dysrhythmias
PMH:
ESRD secondary to Pauci-immune Crescentric Glomerulonephritis
from hydralazine, on HD since [**Month (only) 205**] (Tu, Th, Sa)
Paroxysmal AFib/Aflutter in [**8-6**] during acute renal failure,
loculated pericardial effusion
Steal Syndrome from AV fistula
Hypertension
Dyslipidemia
GERD
Gout
Age-related Macula Degeneration
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace pedal edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Cardiac Surgery, Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time: [**Telephone/Fax (1) 170**] Date/Time:[**2197-5-30**] 3:00 in the [**Hospital Unit Name 3269**] [**Last Name (NamePattern1) **]
Cardiology, Provider: [**Name10 (NameIs) **] [**Name8 (MD) 10828**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**Telephone/Fax (1) 62**] Date/Time:[**2197-6-6**] 2:00 [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Follow-up with Renal for HD on Tues-[**Last Name (un) **]-Sat.
Please call to schedule the following:
Electrophysiology, Dr. [**Last Name (STitle) **] in 1 month [**Telephone/Fax (1) 62**]
Primary Care Dr. [**Last Name (STitle) 20009**],[**First Name3 (LF) 5557**] D. [**Telephone/Fax (1) 9347**] in [**5-2**] weeks
Labs: PT/INR
Coumadin for a-fib
Goal INR [**3-2**]
First draw [**2197-5-10**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by MD
**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:[**2197-5-9**]
|
[
"V42.2",
"285.9",
"996.73",
"274.9",
"585.6",
"427.31",
"403.91",
"427.5",
"362.50",
"276.1",
"E879.8",
"414.01",
"583.89",
"427.41",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5325, 5503
|
3439, 3975
|
339, 346
|
5946, 6130
|
2514, 3416
|
6918, 8148
|
1736, 1919
|
4266, 5302
|
5524, 5925
|
4001, 4243
|
6154, 6895
|
1934, 2495
|
270, 301
|
374, 1143
|
1165, 1566
|
1582, 1720
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,950
| 148,886
|
37633
|
Discharge summary
|
report
|
Admission Date: [**2101-10-5**] Discharge Date: [**2101-10-10**]
Date of Birth: [**2041-9-8**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Patient is a 60 yo RHW originally from [**Country 9819**] with HTN,
possible hypercholesterolemia, gout presents with a new left
basal ganglionic hemorrhage, transferred from [**Hospital 8**]
Hospital. Per patient, 2 days while
at PCP for routine [**Name9 (PRE) 16574**], she was found to have elevated SBP
of 224 hence she was sent to [**Hospital 8**] Hospital where she
received labetalol 100mg which brought down the BP to 190 then
sent home from the ED. Patient reports that she has brief L
frontal pressure-like HA after labetalol but none prior to the
medication.
Then the next morning, yesterday morning, she felt that she was
slurring her speech mildly with generalized fatigue and
weakness.
However, she denies any HA, focal weakness, numbness or visual
symptoms. She then returned to PCP's office this morning where
she again felt that she was slurring her speech then while in
the
bathroom of the PCP's office, patient felt weak and fell
backwards. She did not have LOC and did not hit her head but
she
was subsequently taken back to [**Hospital 8**] Hospital where she had
head CT which showed L BG bleed hence she was transferred here.
Upon arrival, her BP was again in 220's but patient refused
labetalol hence was started esmolol gtt prior to neurology
consult.
Patient denies any previous hx of stroke. She denies any trauma
or injury. ROS completely negative including chest pain,
palpitations, fever/chills, dysuria, N/V/D or sick contact.
[**Name (NI) **] than brief L frontal pressure pain after labetalol dose 2
days ago, no HA since or prior.
Of note, patient was scheduled to have renal biopsy for renal
insufficiency hence she was not taking any ASA but patient
reports not having taken ASA for a long time. Also, she reports
baseline SBP 160's.
Past Medical History:
1. HTN
2. Gout
3. Renal insufficiency
4. Gallstone
5. Anemia
Social History:
Lives with husband and 3 sons - originally from [**Country 9819**]. No hx
of tobacco, EtOH or illicit drug use.
Family History:
NC
Physical Exam:
T 98.3 BP 218/91 HR 66 RR 18 O2Sat 100% RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No carotid or vertebral bruit
CV: RRR, no murmurs/gallops/rubs
Lung: Clear
Abd: +BS, soft, nontender
Ext: No edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Mildly
inattentive, 2 mistakes with [**Doctor Last Name 1841**] backwards. Speech is fluent
with normal comprehension and repetition; naming intact.
Moderate
dysarthria. [**Location (un) **] intact. No right left confusion. No evidence
of apraxia or neglect.
Cranial Nerves:
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Fundoscopic
exam normal with sharp disc margins.
III, IV & VI: Extraocular movements intact bilaterally, no
nystagmus.
V: Sensation intact to LT and PP.
VII: Mild R NLF flattening at rest.
VIII: Hearing intact to finger rub bilaterally.
X: Palate elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline, movements intact
Motor:
Normal bulk and tone bilaterally. No observed myoclonus or
tremor. No asterixis but slight R pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, cold and
proprioception throughout but decreased vibration in both toes.
Reflexes:
+1 and symmetric for UEs and 2s for patellar and Achilles.
Toes downgoing bilaterally
Coordination: FTN, FTF and RAMs normal.
Gait: Deferred.
Pertinent Results:
[**2101-10-10**] 05:25AM BLOOD WBC-7.6 RBC-3.20* Hgb-8.5* Hct-26.6*
MCV-83 MCH-26.6* MCHC-31.9 RDW-14.2 Plt Ct-278
[**2101-10-5**] 02:50PM BLOOD Neuts-68.1 Lymphs-23.4 Monos-2.7 Eos-5.3*
Baso-0.4
[**2101-10-6**] 02:09AM BLOOD PT-12.5 PTT-26.4 INR(PT)-1.1
[**2101-10-10**] 05:25AM BLOOD Glucose-104 UreaN-59* Creat-2.7* Na-140
K-4.4 Cl-110* HCO3-17* AnGap-17
[**2101-10-7**] 03:31PM BLOOD ALT-10 AST-11 AlkPhos-91 Amylase-90
TotBili-0.3
[**2101-10-10**] 05:25AM BLOOD Calcium-9.0 Phos-5.2* Mg-2.0 Cholest-170
[**2101-10-8**] 06:50AM BLOOD calTIBC-285 Ferritn-71 TRF-219
[**2101-10-10**] 05:25AM BLOOD %HbA1c-6.3*
[**2101-10-10**] 05:25AM BLOOD Triglyc-134 HDL-40 CHOL/HD-4.3
LDLcalc-103
IMAGING
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2101-10-5**]
3:23 PM
HEAD CT WITHOUT IV CONTRAST: There is a 1.9 x 1.4 cm hemorrhage
involving the
left basal ganglia, predominantly the globus pallidus and
putamen (2:10).
There is surrounding edema and mass effect upon the sulci, with
no shift of
midline structures or herniation. No other site of hemorrhage is
identified.
The ventricles and sulci elsewhere appear normal in size and
configuration for
the patient's age. There is periventricular hypodensity,
consistent with
chronic small vessel ischemic disease. There are intracranial
vascular
calcifications. The visualized paranasal sinuses and soft
tissues appear
unremarkable.
IMPRESSION: Left basal ganglia hemorrhage in a configuration
most suggestive
of hypertensive hemorrhage. Less likely etiology includes
underlying mass
lesion. For which MRI could be considered when patient is
clinically stable.
Brief Hospital Course:
Ms. [**Known lastname 9590**] is a 60 year old right handed woman with a history of
hypertension and chronic kidney disease admitted for evaluation
and treatment of a left basal ganglion bleed.
# Basal Ganglionic Hemorrhage: The patient presented was
transferred from an OSH(on esmolol drip) with severely elevated
BP and L BG hemorrhage. She reports having slurred speech and
diffuse weakness since the morning prior to admission after
being treated at OSH ED for elevated SBP of 224 the day before.
She had a head CT which showed a 2 cm L basal ganglia
hemorrhage, most likely secondary to poorly controlled
hypertension. She was titrated off the esmolol drip, onto a
combination of PO labetolol and amlodipine. On the day of
discharge, blood pressures were well controlled, in the range of
120-140s. Ms. [**Known lastname 9590**] was instructed on the importance of
maintaining appropriate blood pressure control, to avoid similar
events in the future. She was evaluated by PT who cleared her
for discharge home. Exam on discharge was notable only for mild
right upper extremity weakness.
# CRI: On admission Ms. [**Known lastname 9590**] had known CRI, of unclear
etiology, which is undergoing evaluation as an outpatient. Her
lisinopril was held, and replaced with labetolol and amlodipine,
given concern for her kidney function. She was seen by
Nephrology while an inpatient, who recommended following a low
potassium diet. The patient will follow-up with Dr. [**Last Name (STitle) **] as an
outpatient for further management.
Medications on Admission:
1. Lisinopril 20mg daily
2. Colchicine PRN
3. Fe2+
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
Disp:*135 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Low potassium diet
Please pursue this diet under the direction of your nephrologist
Dr. [**Last Name (STitle) **]
Discharge Disposition:
Home
Discharge Diagnosis:
left basal ganglia hemorrhage
uncontrolled hypertension
chronic kidney disease
Discharge Condition:
Slight right hemiparesis (right deltoid [**5-1**]). R IP (5-/5), R
Hamstring (5-/5). Fluent speech. No dysnomia.
Discharge Instructions:
You were admitted for right sided weakness and found to have
bleeding within your brain. This was likely due to poorly
controlled blood pressure.
It is essential that you take your blood pressure medications
and see your doctor regularly for adjustments to them as
necessary. Please utilize a home blood pressure cuff for
monitoring at home and record regular measurements for review
with your primary care doctor.
Call 911 if you experience any sudden worsening of your
weakness, incoordination, difficulty understanding or producing
speech, double vision, loss of sensation or any other concerning
symptoms.
Followup Instructions:
Please see your primary care doctor this week.
You have an appointment to see Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in the stroke
neurology division for further care.
Appointment Date/Time: Monday, [**11-14**] at 1pm.
Office Phone: [**Telephone/Fax (1) 2574**]
Please see Dr. [**Last Name (STitle) **] for further care of your kidney problems.
[**Name (NI) **] will pursue a biopsy as previously scheduled.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"574.20",
"403.90",
"285.9",
"431",
"342.81",
"276.7",
"274.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7948, 7954
|
5745, 7291
|
320, 326
|
8077, 8192
|
4105, 5722
|
8852, 9400
|
2372, 2376
|
7393, 7925
|
7975, 8056
|
7317, 7370
|
8216, 8829
|
2391, 2611
|
277, 282
|
354, 2141
|
3021, 4086
|
2650, 3005
|
2635, 2635
|
2163, 2226
|
2242, 2356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,402
| 126,896
|
20901
|
Discharge summary
|
report
|
Admission Date: [**2102-6-13**] Discharge Date: [**2102-6-21**]
Date of Birth: [**2047-3-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
Pre-op for liver/kidney Tx with recent hospitalization for UGIB,
grade 1 varices, hepatorenal syndrome
Major Surgical or Invasive Procedure:
Liver and kidney transplant on [**2102-6-14**]
History of Present Illness:
55 y/o male with ESLD secondary to Hep C and ETOH cirrhosis
recently admitted in early [**Month (only) **] for an UGIB requiring blood
transfusions. Readmission on [**2102-6-5**] with pre-syncope most
likely related to intravascular volume depletion. Called in for
potential liver/kidney Tx on [**2102-6-13**]
Past Medical History:
Hepatitis C/ETOH induced cirrhosis
(SBP [**2100-1-7**], no variceal bleeds, EGD [**2101-10-19**] Grade 1 varices)
Mitral valve prolapse
Hypertension
Gout
Osteopenia
CKD - baseline creatinine 2.0
Anemia
UGIB [**5-30**]
Social History:
The pt denies current cigarette use, but reports smoking 10
cig/day for 20 years. He also quit drinking 1 [**12-26**] yr ago but
prior had drank for 23 years with 1 pint of gin or brandy a day.
He denies IVDU, but has snorted cocaine in the past. He works
at the JP VA currently and lives in the [**Location (un) 4398**] alone. His
sister is his HCP and is very supportive
Family History:
Father-HTN, MI in his 80s
Mother- "spine cancer"
Physical Exam:
On admission:
VS: 97.5, 89/55, 96, 18, 96% RA, 69 kg
In NAD
OMM, + icterus
Lungs CTA bilaterally
Cardio: RRR
Abd: + BS, + Ascites, Sl TTP RLQ (at baseline)
Trace LE edema
Pertinent Results:
Labs on discharge: [**2102-6-21**]
Na 140 K: 3.5 Cl:108 Co2: 27 BUN:15 Creat 0.8 Glucose:72
Ca: 7.6 Mg: 1.2 P: 2.6
AST: 64 ALT: 225 AP: 136 Tbili: 1.1 Alb: 2.2
UricA:3.6
WBC: 4.7 Hgb: 9.3 Hct: 27.0 Plt: 56
Labs on Admission: [**2102-6-13**]
GLUCOSE-91 UREA N-37* CREAT-2.9* SODIUM-136 POTASSIUM-4.1
CHLORIDE-110* TOTAL CO2-15* ANION GAP-15
ALT(SGPT)-43* AST(SGOT)-137* ALK PHOS-360* TOT BILI-3.3*
ALBUMIN-3.3* CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.7
WBC-6.3 RBC-2.85* HGB-8.9* HCT-25.9* MCV-91 MCH-31.1 MCHC-34.2
RDW-18.5*
PLT COUNT-82*
PT-16.3* PTT-35.1* INR(PT)-1.5*
FIBRINOGEN-102*
Brief Hospital Course:
Pt admitted from home for liver/kidney transplant.
-Orthotopic liver transplant, piggyback technique,
portal vein-to-portal vein, hepatic artery-to- hepatic artery
and bile duct-to-bile duct anastomoses.
-Right iliac fossa renal transplant with 6-French double-J
stent.
[**6-15**] Doppler for L arm swelling r/o dvt left upper extremity arm
swelling. No thrombus seen
Extubated on POD 2. Uneventful post-op course. Liver enzymes
trending down and creatinine down to baseline creat around 0.8
Medications on Admission:
Lactulose 30''', Allopurinol 100 qod, Colchicine 0.6, Atenolol
25, Omeprazole 20', Levo 250, simethicone 80'''', protonix 40'',
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 doses.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
S/P liver/kidney transplant for HCV/cirrhosis
Discharge Condition:
Good
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if you develop fever, chills, nausea,
vomiting, increased abdominal pain/discomfort, increased or
bloody drainage from wound sites or drain. Also call if you
notice a decrease in urine output or if you have
frequency,urgency or blood in your urine.
Lab tests every Monday and Thursday: CBC, Chem 10, Calcium,
Phos, AST, ALT, Alk Phos, T Bili, albumin, U/A and trough
Prograf level. Fax results to transplant office: [**Telephone/Fax (1) 697**]
Do not drive if using pain medications
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2102-6-26**] 10:30
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2102-7-3**] 8:50
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2102-7-10**] 9:10
Completed by:[**2102-7-10**]
|
[
"070.70",
"572.4",
"585.6",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"55.69",
"50.59",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
3799, 3857
|
2333, 2826
|
417, 466
|
3947, 3954
|
1714, 1714
|
4518, 4975
|
1457, 1507
|
3005, 3776
|
3878, 3926
|
2852, 2982
|
3978, 4495
|
1522, 1522
|
275, 379
|
1733, 1935
|
494, 805
|
1949, 2310
|
827, 1047
|
1063, 1441
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,251
| 144,310
|
31465
|
Discharge summary
|
report
|
Admission Date: [**2201-7-20**] Discharge Date: [**2201-8-6**]
Date of Birth: [**2126-1-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
SOB- presented to [**Hospital3 **] and found to have bilat
pleural effsuions. Attempted tap was unsuccessful.
Major Surgical or Invasive Procedure:
[**2201-7-21**] Transthoracic ultrasound. Right Pigtail chest tube
placement.
[**2201-7-21**] Transthoracic ultrasound. Left thoracentesis
[**2201-7-24**] 1) Right video-assisted thoracoscopy converted to right
thoracotomy, decortication of lung, along with pleural biopsy.
2)Diagnostic esophagogastroscopy. 3. Flexible bronchoscopy.
History of Present Illness:
75M w/AS, s/p aortic valve replacement (tissue) [**8-2**], CAD, AF on
coum-now held, CVA, CHF EF 45% w/SOB, bilateral pleural
effusions. Had unsuccessful thorocentesis @ [**Location (un) 620**], admitted
for possible pigtail placement. 30 pack year history, exposure
to asbestos, w/weightloss. Admitted for drainage of effusion and
diagnosis.
Past Medical History:
1. Aortic stenosis
2. A. fib
3. HTN
4. Hypercholesterolemia
5. h/o TIA (generalized weakness, diplopia, dysarthria) in
[**5-2**]
6. h/o stroke (R-sided paresthesias) in [**2186**]
7. h/o intermittent vertigo after L ear infection
7. h/o hernia repair
8. h/o L shoulder surgery
Social History:
Social history is significant for the 15 pack years, quit 37
years ago. He has 1 beer/day. He denies recreational drug use.
Family History:
Father died of stroke in his 40s. Brother has HTN and MS. Pt
is unaware of h/o MI, SCD.
Physical Exam:
On discharge:
Vital: 97.8 97.8 78 141/72 18 98% 2L NC
NAD, alert
Regular rate, afib
Lungs clear with dry crackles R upper lung fields
Abdomin soft, non-tender
Chest tube, thoracotomy sites clean, dry, intact
+1 leg edema
Pertinent Results:
[**2201-8-5**] WBC-10.5 RBC-3.40* Hgb-9.1* Hct-28.5* Plt Ct-356
[**2201-8-4**] WBC-14.4* RBC-3.40* Hgb-9.2* Hct-28.9* Plt Ct-333
[**2201-7-29**] WBC-9.7 RBC-2.91* Hgb-7.8* Hct-24.1* Plt Ct-330
[**2201-7-20**] WBC-8.9 RBC-4.05* Hgb-10.8* Hct-33.2* Plt Ct-325
[**2201-8-5**] Glucose-92 UreaN-8 Creat-0.6 Na-137 K-4.2 Cl-100
HCO3-27
[**2201-7-20**] Glucose-142* UreaN-22* Creat-1.0 Na-136 K-4.1 Cl-96
HCO3-31
Micro:
[**2201-7-31**] URINE Source: Catheter. FINAL REPORT [**2201-8-2**]**
URINE CULTURE (Final [**2201-8-2**]):
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2201-8-6**] 07:03AM BLOOD WBC-9.8 RBC-3.32* Hgb-8.9* Hct-27.7*
MCV-83 MCH-26.6* MCHC-32.0 RDW-16.4* Plt Ct-360
[**2201-8-6**] 07:58AM BLOOD PT-19.3* INR(PT)-1.8*
[**2201-8-6**] 07:03AM BLOOD Glucose-84 UreaN-6 Creat-0.6 Na-133 K-3.7
Cl-98 HCO3-29 AnGap-10
Brief Hospital Course:
Pt was admitted and underwent a right pigtail catheter
placemment for a moderate amount bloody fluid and left
thoracentesis for 1100cc of serosang fluid.
On [**7-22**], the patient experienced hypotension with systolic
pressure dropping the high 60s. He responded to fluid
resuscitation. EKG and cardiac enzymes were normal. Creatinine
also was elevated but also responded to fluids. He was
maintained on a heparin drip.
A chest CT revealed a trapped right lung with pleural band mass.
On [**2201-7-24**] he underwent Right video-assisted thoracoscopy
converted to right thoracotomy, decortication of lung, along
with pleural biopsy and Diagnostic esophagogastroscopy. He was
transferred to the ICU and remained intubate. He was
subsequently extubated without incident in the ICU. He received
1 unit of PRBCs for a low hematocrit.
He was transferred to the floor on [**2201-7-27**]. Physical therapy
evaluated the patient on [**7-27**] and deemed the patient appropriate
for rehab at discharge. A CT guided pigtail was placed on [**7-29**]
for a continued pleural effusion. He was treated for a UTI from
cultures on [**2201-7-31**].
On [**7-31**] the patient had a large tarry guaiac positive bowel
movement. He was transfused 2 units and maintained his
hematocrit. GI was consulted and recommended colonscopy, [**Hospital1 **] PPI
and EGD. Anticoagulation was held. Hematocrit remained stable.
The patient was also transfused on [**8-3**] for a chronically low
hematocrit. All chest tubes and pigtails were removed over the
course of several days.
On [**8-6**], the patient was sent for colonoscopy and EGD. He
refused these studies. He was extensively counseled on the
risks of not performing these studies, the risk being GI
bleeding. He was also was told and acknowledged that this would
limit his ability to be anticoagulated at this time. He was
informed of his risk for stroke with a history of atrial
fibrillation and continued to defers the study.
Both the patient's wife and cardiologist Dr. [**Last Name (STitle) 10543**] were informed
of his decision. He will follow-up with Dr. [**Last Name (STitle) 10543**] in 1 week to
discuss further anticoagulation.
Medications on Admission:
lidocaine patch one patch topically to the left shoulder 12
hours on and 12 hours off, Coumadin as directed, Refresh Tears
eye drops to both eyes as needed for dry eyes, Toprol-XL 200 mg
daily, levothyroxine 25 mcg daily, Lasix 40 mg daily, Zocor 10
mg at bedtime, enalapril 10 mg daily, multivitamin with minerals
one tablet daily, Tylenol 1000 mg four times a day, Flomax 0.4
mg at bedtime, Lexapro 10 mg daily, milk of magnesia PRN,
bisacodyl PRN, Fleet enema PRN.
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Levothyroxine 50 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
8. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: One (1) PO Q8H (every 8 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Bilateral pleural Effusions
Aortic Stenosis s/p valve replacement in [**8-2**], atrial
fibrillation, CHF EF 45%, CVA [**2186**] on warfarin, Hyperlipidemia,
HTN, Hypothyroidism
Guaiac positive stools
PSH: s/p rotator cuff repair, CAD two-vessel disease, s/p knee
replacement in [**2200-12-26**].
Discharge Condition:
Deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills, Increased cough or shortness of breath
-Chest pain, Incision develops drainage.
-Chest-tube site cover site with a bandaid until healed
You may shower: No tub bathing or swimming for 6 weeks
Hold coumadin until seen by Dr. [**Last Name (STitle) 10543**] in 1 week.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**2204-8-17**]:00 am on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
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) **]. [**Last Name (STitle) 10543**] [**Telephone/Fax (1) 4475**] for restart of
coumadin
Completed by:[**2201-8-6**]
|
[
"599.0",
"V64.42",
"041.6",
"244.9",
"428.0",
"438.20",
"427.31",
"272.0",
"276.51",
"584.9",
"511.0",
"V58.61",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"42.23",
"88.73",
"99.04",
"33.22",
"34.24",
"03.91",
"34.51",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
7209, 7286
|
3214, 5394
|
384, 720
|
7626, 7642
|
1912, 3191
|
8059, 8523
|
1562, 1653
|
5912, 7186
|
7307, 7605
|
5420, 5889
|
7666, 8036
|
1668, 1668
|
1683, 1893
|
235, 346
|
748, 1092
|
1114, 1401
|
1417, 1546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,965
| 144,161
|
51656
|
Discharge summary
|
report
|
Admission Date: [**2198-3-26**] Discharge Date: [**2198-4-4**]
Date of Birth: [**2163-10-28**] Sex: M
HISTORY OF PRESENT ILLNESS: This is a 34-year-old gentleman
with a history of end-stage renal disease who is now status
post living-related kidney transplant. This kidney
transplant was performed on [**2196-3-2**]. He had been
On the day of admission, a donor organ had become available,
and Mr. [**Known lastname **] was selected to be the recipient.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2195-5-21**].
3. Hypertension.
4. Diabetic neuropathy.
5. Diabetic retinopathy.
MEDICATIONS ON ADMISSION: Medications on admission included
Prograf 2 mg p.o. q.a.m. and 3 mg p.o. q.p.m.,
metoprolol 50 mg p.o. b.i.d., Norvasc 2.5 mg p.o. q.d.,
Zantac 150 mg p.o. q.d., prednisone 7.5 mg p.o. q.d.,
Zestril 7.5 mg p.o. q.h.s., amitriptyline 25 mg p.o. q.h.s.,
nortriptyline 100 mg p.o. q.d.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count of 13.3, hematocrit of 45.3, platelets of 245.
Chemistries were sodium of 138, potassium of 4.8, chloride
of 99, bicarbonate of 30, blood urea nitrogen of 27,
creatinine of 1.3, blood sugar of 263.
HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to [**Hospital1 346**] on [**2-24**].
Early in the morning on [**2198-2-25**], he was brought to the
operating room and had a cadaveric pancreas transplant. The
operation was performed by Dr. [**Last Name (STitle) **] and assisted by
Dr. [**Last Name (STitle) 13853**] and Dr. [**First Name (STitle) **]. The procedure was performed under
general endotracheal anesthesia and was performed with an
accompanying 300-cc blood loss.
The operation was uncomplicated. The patient tolerated the
procedure well and was then transported to the Surgical
Intensive Care Unit. Please see previously dictated
Operative Note for more details.
Mr. [**Known lastname 107028**] hospital course was complicated by an episode of
sudden hypotension immediately postoperatively and he was taken
back to the operating room. An exploratory laparotomy was
performed where no evidence of active bleeding was found. He
received 2 liters of crystalloid and 1 unit of packed red blood
cells in the operating room. His abdomen was
closed, and he was transferred to the Surgical Intensive Care
Unit in stable condition.
Mr. [**Known lastname **] was extubated in the Surgical Intensive Care Unit
on postoperative day one and transferred to the patient care
floor on postoperative day two.
His nasogastric tube "fell out" on postoperative day three.
Also, on postoperative day three, his [**Location (un) 1661**]-[**Location (un) 1662**] drain was
removed.
By postoperative day four, the patient was started on a diet
of sips. On postoperative day seven, the patient was
tolerating a regular diet.
The [**Hospital 228**] hospital course was complicated by feelings of
"bloatedness and heaviness" in his lower abdomen. This was
accompanied by a fullness in his lower abdomen. He was
treated with enemas and continued to have bowel movements
during the hospitalization, and it was felt as though his
distention was in fact unchanged from his preoperative
baseline.
On postoperative day eight, the patient had a low-grade fever
with a temperature maximum of 100.5 degrees Fahrenheit. His
temperature was accompanied by the feeling of general
malaise. Because of the early removal of the nasogastric
tube, the timing from the operation of his symptoms, it was
thought prudent to rule out an anastomotic leak. A CT scan
of the abdomen with oral contrast was performed on
postoperative day nine. This showed no evidence of either
leak or abscess. At this point, the patient was tolerating
p.o., had been afebrile for over 24 hours, and had no further
symptoms. The decision was made to send him home.
DISCHARGE STATUS: Discharge disposition was to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES:
1. Status post cadaveric pancreas-after-kidney transplant.
2. Status post exploratory laparotomy for hypotension.
MEDICATIONS ON DISCHARGE:
1. FK-506 2 mg q.a.m. and 3 mg q.p.m.
2. Rapamune 5 mg p.o. q.d.
3. Prednisone 20 mg p.o. q.d.
4. Bactrim 1 tablet p.o. q.d.
5. Nystatin swish-and-swallow p.o. q.d.
6. Lopressor 50 mg p.o. b.i.d.
7. Zestril 5 mg p.o. q.d.
8. Protonix 40 mg p.o. q.d.
9. Colace 100 mg p.o. b.i.d.
10. Aspirin 325 mg p.o. q.d.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) **] in the clinic. Followup has already been arranged.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2198-4-5**] 19:14
T: [**2198-4-7**] 07:25
JOB#: [**Job Number 107029**]
|
[
"458.2",
"250.51",
"250.61",
"362.01",
"V45.81",
"401.9",
"V42.0",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.80",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
4018, 4135
|
4162, 4489
|
684, 1234
|
1253, 3946
|
3961, 3997
|
4511, 4902
|
147, 475
|
497, 657
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,568
| 108,541
|
45164
|
Discharge summary
|
report
|
Admission Date: [**2112-9-3**] Discharge Date: [**2112-9-12**]
Service: MEDICINE
Allergies:
Halothane
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hip fx
Major Surgical or Invasive Procedure:
-R ORIF
-L cordis placed and d/c'd prior to transfer
History of Present Illness:
Pt is a [**Age over 90 **] year old man with a history of CAD, HTN, A Fib, CVA
who presents status post fall. Pt was ambulating with walker in
nursing home and had an unwitnessed fall. Pt is a poor
historian and can't relate details of fall. Pt apparently
tripped and fell backwards landing on his right side. There was
no loss of consciousness, no chest pain. Pt presented with pain
in right arm and right hip pain.
.
In the [**Name (NI) **], pt's vitals were 97.1, 134/52, 66, 20, 93% on RA. Pt
was given Morphine 4 mg IV, Dilaudid 0.5 mg IV for pain relief.
Pt voided and a foley was placed. Pt was started on 2L O2
w/nasal canula. Pt placed in right arm sling. No acute
intracranial hemorrhage is identified on CT. No acute cervical
pathology including no fracture on CT c-spine. Humerus xrays
showed impacted comminuted fracture of the surgical neck of the
right humerus with overriding of the fracture fragments. Pelvis
xrays showed a cervical fracture of the right femur.
Past Medical History:
1. CAD s/p 3 vessel CABG in [**2096**]
- Last stress was [**6-/2102**] which showed moderate reversible
perfusion defects in the inferior, inferolateral, and posterior
walls
- Last echo was [**7-3**] LVEF of 35%, [**2-2**]+ AR, 3+ MR, and [**2-2**]+ TR
2. HTN
3. Hypercholesterolemia
4. Hypothyroidism
5. Macular degeneration
6. Small brainstem/cerebellar CVA- [**7-3**]
7. s/p hip replacement
8. CRI (creat 2.0-2.6)
9. A fib --> on coumadin
Social History:
Currently living at [**Location (un) 5481**] [**Hospital3 **]. Denies EtOH,
tobacco, or drug use.
Family History:
NC
Physical Exam:
Vitals: 95.1, 92, 119/42, 22, 93%
Gen: NAD, alert
HEENT: perrla, eomi, ncat, c-collar in place, op clear
Resp: ctab, no crepitus
Card: RRR, +S3 vs mechanical click
ABD: soft, nt, nd
EXT: + pain with flexion/rotation of right hip, limited rom
right hip, increased pain at right shoulder, 2+ pulses,
Skin: warm, dry
Neuro: CN 2-12 intact
Pertinent Results:
Admission Labs:
[**2112-9-3**] 11:50AM BLOOD WBC-18.0*# RBC-3.91* Hgb-10.8* Hct-31.8*
MCV-81* MCH-27.6 MCHC-34.0 RDW-16.7* Plt Ct-421
[**2112-9-3**] 11:50AM BLOOD PT-17.1* PTT-32.8 INR(PT)-1.6*
[**2112-9-3**] 11:50AM BLOOD Glucose-148* UreaN-67* Creat-2.0* Na-137
K-4.2 Cl-97 HCO3-28 AnGap-16
Discharge Labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2112-9-12**] 04:17AM 11.1* 3.29* 9.7* 29.1* 88 29.6 33.5 17.5*
433
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2112-9-12**] 04:17AM 156* 45* 1.2 143 3.9 113* 23 11
.
.
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT [**2112-9-3**] 3:13 PM
Impacted, comminuted fracture of the surgical neck of the
proximal humerus, with overriding and angulation of the distal
fracture fragment. The fracture component involves the base of
the greater tuberosity, but may not be complete.
.
ELBOW (AP, LAT & OBLIQUE) RIGHT [**2112-9-3**] 11:58 AM
Impacted comminuted fracture of the surgical neck of the right
humerus with overriding of the fracture fragments.
.
CHEST (SINGLE VIEW) [**2112-9-3**] 11:58 AM
1. Cardiomegaly.
2. Large left thyroid mass extending into the mediastinum better
seen on recent CT.
3. No pneumonia or CHF.
.
PELVIS (AP ONLY),KNEE (2 VIEWS) RIGHT [**2112-9-3**] 11:59 PM
1. Cervical fracture of the right femur.
2. Linear lucency along the prosthetic bone interface of the
left hip prosthesis femoral component, not fully evaluated on
this radiographs. A dedicated study is recommended to rule out
loosening.
3. Small right knee joint effusion.
.
CT HEAD W/O CONTRAST [**2112-9-3**] 12:05 PM
1. No acute intracranial hemorrhage is identified.
2. The left frontal meningioma is unchanged in size, however,
demonstrates interval increase in density, most likely related
to interval calcification.
3. Encephalomalacia of the right occipital lobe consistent with
the patient's history of infarction in this area.
.
CT C-SPINE W/O CONTRAST [**2112-9-3**] 12:06 PM
1. No acute cervical pathology including no fracture.
2. Unchanged appearance of anterolisthesis of C4 over C5,
probably degenerative.
3. Multilevel degenerative changes of the cervical spine as
mentioned in the body of the report.
4. Large thyroid goiter with extension to superior mediatinum.
CT chest can help for further assessment.
.
[**2112-9-5**]: Hip films:
FINDINGS: There is a left bipolar prosthesis seen without
evidence of hardware-related complication. A transcervical
fracture of the right femoral neck is seen with varus angulation
at the fracture line. The degree of angulation is unchanged
compared to the previous study. No additional fracture or
dislocation is seen. The sacrum is obscured by overlying bowel
gas. Soft tissues are otherwise unremarkable.
IMPRESSION:
Right femoral neck fracture, unchanged in alignment compared to
the previous study.
.
Chest CT [**2112-9-8**]:
CT ABDOMEN: Visualized lung bases are notable for marked global
cardiomegaly. There is mild-to-moderate dependent bibasilar
atelectasis, greater on the left. There is no pleural or
pericardial effusion. Note is also made of sternotomy wires and
evidence of previous cardiac surgery.
Absence of intravenous contrast limits evaluation of the
abdominal parenchymal organs and vasculature. Liver contour is
smooth, and there is no biliary ductal dilatation or ascites.
There is a large, multilobulated, fluid-filled mass, with
well-defined borders, seen in the right upper quadrant. It may
arise from the caudate lobe of the liver, but this is difficult
to determine without intravenous contrast. It could also arise
from adjacent stromal tissues or mesentery. It contains multiple
small internal calcifications, and measures approximately 15 cm
in craniocaudal dimension, and 11 x 8.5 cm in greatest axial
dimension, not significantly changed when compared to prior
ultrasound. There is one other small 9 mm hypodensity in segment
V, incompletely characterized without contrast.
Multiple small calcified gallstones are seen within the
gallbladder lumen, but the gallbladder is not distended and
there is no wall thickening or pericholecystic fluid. Pancreas,
spleen, adrenal glands, stomach, and intra- abdominal loops of
bowel demonstrate normal non-contrast appearance. Kidneys are
mildly atrophic bilaterally, but otherwise unremarkable. There
is no free air, free intraperitoneal fluid, or abnormal
intra-abdominal lymphadenopathy.
CT PELVIS: Pelvic loops of large and small bowel are
unremarkable. Deep structures in the lower pelvis are obscured
by streak artifact from bilateral hip prostheses, but there is
no definite free pelvic fluid or abnormal pelvic or inguinal
lymphadenopathy. Foley catheter balloon is seen within a
decompressed bladder. There is a large left inguinal hernia,
which contains fluid and air-filled loops of non-distended small
bowel. There is no sign to suggest obstruction or strangulation.
A small punctate calcification is also seen within the left
hernia sac. There is no sign of retro- or extra- peritoneal
hematoma. Note is made of a left femoral approach central venous
catheter in place.
OSSEOUS STRUCTURES: Bilateral hip arthroplasties are seen, and
subcutaneous gas seen in the soft tissues of the right thigh is
consistent with recent surgery.
There is no suspicious osteolytic or sclerotic lesion seen.
There is diffuse osteopenia. There is compression deformity of
the L3 vertebral body, which is new at least since L-spine MRI
of [**2106-6-24**]. There is greater than 50% loss of vertebral body
height, particularly centrally within the vertebral body. There
is slight retropulsion of some bony fragments into the spinal
canal.
IMPRESSION:
1. No evidence of retroperitoneal hemorrhage. No sign of
bleeding within the abdomen or pelvis.
2. Moderate-to-large left inguinal hernia, containing fluid and
air-filled loops of small bowel, without evidence of obstruction
or incarceration.
3. 15-cm lobulated mass in the right upper quadrant. This is
incompletely evaluated without intravenous contrast, but is not
significantly changed in size since prior ultrasound of
[**2108-1-30**]. It may represent a mesenchymal or stromal tumor, but
it could also possibly arise from the caudate lobe of the liver,
and may represent extrahepatic spread of giant hemangioma.
4. Cholelithiasis, without evidence of cholecystitis.
5. L3 compression fracture, new since last L-spine exam of
[**2106-6-24**]. Slight retropulsion of some bony fragments into the
spinal canal. CT is unable to provide intrathecal detail
comparable to MRI. If there is clinical concern for cauda
impingement, or other neurologic symptoms, MRI of the lumbar
spine is recommended.
CT head [**2112-9-9**]:
FINDINGS: Comparison made to prior study dated [**2112-9-3**].
Again seen is a 1.8 cm x 1.5 cm left parafalcine mass anteriorly
which is likely the result of a meningioma. Compared to the
prior study, there is no significant interval change. Again see
is a right occiptal encephalomalacia consistent with patient
history of prior infarct in this location. There is prominence
of the ventricular system and cerebral sulci which is
age-related brain atrophy.
There is no evidence of an acute intracranial bleed. No CT
evidence of an acute territorial infarct is noted. The basal
cisterns are patent. The visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION: Compared to the prior study dated [**2112-9-3**], there is
no significant interval change. Stable left anterior parafalcine
meningioma. No evidence of an acute intracranial hemorrhage. Old
right occipital area of encephalomacia consistent with the
patient history of prior infarct.
CXR [**2112-8-31**]:
IMPRESSION: AP chest compared to [**9-6**] through 10:
Nasogastric tube ends in the upper stomach and should be
advanced 2-4 cm to move all the side ports beyond the
gastroesophageal junction. Moderate cardiomegaly and severely
enlarged central pulmonary arteries are longstanding. Borderline
interstitial edema is new since [**9-6**]. Significant rightward
displacement of the trachea is due to a large left goiter. Tip
of the left PIC catheter projects over the mid-to-low SVC. No
pneumothorax or appreciable pleural effusion.
Brief Hospital Course:
A/ Pt is a [**Age over 90 **] M with h/o Parkinson's disease, dementia, AF,
presenting w/R hip fx, R humerus fx after unwitnessed fall
.
Plan:
#. R hip fracture: Patient initially went to the OR and had an
ORIF. The procedure was well tolerated. Ortho was following
the patient and he is cleared for weight bearing as tolerated.
On [**9-7**], went to OR for ORIF/hemiarthroplasty of R hip. His
course was c/b GIB and hypotension which resolved. He is to
follow up with Dr. [**Last Name (STitle) **] in 1 week due to slow ooze but wound
looks well. Ortho aware pt is leaving to rehab on [**9-12**]. Pt was
kept on lovenox 40mg daily for ppx.
#. Hypotension: Patient was found to have hypotension to the 60s
on the floor. This was likely secondary to dehydration and poor
PO intake as well as GI bleed. Once patient was volume
resusitated he was no longer hypotensive. His BP meds
(carvediolol, furosemide) were held in this setting but should
be restarted as an outpatient as he tolerates. His carvedilol
was restarted at a lower dose 6.25 mg [**Hospital1 **] on [**9-12**], it needs to
be titrated as his BP tolerates to his home dose 12.5mg [**Hospital1 **].
#. GI bleeding: On POD#1, was found to be somnolent with new L
eye ptosis by [**Hospital1 **] intern. Over next 30 minutes, had a
melanotic, OB + stool and coffee ground emesis. Was transiently
bradycardic to 30s with BP 60s/palp; surgery was consulted for
IV access and placed L groin Cordis. Pt was noted to have new
lower abdominal/pelvic distension at time line was placed. BP
stabilized with 2 liters NS, and patient transferred to MICU.
While in the MICU, the patient had stable hematocrits and did
not require additional transfusions. Given that he had no signs
of active bleeding as well as stable hematocrit and
hemodynamics, the decision by GI was made to defer endoscopy for
now. If the family desires, the patient may need an outpatient
endoscopy/colonoscopy. Of note there is a mass on CT that was
not evaluated further. Given his AF and GIB he was not
anticoagulated but b/c he was hemodynamically stable, ASA 81mg
was started on [**9-12**]. His last transfusion was on [**9-9**] and HCT
was very stable, guaiac negative on [**9-11**].
#. R humerus fracture: does not require operative management.
Recommend sling for 6 weeks per Ortho and pain management.
#. Dementia: Patient was continued on Namenda, aricept. Other
sedating medications were limited.
#. Systolic Dyfunction: EF 40-45% on TTE [**2111**]. Continue lasix
100 mg daily and aldactone 25 mg daily
#. Atrial fibrillation: Was initially continued on Coreg, ASA.
The coreg was held as above but was restarted on [**9-12**] at a lower
dose. For now the patient is not on coumadin. However, it
should be restarted on [**2-2**] weeks if there are no more signs of
bleeding. Aspirin 81mg was started on [**9-12**].
.
#. Chronic Renal Failure: Creatinine is 1.2, which is below
baseline.
.
#. Nutrition: Given patient's poor mental status an NGT was
placed for TF/nutrition. On [**9-12**] S&S evaluation cleared the pt
for thin liquids and regular solids. NGT was d/c'd prior to
transfer. RECOMMENDATIONS: 1. Suggest a PO diet of thin liquids
and regular consistency solids. 2. Pills whole with purees. 3.
Assist with feeding during meals as needed.
.
#. Code: DNR/DNI
Contact: [**Name (NI) 53767**], [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 96535**] (HCP)
Medications on Admission:
Carvedilol 12.5 mg PO BID
Donepezil 10 mg PO DAILY
Midodrine 2.5 mg PO BID
Furosemide 100 mg PO DAILY
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Atorvastatin 10 mg PO DAILY
Lisinopril 5 mg PO DAILY
Levothyroxine Sodium 50 mcg PO DAILY
Vitamin D 400 UNIT PO DAILY
Calcium Carbonate 500 mg PO DAILY
Docusate Sodium 100 mg PO BID
Aspirin 81 mg PO DAILY
FoLIC Acid 1 mg PO DAILY
Multivitamins 1 CAP PO DAILY
Namenda *NF* 10 mg Oral [**Hospital1 **]
Spironolactone 25 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Ferrous Sulfate 325 mg PO DAILY
Coumadin
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Tramadol 50 mg Tablet Sig: 0.25 Tablet PO Q6H (every 6 hours)
as needed.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours).
13. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours).
14. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Pantoprazole 40 mg IV Q12H
18. 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.
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
-R hip fracture
-R humerus fracture
-GIB
Secondary
-Dementia/Parkinson's Disease
-Systolic Dysfunction
-AFib
Discharge Condition:
Stable, tolerating POs, mentating well
Discharge Instructions:
Please take all your medications as directed.
.
Please return to the emergency department if your Right Hip
wound is bleeding, has pus or discharge coming from it or the
area around the wound is red, more painful or worrisome, having
fevers or difficulty breathing.
Followup Instructions:
You must follow up with Dr. [**Last Name (STitle) **] from Orthopeadic Surgery in
1 week, please call his office at [**Telephone/Fax (1) 1228**] for an
appointment.
Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2112-12-5**] 2:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2112-9-12**]
|
[
"V58.61",
"812.20",
"585.9",
"820.03",
"V45.81",
"427.31",
"458.29",
"403.90",
"244.9",
"550.90",
"276.51",
"332.0",
"272.0",
"E885.9",
"414.01",
"V43.64",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16030, 16096
|
10461, 13884
|
230, 285
|
16257, 16298
|
2279, 2279
|
16613, 17121
|
1904, 1908
|
14488, 16007
|
16117, 16236
|
13910, 14465
|
16322, 16590
|
2588, 10438
|
1923, 2260
|
184, 192
|
313, 1306
|
2295, 2572
|
1328, 1772
|
1788, 1888
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,274
| 126,354
|
42958+58575
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-11-4**] Discharge Date: [**2128-11-19**]
Date of Birth: [**2083-1-21**] Sex: F
Service:
ADMISSION DIAGNOSIS: Fulminant colitis.
CHIEF COMPLAINT: Copious diarrhea, abdominal pain, and
hypertension.
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
female with a history of diabetes, status post kidney and
pancreas transplant in [**2127-2-21**] (complicated by renal
artery torsion with subsequent removal of the kidney in
[**2127-8-24**] followed by kidney re-transplantation in
[**2128-2-21**]).
The patient's postoperative course has been notable for
gastrointestinal problems with constipation alternating with
diarrhea. The patient now presents on [**2128-11-4**]
critically ill with the sudden onset of abdominal pain at
noon followed by syncope and nasal fracture with subsequent
copious diarrhea.
Although the patient was hemodynamically stable on initial
Emergency Department presentation, she subsequently became
hypotensive to the 70s.
PAST MEDICAL HISTORY:
1. Diabetes.
2. End-stage renal disease (on hemodialysis).
3. Coronary artery disease.
4. Legally blind.
5. Hypertension.
6. Gastroparesis.
7. Asthma.
PAST SURGICAL HISTORY:
1. Status post kidney and pancreas transplant in [**2127-10-24**].
2. Status post kidney re-transplantation in [**2128-2-21**].
3. Ventral hernia repair.
4. Coronary artery bypass graft in [**2126**].
ALLERGIES: BETADINE (causes anaphylaxis).
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. Prograf 3 mg by mouth twice per day.
2. Prednisone 5 mg by mouth once per day.
3. Imuran 50 mg by mouth once per day.
4. Aspirin 81 mg by mouth once per day.
5. Folate.
6. Bactrim-SS one tablet by mouth once per day.
7. Desipramine 150 mg by mouth once per day.
8. Lopressor 100 mg by mouth twice per day.
9. Vasotec 10 mg by mouth once per day.
10. Norvasc 5 mg by mouth twice per day.
11. Protonix 40 mg by mouth once per day.
12. Reglan 10 mg by mouth three times per day
13. Imodium two to three tablets by mouth as needed.
14. Flovent inhaler.
15. Ventolin inhaler.
16. Ambien by mouth as needed.
REVIEW OF SYSTEMS: Review of systems revealed no fever, now
with chills. No change in bowel habits recently. The
patient is on Bactrim and no other antibiotics.
SOCIAL HISTORY:
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature was 95 degrees Fahrenheit,
her heart rate was 65, her blood pressure was 130/80 (with a
subsequent decrease to 70/40 later on), her respiratory rate
was 25, and her oxygen saturation was 97% on room air. In
general, the patient looked uncomfortable with a swollen nose
and blood on his lips. The nose was ecchymotic. The patient
is legally blind. The lungs were clear to auscultation
bilaterally. No wheezes or rales. Heart revealed a regular
rate and rhythm. The abdomen was thin, very distended, and
tender. There was some guarding. Rectal examination was
guaiac-positive.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed the patient's white blood cell count was
5.8, her hematocrit was 36.5, and her platelets were 115.
The patient's lactate was 7.8. Electrolytes revealed the
patient's sodium was 128, potassium was 4.9, chloride was 99,
bicarbonate was 16, blood urea nitrogen was 26, creatinine
was 2.1, and her blood glucose was 88. Arterial blood gas
revealed pH was 7.05, her PCO2 was 60, and her PO2 was 115,
bicarbonate was 18, base -14. Her alanine-aminotransferase
was 234, her aspartate aminotransferase was 65, her alkaline
phosphatase was 47, her total bilirubin was 0.4, her amylase
was 88, and her lipase was 79.
PERTINENT RADIOLOGY/IMAGING: A computed tomography of the
abdomen and pelvis on admission revealed diffuse pneumatosis
of the cecum and small bowel with portal venous air;
consistent with ischemia.
A computed tomography of the head showed no intracranial
hemorrhage (taken due to a report of syncope and fall with
signs of facial trauma).
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was taken to
the operating room the next day where she had a subtotal
colectomy with ileostomy. Surgical pathology of the specimen
showed markedly dilated proximal colon with extensive
ischemic necrosis focally transmural; consistent with toxic
megacolon.
The patient was taken to the Surgical Intensive Care Unit for
further stabilization. The patient remained in the Surgical
Intensive Care Unit until [**11-13**] where she required a
significant amount of blood products. More specifically, 9
units of packed red blood cells, 5 units of platelets, and 13
units of fresh frozen plasma, and 2 units of cryoprecipitate.
The patient was intubated for management of her respiratory
status and was eventually extubated on [**11-13**].
While the patient was still in the Intensive Care Unit, total
parenteral nutrition was started for nutritional support. On
[**11-10**], a postpyloric feeding tube (nasojejunal tube)
was placed on [**11-10**] for tube feeds, and the patient was
started on Nepro full strength tube feed formula starting at
10 cc per hour and flushing slowly. The tube feed formula
was changed on [**11-13**] to ProMod with fiber full
strength. The patient remained on this formula until the day
of discharge on goal rate.
In terms of medications, the patient was started from the day
of her admission on her home medications of
immunosuppression; that was tacrolimus and azathioprine plus
intravenous steroids.
Blood cultures, urine cultures, and peritoneal cultures were
drawn on [**11-4**] and [**11-5**] along with Clostridium
difficile toxin assays (stool test). On [**11-5**],
[**11-6**], and [**11-7**] all cultures were negative, and
the screening culture for vancomycin-resistant enterococcus
and methicillin-resistant Staphylococcus aureus were also
negative on [**11-8**]. However, was started on Flagyl 500
mg three times per day for presumed Clostridium difficile
colitis started on no evidence 14 and continued until
[**11-16**] for empiric treatment of suspected Clostridium
difficile colitis.
The patient was transferred to the floor on [**11-13**].
Since then the patient has been improving. The patient has
been afebrile and has been tolerating her tube feeds. Total
parenteral nutrition was eventually stopped. The patient was
advanced on her tube feeds at a goal rate. On [**11-17**],
she was advanced to clears. On [**11-18**], she was advanced
to a regular diet without any problems.
The plan was for the patient to be discharged on [**11-19**]
to a rehabilitation facility on no antibiotics, on her
immunosuppression medications (tacrolimus currently at 5 mg
by mouth twice per day; azathioprine 50 mg by mouth at hour
of sleep, and prednisone 5 mg by mouth once per day). The
patient was also to be discharged on all of the rest of her
home medications and Bactrim as prophylaxis.
The patient was instructed to follow up with Dr. [**Last Name (STitle) **]
(Nephrology) and with Dr. [**Last Name (STitle) **] (at the Transplant Center)
per instructions.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Tacrolimus 5 mg by mouth twice per day.
2. Desipramine 150 mg by mouth once per day.
3. Reglan 10 mg by mouth four times per day.
4. Tylenol 325 mg to 650 mg by mouth q.4-6h. as needed.
5. Lansoprazole 30 mg by mouth once per day.
6. Metamucil one wafer by mouth every day.
7. Azathioprine 50 mg by mouth at hour of sleep.
8. Labetalol 200 mg by mouth three times per day.
9. Imodium 4 mg by mouth three times per day as needed (for
diarrhea).
10. Albuterol nebulizers.
11. Amlodipine 5 mg by mouth twice per day.
12. Bactrim-SS one tablet by mouth once per day.
13. Prednisone 5 mg by mouth once per day.
DISCHARGE DIAGNOSES:
1. Status post subtotal colectomy with ileostomy.
2. Toxic Megacolon.
3. Status post kidney and pancreas transplant.
4. CAD
5. HTN
6. IDDM
7. Asthma
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2128-11-18**] 18:31
T: [**2128-11-18**] 18:52
JOB#: [**Job Number 92730**]
Name: [**Known lastname 8997**], [**Known firstname 1873**] Unit No: [**Numeric Identifier 14591**]
Admission Date: [**2128-11-4**] Discharge Date: [**2128-11-19**]
Date of Birth: [**2083-1-21**] Sex: F
Service:
DISCHARGE STATUS: The patient is discharged to home with
services (VNA, physical therapy).
DISCHARGE MEDICATIONS: The patient is to resume her
prehospital medications except for Vasotec (Dr. [**Last Name (STitle) 14592**] will
resume this as an outpatient if the patient's creatinine and
potassium remain okay). Another notable change in the
patient's medications is her dose of Prograf which is now 5
mg p.o. b.i.d.
DISCHARGE DIAGNOSES:
1. Fulminant colitis status post subtotal colectomy with end
ileostomy.
2. Sepsis.
3. Syncope with nasal fracture and facial trauma.
4. Pancreas and kidney transplants (3/[**2126**]).
5. Kidney retransplant (3/[**2127**]).
FOLLOWUP: Follow up in one and two weeks with Dr. [**Last Name (STitle) 14593**] and
then with Dr. [**Last Name (STitle) 14594**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4043**]
Dictated By:[**Name8 (MD) 5018**]
MEDQUIST36
D: [**2128-11-19**] 10:39
T: [**2128-11-19**] 10:39
JOB#: [**Job Number 14595**]
|
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] |
icd9cm
|
[
[
[]
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[
"45.73",
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icd9pcs
|
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8910, 9504
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8584, 8889
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7135, 7800
|
1483, 2150
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|
4084, 7108
|
150, 170
|
2171, 2316
|
188, 241
|
270, 1002
|
1024, 1183
|
2333, 4055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,000
| 186,778
|
53917+59561
|
Discharge summary
|
report+addendum
|
Admission Date: [**2176-8-31**] Discharge Date: [**2176-9-4**]
Date of Birth: [**2099-1-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Left heart catheterization with balloon angioplasty
History of Present Illness:
77F [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) 11042**] [**Last Name (NamePattern4) **] resident with dementia, ESRD on HD, presented
to ED after hypotension after HD and report of "not seeming
herself" after HD session Sat pm. Patient not able to provide
further details of history [**1-27**] dementia.
In the ED, EKG CHB and STE in II, III, aVF; Code STEMI called at
3:30p. Given 325mg ASA PR, heparin bolus; pt refused/unable to
take po meds, so was not plavix loaded, and no GPIIb/IIIa [**1-27**]
renal failure.
Went to cath lab, mid RCA was totally occluded and treated with
PTCA with good result. Required fentanyl, versed during
procedure due to restlessness. Pacing wire placed for CHB and
sent to CCU.
Past Medical History:
ESRD on HD T/Th/S
Hypertension
h/o psychiatric hospitalization for "nerves" (exact psych dx
unknown to family)
DM
restless leg syndrome
h/o SDH after a fall (family reports pt was "dropped from
stretcher by EMS" years ago), for which she had been on
prophylactic dilantin, weaning down according to family
note, pt does not carry diagnosis of Parkinson's--sinemet is
apparently for restless legs
.
Cardiac History:
CABG: none
Percutaneous coronary intervention: none
Pacemaker/ICD placed: none
Social History:
Lives in nursing home; gets routine care at [**Hospital1 2025**]. Family says no
h/o tobacco use, no h/o alcohol use.
Family History:
Unobtainable due to pt. nonresponsive to hospital staff.
Physical Exam:
VS: T 98.8, BP 121/58, HR 73, RR 15, O2 100% on 2L NC
Gen: elderly african american female. Oriented x2, responds to
voice at times and to noxious stimuli.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Oral mucosae
dry.
Neck: Supple with JVP <10 cm. Paramedian left scar on neck.
CV: PMI located in 5th intercostal space, midclavicular line.
III/VI early systolic murmur LLSB-->axilla, normal S1, paradoxic
S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
[**2176-9-2**] Echo
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with akinesis of
the basal half of the inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 40 %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta and aortic arch is
mildly dilated. The aortic valve leaflets are moderately
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral leaflets are mildly thickened
Mild to moderate ([**12-27**]+) mitral regurgitation is seen. Diastolic
mitral regurgitation is seen (due to first degree AV block) The
estimated pulmonary artery systolic pressure is normal. There is
a very small inferolateral/inferior pericardial effusion without
evidence of hemodynamic compromise.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD. Mild-moderate mitral
regurgitation. Increased LVEDP. Dilated thoracic aorta.
[**2176-8-31**] ECG
Sinus bradycardia with 1st degree A-V block.
Prolonged QT interval
Inferior ST elevation, CONSIDER ACUTE INFARCT
ST segment depression in leads l, aVL, V2-V3 - is reciprocal
Since previous tracing of [**2175-9-21**], acute myocardial infarction,
and sinus
bradycardia now present
.
[**2176-8-31**] Head CT
CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage,
shift of
normally midline structures, or evidence of acute major vascular
territorial
infarct. Hypodensity is consistent with chronic small vessel
ischemic
changes. Mineralization of the basal ganglia is noted
bilaterally.
Atherosclerotic calcifications involve the cavernous carotids
and vertebral
arteries bilaterally. The imaged portions of the paranasal
sinuses and
mastoid air cells are well aerated.
IMPRESSION: No intracranial hemorrhage or edema.
.
[**2176-8-31**] cardiac cath
1. Two vessel coronary artery disease.
2. Complete heart block
3. Normal systemic pressure
4. Successful POBA of an occluded RCA (culprit artery) with
20-30%
residual stenosis and non flow-limiting dissection.
[**2176-8-31**] 03:35PM BLOOD WBC-5.8 RBC-3.40* Hgb-9.4* Hct-29.8*
MCV-88 MCH-27.7 MCHC-31.7 RDW-18.5* Plt Ct-212
[**2176-9-3**] 06:20AM BLOOD WBC-6.4 RBC-3.03* Hgb-8.2* Hct-26.5*
MCV-88 MCH-27.2 MCHC-31.0 RDW-19.3* Plt Ct-313
[**2176-8-31**] 03:35PM BLOOD PT-14.1* PTT->150* INR(PT)-1.2*
[**2176-9-3**] 06:20AM BLOOD PT-13.1 PTT-30.6 INR(PT)-1.1
[**2176-8-31**] 03:35PM BLOOD Fibrino-833*
[**2176-9-1**] 03:04AM BLOOD Glucose-96 UreaN-35* Creat-4.7* Na-144
K-3.4 Cl-100 HCO3-33* AnGap-14
[**2176-9-3**] 06:20AM BLOOD Glucose-78 UreaN-53* Creat-8.1*# Na-143
K-4.3 Cl-99 HCO3-29 AnGap-19
[**2176-8-31**] 03:35PM BLOOD CK(CPK)-76 Amylase-35
[**2176-9-1**] 03:04AM BLOOD ALT-11 AST-26 CK(CPK)-571* AlkPhos-88
TotBili-0.4
[**2176-9-1**] 09:05AM BLOOD CK(CPK)-1008*
[**2176-9-1**] 09:33AM BLOOD CK(CPK)-1060*
[**2176-9-1**] 04:11PM BLOOD CK(CPK)-1121*
[**2176-9-2**] 05:16AM BLOOD CK(CPK)-844*
[**2176-8-31**] 03:35PM BLOOD cTropnT-17.13*
[**2176-8-31**] 03:35PM BLOOD CK-MB-NotDone
[**2176-9-1**] 03:04AM BLOOD CK-MB-5 cTropnT-17.01*
[**2176-9-1**] 09:05AM BLOOD CK-MB-5 cTropnT-15.74*
[**2176-9-1**] 09:33AM BLOOD CK-MB-6 cTropnT-16.17*
[**2176-9-1**] 04:11PM BLOOD CK-MB-6 cTropnT-15.56*
[**2176-9-2**] 05:16AM BLOOD CK-MB-4 cTropnT-18.28*
[**2176-9-1**] 03:04AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.1
[**2176-8-31**] 03:35PM BLOOD Triglyc-60 HDL-8 CHOL/HD-11.8 LDLcalc-74
[**2176-8-31**] 03:35PM BLOOD Phenyto-<0.6*
[**2176-8-31**] 03:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2176-8-31**] 03:39PM BLOOD Glucose-146* Lactate-2.6* Na-147 K-3.8
Cl-94* calHCO3-39*
Brief Hospital Course:
77F with ESRD on HD, dementia, psycosis, HTN, presents with
acute STEMI s/p POBA and CHB now resolved.
.
# CAD/Ischemia: STEMI, received POBA to RCA with good
angiographic result.
Pt. was started on atorvastatin 80mg, asa, clopidogrel,
losartan. Pt. also had complete heart block secondary to RCA
infarction. Pt. had temporary pacer left in at time of cath and
she was weaned from this over 2 days. We did not start pt. back
on labetalol as her PR interval was still 330ms at time of d/c.
CK peaked at 1121 w/ troponin of 15.56.
.
# Pump: EF unknown: echo showed LVEF = 40 %. Pt. was not
restarted on beta blocker because of her remaining heart block.
Pt. did not appear volume overloaded on exam, no crackles, no
edema, no JVD. HD dependent.
.
# Rhythm: Pt. presented in complete heart block and had
temporary pacer inserted, over 2 days she progressed to not
needing the pacer and it was removed. NSR with first degree AV
block PR 330ms on day of d/c.
.
# Valves: murmur c/w MR, The mitral leaflets are mildly
thickened Mild to moderate ([**12-27**]+) mitral regurgitation on echo.
Not acutely a problem.
.
# HTN: on 4 drugs as outpt, with history of admissions with
hypertensive urgency, but well controlled during this admission.
.
# DM: very brittle per family; symptomatic hypoglycemia if BS
<150. Continued on SSI during this admission BG remained
relatively well controlled.
.
# psych: unclear history of psychiatric disorder and now
dementia; Pt. was minimally interactive with staff during
admission, but apparently per family she rarely talks with
hospital staff but will talk w/ daughter.
.
# h/o subdural hematomas: no SHD on head CT in ED; family says
being weaned off dilantin. Phenytoin level below assay. Did not
restart phenytoin.
.
# GERD: continued omeprazole
.
# FEN:
Was evaluated by speech and swallow and determined that she
could continue w/ solids and thin liquids if supervised.
.
# Code: full
.
# Communication: with daughter
Medications on Admission:
phoslo 1 tab tid
zyprexa 7.5mg daily
novolin R SS
omeprazole 20mg daily
duonebs prn
renagel 1600mg tid
lactulose prn constipation
colace
aspirin 81mg daily
norvasc 5mg daily
sinemet 10/100 tid
neurontin 300mg daily
isordil 60mg q8h
labetalol 800mg tid
losartan 50mg daily
mirtazipine 7.5mg hs
nephrocaps daily
trazodone 25mg daily
tylenol 650mg prn
vicodin 5/500 q6h prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as
needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed.
7. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
15. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
16. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
17. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
18. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
21. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
give 3 doses 5 minutes apart, check BP between doses. If still
has chest pain after 3 doses, call PCP. .
22. Hydrocodone-Acetaminophen 5-500 mg Capsule Sig: One (1)
Capsule PO four times a day as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11729**] Nursing Home
Discharge Diagnosis:
Inferior ST elevation myocardial infarction
Complete heart block
End Stage Renal disease on hemodialysis
Hypertension
Complete Heart Block, now First Degree AV Conduction Delay
Diabetes
Discharge Condition:
Stable
Discharge Instructions:
You had a heart attack and a cardiac catheterization that showed
extensive coronary artery disease. You had a balloon angioplasty
to one of these vessels that was causing your symptoms. Because
of your extensive disease, you will be treated with medicine to
prevent another heart attack.
New medicines are Plavix and aspirin, these prevent blood clots.
Your labetolol was stopped because your heart rate was low, this
may be restarted in the future. You were also started on
Atorvastatin to prevent further buid up of plaque in your
coronary arteries.
.
You will need to follow-up with your primary care provider, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) 1446**] [**Last Name (NamePattern1) **]. You will also continue with your hemodialysis
treatments.
.
Please take all of your medications exactley as prescribed.
.
Please come back to the hospital if you have a slow heart rate
again, chest pain that is not relieved with nitroglycerin,
severe bleeding, trouble breathing or low blood pressure.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) 1446**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2579**] will see you at The Kidney Center next
week during dialysis.
You will still need dialysis on your current schedule.
Completed by:[**2176-9-3**] Name: [**Known lastname **],[**Known firstname 732**] Unit No: [**Numeric Identifier 18112**]
Admission Date: [**2176-8-31**] Discharge Date: [**2176-9-4**]
Date of Birth: [**2099-1-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4871**]
Addendum:
Pt. also had speech and swallow evaluation for question of
aspiration which suggested that pt. can continue solids with
thin liquids and 1:1 supervision during meals to monitor for
aspiration.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1776**] Nursing Home
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern4) 4878**] MD [**MD Number(1) 4879**]
Completed by:[**2176-9-3**]
|
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icd9pcs
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13404, 13622
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325, 379
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11472, 11481
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2813, 6678
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1807, 1865
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274, 287
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407, 1138
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1160, 1656
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1672, 1791
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,010
| 110,747
|
51933
|
Discharge summary
|
report
|
Admission Date: [**2167-1-22**] Discharge Date: [**2167-1-30**]
Date of Birth: [**2091-7-12**] Sex: F
Service: MEDICINE
Allergies:
Enalapril / Shellfish
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
Balloon Angioplasty of AV fistula
History of Present Illness:
75F dm, esrd, chf presents with nausea, vomiting, and GI upset
for x2 days. Pt called PCP [**1-21**], day before admit, with
complaints of "feeling sick" for previous 4 days with gi upset.
At that time, denied vomiting, cough, irregular bowel movement.
She then related the symptoms to eating a hot dog and jelly
beans. PCP thought she sounded quite miserable and not herself,
plan was for ED evaluation if worsened.
Pt also complains of fatigue during this time period. Denies
vision changes, sore throat, dysphagia, epigastric discomfort,
diarrhea or bloody stools. Denies MSK cramps.
In [**Hospital1 18**] ED, vital signs stable, sbp 160/80, hr 120, rr 18,
satting 97% ra, afebrile. Abd soft, mildly tender lower
quadrants. Glucose elevated at 346, given insulin. EKG showed
st-depressions v5-v6, cxr normal, ct scan abd showed mild
diverticulitis. Cards consulted for troponin bump with
tachycardia. Given 2.5l IVF, given aspirin 325mg once,
initiated on flagyl and cipro, which caused a rash, then
switched to zosyn. Lactate initially 4.0, resolved to 2.6 with
IVF. Transferred to MICU for persistent tachycardia and
troponin bump, in stable condition.
Past Medical History:
1. TII diabetes mellitus - insulin-dependent - diag [**2130**].
2. Chronic kidney disease - stage 5 - followed by Dr.
[**Last Name (STitle) 7473**]. Left av-fistula in place with question of proximal
narrowing, pending surgical evaluation. Has not been
hemodialyzed as of yet.
3. CHF - [**2160**] EF 20-30%, [**2-/2166**] ECHO persistent LVH, likely [**1-10**]
hypertensive heart disease, with mild MR, mild-to-moderate TR.
Followed by [**Hospital 1902**] clinic, cardiomyopathy thought [**1-10**] htn dm.
4. Sensory neuropathy.
5. Onychodystrophy
6. Hyperkeratotic lesions plantar aspects feet
7. Ischemic colitis - [**4-/2166**]
8. LGIB - [**4-/2166**] - thought possible [**1-10**] to ischemic colitis
9. Diverticulosis
10. Breast cancer (invasive ductal, dx [**2156**]). diagnosed [**9-/2157**]
with a 1.5 cm grade II infiltrating ductal cancer of the right
breast, clean lymph nodes, ER positive, HER-2/neu negative.
Presumed remission now s/p five years on tamoxifen.
11. Renal osteodystrophy
12. Hypercholesterolemia
13. TB @ 21 yo, s/p lobectomy
14. Fibroids, s/p hysterectomy
Social History:
She is living with her daughter, grandson, his
wife and great granddaughter who is two months old. She is
finding that to be quite acceptable to her. She does not smoke.
She does not drink alcohol.
Family History:
Mother -- breast cancer
[**Name (NI) **] -- breast cancer
Brother -- melanoma
Physical Exam:
T 98 BP 160/80 HR 134 RR 20 98%ra
Gen - NAD, A/Ox3, sitting in bed, vomiting (yellow-brownish
fluid, no blood identified). conversant, cooperative, not able
to finish all sentences due to vomiting..
HEENT - no conjunctival pallor, no scleral icterus appreciated,
mildly dry membranes. no posterior pharyngeal erythema
appreciated.
NECK - no posterior/anterior LAD, +JVD 2cm superior to clavicle
bil in upright position.
CV - RRR, S1+S2+S3-S4-, 3/6 sem lsb with radiation to the back
LUNGS - CTAB, good air movement bilaterally, no crackles
appreciated, no wheezes appreciated
ABD - NABS, soft, non-tender, non-distended. No organomegaly
appreciated.
EXT - trace lower extremity edema. 2+ palpable pulses
bilaterally dorsalis pedis, posterior tibial, radial, ulnar, all
2+.
SKIN: No rashes/lesions, ecchymoses.
NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not
do fundoscopy. Preserved sensation throughout. MSK 4+/5
bilaterally, upper extremities and lower extremities. 1+
reflexes L4 bilaterally.
PSYCH - Listens and responds to questions appropriately
.
T 97.2 BP 122/60 HR 74 RR 18 98%ra
Gen - NAD, A/Ox3, sitting in bed in NAD
HEENT - no JVD, no lympadenopathy
CV - RRR, S1+S2+S3-S4-, [**2-12**] murmur (refered from AV fistula)
LUNGS - CTAB, good air movement bilaterally, no crackles
appreciated, no wheezes appreciated
ABD - NABS, soft, non-tender, non-distended. No organomegaly
appreciated.
EXT - no lower extremity edema. AV fistula in left arm w/o
bleeding or bruising, in tact.
SKIN: No rashes/lesions, ecchymoses.
NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact,
strength 5/5
Pertinent Results:
CBC
[**2167-1-22**] 06:00AM BLOOD WBC-13.4* RBC-4.44 Hgb-12.0 Hct-35.6*
MCV-80* MCH-26.9* MCHC-33.6 RDW-15.2 Plt Ct-289
[**2167-1-22**] 06:00AM BLOOD Neuts-86.5* Lymphs-8.3* Monos-5.0 Eos-0.1
Baso-0.1
[**2167-1-24**] 03:54AM BLOOD WBC-12.0* RBC-4.11* Hgb-10.9* Hct-34.5*
MCV-84 MCH-26.4* MCHC-31.5 RDW-15.1 Plt Ct-253
[**2167-1-25**] 06:50AM BLOOD WBC-11.1* RBC-3.78* Hgb-9.8* Hct-31.1*
MCV-82 MCH-25.9* MCHC-31.5 RDW-15.2 Plt Ct-263
[**2167-1-26**] 09:45AM BLOOD WBC-10.5 RBC-3.86* Hgb-10.0* Hct-32.5*
MCV-84 MCH-26.0* MCHC-30.8* RDW-15.5 Plt Ct-269
.
Chem 7
[**2167-1-22**] 06:00AM BLOOD Glucose-375* UreaN-65* Creat-4.6* Na-140
K-5.0 Cl-98 HCO3-22 AnGap-25*
[**2167-1-23**] 12:07AM BLOOD Glucose-120* UreaN-70* Creat-5.2* Na-144
K-4.6 Cl-111* HCO3-21* AnGap-17
[**2167-1-25**] 06:50AM BLOOD Glucose-75 UreaN-67* Creat-5.5* Na-140
K-4.1 Cl-103 HCO3-23 AnGap-18
[**2167-1-27**] 06:40AM BLOOD Glucose-126* UreaN-50* Creat-4.8*# Na-138
K-4.0 Cl-98 HCO3-23 AnGap-21*
[**2167-1-29**] 06:15AM BLOOD Glucose-107* UreaN-35* Creat-4.5*# Na-139
K-4.0 Cl-100 HCO3-28 AnGap-15
.
Cardiac Enzymes
[**2167-1-22**] 06:00AM BLOOD cTropnT-0.18*
[**2167-1-22**] 11:00AM BLOOD cTropnT-0.17*
[**2167-1-23**] 12:07AM BLOOD cTropnT-0.22*
[**2167-1-24**] 03:54AM BLOOD cTropnT-0.14*
[**2167-1-22**] 11:00AM BLOOD CK(CPK)-62
[**2167-1-23**] 12:07AM BLOOD CK(CPK)-76
.
Misc
[**2167-1-22**] 06:49AM Lactate-4.0*
[**2167-1-22**] 11:03AM Lactate-2.3*
[**2167-1-22**] 04:17PM Lactate-1.9
[**2167-1-25**] 11:16AM Lactate-1.7
[**2167-1-29**] 06:15AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.0
[**2167-1-22**] 06:00AM BLOOD ALT-11 AST-28 CK(CPK)-95 AlkPhos-86
TotBili-1.0
[**2167-1-22**] 06:00AM BLOOD Lipase-16
.
Echo
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate to severe global left ventricular hypokinesis with
akinesis of the mid inferior and mid inferolateral walls and
hypokinesis of remaining segments (LVEF = 30 %). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-10**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate to severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-2-12**],
there has been global deterioration of left ventricular systolic
function. The estimated pulmonary artery systolic pressure is
greater and right ventricular free wall hypokinesis is now
present..
.
Exercise MIBI
Excercise: In the presence of 0.[**Street Address(2) 107513**] depression and
T wave inversions inferiorly and in leads V3-6, there were no
significant ST segment changes throughout the study. The rhythm
was sinus with one apb during infusion. The patient was
hypertensive at baseline with an appropriate response to the
infusion; heart rate response was flat. No signficant EKG
changes in the presence of baseline abnormalities. No anginal
type symptoms.
Nuclear report: Inferior wall perfusion cannot be evaluated due
to subdiaphragmatic activity. Decreased LVEF of 39% and
moderately increased left ventricular cavity size.
.
CXR [**1-23**]: Worsening, mild-to-moderate fluid overload and
persistent cardiomegaly.
.
AV fistulagram: Stenosis at arterial anastomosis site of left
upper extremity AV fistula. Successful balloon dilatation with
6-mm balloons and with improvement of flow.
Brief Hospital Course:
75F dm, esrd, chf presents with nausea, vomiting, and GI upset
for x2 days, found to have mild diverticulitis and NSTEMI in
setting of tachycardia. She was briefly admitted to MICU for
tachycardia and diverticulitis w/ a concern for impending sepsis
with low BP with an elevated lactate. She received fluids and
Zosyn. She was observed in the MICU for 2 days with resoving
lactate and leukocytosis and then transfered to the floor.
.
# Diverticulitis - Pt's primary symptoms over the three days
prior to admission were gastrointestinal in origin with nausea,
vomiting, and overall "GI upset." She has a history of ischemic
vs. infectious colitis in [**2165**] in tranverse and descending
colon, which has resolved on CT scan. CT scan did reveal new
diverticulitis which was thought to be the etiology of her
symptoms. She received cipro and flagyl in the ED and developed
a rash. In the MICU she was swithed to Zosyn. Initially, there
was a concern for impending sepsis with blood pressures in the
90's and an elevated lactate to 4.0. She was given fluids and
Zosyn for two days. Her symptoms and blood pressure improved. In
addition, her lactate level come down to normal. She was then
transfered to the floor where she was switched to Augmentin to
complete a 10 day course of abx. She remained afebrile with
decreasing leukocytosis (13->6) and resolving symptoms. She was
discarged with no abdominal pain, nausea or vomiting.
.
# NSTEMI - On admission, she had several EKGs with TWI in
lateral leads and I/II, not concordant with any coronary
distribution. Her troponins were found to be mildly elevated,
with flat CK: troponin 0.18->0.22, CK 95->53. A cardiology
consult was called for assistance with EKG changes and mild
troponin elevation. They determined that these changes were
likely due to demand ischemia and recomended against heparin or
cardiac catheterization. She was continued on ASA, BB and
statin.
.
# CHF- The patient has history of non-ischemic cardiomyopathy
with depressed EF (30%) which then recovered to 55%. Pt had
echocardiogram done on this admission to further evaluate
cardiac status. The echo showed moderate to severe global left
ventricular hypokinesis with akinesis of the mid inferior and
mid inferolateral walls and hypokinesis of remaining segments
(LVEF = 30 %). The regional areas of hypokinesis in the
inferior/inferiorlateral walls raised the possibility of new
ischemic cardiomyopathy. A pMIBI was performed which was unable
to assess the inferior walls and vessels due to subdiaphragmatic
activity. The remainder of the walls were without perfusion
defects. This study may need to be repeated in the future to
assess the inferior walls and reasses her EF. She will follow up
with her cardiologist, Dr. [**First Name (STitle) 437**]. While in house, she became
slightly volume overload from IVF in the MICU. She had mild
symptoms of orthopnea, but no SOB or hypoxia. She was dialized
with resolution of her symptoms. Lasix was discontinued as she
is now on HD.
.
# Hypertension - The patient was continued on amlodipine and
metoprolol after her blood pressure returned to [**Location 213**].
Clonidine was discontinued. As she became hypertensive, she was
started on Valsartan with an improvement in blood pressure.
.
# ESRD - Stage 5 CKD, likely [**1-10**] diabetes and hypertension
followed by Dr. [**Last Name (STitle) 7473**]. She has been on oral iron
supplementation and procrit for associated anemia. The fistula
had been in place in anticipation of starting HD. There was
previous concern for a proximal narrowing of the fistula with a
loud bruit. She received an AV fistulogram which showed proximal
stenosis. The stenosis was sucessfully dilated via balloon
angioplasty by IR. She was started on dialysis for the first
time, and received HD several times. She did have one episode of
symptomatic orthostatic hypotension after her third HD where 1.5
kg was removed. This episode occured in conjuntion with
receiving her BP meds just after HD. She had no further episodes
of orthostatic hypotension, and her blood pressure remained
stable even with her anti-hypertensives. She was discharged with
a plan for HD MWF at Da Vita Dialysis Center. She will follow up
with her nephrologist Dr. [**Last Name (STitle) 4883**]. Her last dialysis session
was [**2167-1-29**] in the PM.
Medications on Admission:
ASPIRIN 81 mg qd
Amlodipine 10 mg qd
Clonidine 0.2 mg [**Hospital1 **]
FERROUS GLUCONATE 325 mg qd
FUROSEMIDE 80 mg qam 40mg qpm
HECTOROL 2.5 mcg--1 capsule(s) by mouth qMWF
LOVASTATIN 20MG qhs
Mastectomy Bra --right side diagnosis cancer of the right breast
NPH (HUMAN) --26 units qam [**First Name8 (NamePattern2) **] [**Last Name (un) 387**]
OMEPRAZOLE 40mg qd
PROCRIT 20,000 unit/mL--inject 6000 units q10 days
RENAGEL 400 mg tid
TOPROL XL 300mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed
for constipation.
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
8. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
10. Insulin
Take NPH and humalog sliding scale as previously prescribed by
[**Last Name (un) **].
11. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO once a
day for 1 days: Last day [**1-31**].
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Diverticulitis
Non-ST segment Elevation Myocoardial Infarction
Renal Failure
Discharge Condition:
improved
Discharge Instructions:
You were admitted for diverticulitis (a colon infection) and a
small heart attack. You were put on antibiotics which helped
heal the infection. Your heart function was also monitored. You
will need to follow up with your cardiologist. You were also
started on hemodialysis and will need to continue going to
hemodialysis from now on.
.
The follow medication changes were made. Take all the rest of
medications a previously directed:
1. Stop taking Clonidine.
2. Start taking Valsartan
3. Stop taking lasix( furosemide).
4. Stop taking iron (ferrous glucontate), hectorol and procrit.
These medications will be given to you at hemodialysis.
5. Lovastatin was changed to Atorvastatin.
6. Take Augmentin (antibiotic)for 1 more day, to complete a 10
day course of antibiotics. Last day [**1-31**].
Followup Instructions:
Please call your cardiologist [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], MD [**Telephone/Fax (1) 3512**] to
make a follow up appointment in the next two weeks.
.
Dialysis on Monday [**2167-2-1**] at 2:30pm at [**Location (un) **] [**Location (un) **]
Dialysis [**Telephone/Fax (1) 5972**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3766**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time: [**2167-2-4**] at 4:00pm
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Date/Time:[**2167-2-2**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2167-2-18**] 10:30
Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2167-5-26**] 10:10
|
[
"250.40",
"404.93",
"276.2",
"584.9",
"428.43",
"285.21",
"585.6",
"428.0",
"425.7",
"250.80",
"272.0",
"562.11",
"V10.3",
"410.71",
"996.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"39.95",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
14197, 14293
|
8239, 12572
|
298, 334
|
14414, 14425
|
4632, 8216
|
15267, 16154
|
2895, 2975
|
13076, 14174
|
14314, 14393
|
12598, 13053
|
14449, 15244
|
2990, 4613
|
243, 260
|
362, 1538
|
1560, 2660
|
2676, 2879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,328
| 195,058
|
2516
|
Discharge summary
|
report
|
Admission Date: [**2143-6-1**] Discharge Date: [**2143-6-5**]
Date of Birth: [**2078-7-3**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Avandia / Iodine; Iodine Containing /
Verapamil
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
fever, chills, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
fever, chills, cough
.
HPI: Mrs [**Known lastname 732**] is at 64 yo female with pmh of DM, htn, s/p CVA,
OSA, and asthma who was admitted to the MICU due to somulence
and concern for sepsis. The week prior to admission she
developed a sore throat and productive cough which caused her to
use her albuterl inhaler more frequently. Then the day prior to
admission she developed fever (to 103.4 at home), chills, and
urinary symptoms (dysuria, incontinence and frequency). She did
report several family members with viral illnesses.
.
In the ED she was febrile to 102.9 and tachycardic with HR in
the 120's to 130's. She required 4 L of oxygen to maintain her
sats in the mid 90's. She was cultured and started on
levofloxacin and vancomycin for PNA, although her CXR showed no
infiltrate. She was also given IVF. She remained tachycardic and
was noted to become somulent (although her ABG showed 7.41/46/81
on 4L) so she was admitted to the MICU.
.
Vanc was continued in the MICU and levofloxacin was changed to
zosyn due to concern for sepsis. She was also started on
oseltamivir due to concern for flu. In the MICU a DFA was sent
and was negative for flu. Swine flu confirmatory testing is
pending at the state lab. Urinary leginella also returned
negative. Patient also has a history of chronic skin ulcers on
her chest, leg, and vulva. These were considered as a possible
source of infection so her antibiotics have been continued.
During her MICU stay her tachycardia resolved and she was weaned
off oxygen, currently sattnig normally on RA.
.
Currently she denies pain or SOB at rest, but admits to SOB with
exertion. Had been constipated until today when she developed
diarrhea. Denies abdominal pain. She has been afebrile since
admission to the MICU.
.
ROS: Denies night sweats, headache, vision changes, chest pain,
nausea, vomiting, BRBPR, melena, hematochezia, hematuria.
.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
1. DMII
2. s/p Stroke in [**2138**] on coumadin
3. Hypertension
4. Baseline Creatinine 1.1-1.3
5. Hyperlipidemia
6. Elevated factor VIII level
7. Patent foramen ovale and interatrial septal aneurysm
8. Obesity
9. Asthma
10. Hidradenitis suppurativa -chronic boils on chest
11. Osteoarthrosis
12. OSA on CPAP
13. Chronic pain
Social History:
SOCIAL HISTORY:
Lives in JP with multiple family members. Quit smoking 20 years
ago after 25 pack-years. Denies drug use, only occasionally uses
alcohol.
.
Family History:
.
FAMILY HISTORY:
Mother died of MI at age 38. Father died of prostate
ca at age 85.
Physical Exam:
PHYSICAL EXAM:
Vitals: T 98.0 P 90 BP 139/69 R 18 Sat 100% on RA. LOS 44 cc +.
GENERAL: Middle-aged, obese female lying in bed in NAD.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD.
CARDIAC: RRR, faint heart sounds, no MRG.
LUNGS: Patient breathing comfortably. CTAB.
ABDOMEN: Obese, +BS, soft NTND.
EXTREMITIES: Slight edema present b/l, 2+DP.
SKIN: small, shallow ulcer under her left arm - drainage; small,
deep ulcer under her left breast - no drainage; under the center
of her breasts there is a very small hole draining a small
amount of pus. Left groin area under pannus a small ulcer
present.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation to light touch throughout. 5/5 strength in her upper
and lower extremities.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2143-6-1**] 03:10PM BLOOD WBC-16.5*# RBC-4.29 Hgb-10.9* Hct-33.1*
MCV-77* MCH-25.3* MCHC-32.9 RDW-15.6* Plt Ct-212
[**2143-6-5**] 06:15AM BLOOD WBC-10.5 RBC-4.06* Hgb-10.8* Hct-31.3*
MCV-77* MCH-26.6* MCHC-34.6 RDW-16.5* Plt Ct-224
[**2143-6-1**] 03:10PM BLOOD Neuts-95.5* Lymphs-2.7* Monos-1.5*
Eos-0.2 Baso-0.1
[**2143-6-1**] 03:10PM BLOOD PT-32.3* PTT-26.1 INR(PT)-3.4*
[**2143-6-5**] 06:15AM BLOOD PT-18.0* PTT-24.8 INR(PT)-1.6*
[**2143-6-1**] 03:10PM BLOOD Glucose-247* UreaN-28* Creat-1.5* Na-139
K-4.1 Cl-102 HCO3-26 AnGap-15
[**2143-6-5**] 06:15AM BLOOD Glucose-72 UreaN-21* Creat-1.2* Na-140
K-3.9 Cl-103 HCO3-27 AnGap-14
[**2143-6-2**] 04:31AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.6 Iron-27*
[**2143-6-3**] 05:30AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7
[**2143-6-3**] 05:30AM BLOOD LD(LDH)-185 TotBili-0.4
[**2143-6-2**] 04:31AM BLOOD calTIBC-234* Ferritn-84 TRF-180*
[**2143-6-3**] 05:30AM BLOOD Hapto-167
CXR:
FINDINGS: As compared to the previous radiograph, there are no
relevant
changes. The size of the cardiac silhouette is at the upper
range of normal. There is no evidence of focal parenchymal
opacities suggesting pneumonia. No pleural effusions, no
evidence of overhydration.
MICROBIOLOGY:
BCx x 2 ([**6-1**])- NGTD
DFA ([**6-1**]) - negative
UCx ([**6-1**]) - NGTD
Ulegionella Ag - negative
BCx ([**6-2**]) - NGTD
.
STUDIES:
CXR ([**6-1**]): No acute cardiopulmonary abnormality. Stable
enlargement of both hila. No evidence of congestive heart
failure.
.
CXR ([**6-2**]): As compared to the previous radiograph, there are no
relevant changes. The size of the cardiac silhouette is at the
upper range of normal. There is no evidence of focal parenchymal
opacities suggesting pneumonia. No pleural effusions, no
evidence of overhydration.
Brief Hospital Course:
64 yo F with a history of morbid obesity, HTN, DM2, chronic skin
ulcers, who presents with fevers, chills, shortness of breath,
and cough.
.
# Sepsis: patient with fever, leukocytosis, tachycardia. Patient
with three criteria for SIRS and potential pulmonary source of
infection. Patient has WBC of 16.5 with left shift but no bands.
In the setting of fevers, chills, dysuria, and cough, concerning
for infectious etiology likely pneumonia. CXR w/o overt
infiltrate however patient has cough, productive sputum. Viral
potential but bacterial etiology possible. Given symptoms of
dysuria, frequency, and incontinence, assessment made for UTI.
Physical exam without CVA tenderness. Patient has hydradenitis,
which may be a source of infection and abscess. No history of
diarrhea.Influenza antigen test sent in ED. Given possibility of
H1N1 Influenza, treated empirically with oseltamavir pending
antigen testing. Pt. placed on droplet precautions, sputum
culture, blood culture, urine legionella sent, and patient
placed on vanc/levo empirically for abx. Pt. afebrile and
eventually ruled out for the flu. Her CXR was without evidence
of infection and her antibiotics were stopped.
.
# Hypoxia: unclear if primary related to pulmonary infection.
Sinus tachycardia. Fever. No infiltrate on CXR. Family with
viral illness, placed on vanc/levo with work as above.
.
# Acute renal failure: Baseline creatinine 1.1-1.3. Cr on
admission 1.5. Likely prerenal in the setting of viral or
bacterial infection. Patient received 1.5L of IV fluids in ED
with a resultant decrease in Cr.
.
# Wound Care: Patient with several wounds in her pannicular
grooves an labia, not purulent, but draining clear liquid with
occasional blood. Wound care consult placed, in addition,
general surgery consult placed given history of these wounds
being followed by general surgery.
.
# Tachycardia: HR to 130s in ED, unresponsive to IV fluids,
though in the setting of fever. This was likely secondary to
fever, and infectious syndrome.
.
# Lactic acidosis: Lactate 2.1. Differential includes tissue
hypoperfusion in the setting of sepsis. Patient denies abdominal
pain. No anion gap.
.
# Microcytic Anemia: HCT 33.1. Baseline HCT 36-37. BP stable. No
active signs of bleeding. On coumadin for CVA with mild
supratherapeutic INR to 3.4. Unlikely source of tachycardia.
Hemolysis and Iron deficiency labs sent.
.
# Somnolence: Patient thought to be somnolent in ED. ABG was
reassuring for no acute hypercarbia. Appeared talkative and
alert in the MICU. Potentially related to fever, infection.
.
# DM 2: Patient on lantus 95u qam. Started on home lantus and
SSI. Held metformin in the setting of acute renal failure.
.
# Hypertension: BP normotensive currently. On Metoprolol and
Valsartan at home. No evidence of sepsis at this time, continued
metoprolol, held valsartan initially and then restarted the next
day prior to transfer.
.
# Chronic pain: secondary to osteoarthritis. Continued
Gabapentin per outpatient regimen, Low dose morphine, lower than
home regimen. closely monitor for sedation.
.
# OSA: on CPAP at home, continued CPAP
.
# Code: full per patient. She wishes we discuss this with her
daughter in AM
.
# Communication: Patient
daughter: [**Name (NI) **] [**Known lastname 732**] [**Name (NI) 11182**] [**Telephone/Fax (1) 12848**]- will confirm med
list with her in AM.
Medications on Admission:
Albuterol inhaler q6h PRN shortness of breath
Allopurinol 100mg po daily
Amoxicillin 500mg po bid
Clindamycin phosphate 1% lotion [**Hospital1 **]
Flonase 50mcg spray [**Hospital1 **]
Flovent 110mcg 2 puffs po bid
Gabapentin 400mg po bid
Lantus 95u qam
Combivent 2 puffs q6h PRN shortness of breath
Lovastatin 10mg po daily
Metformin 500mg po bid
Metoprolol 50mg po daily
Flagyl 0.75% gel - apply to base of wound
Morphine 15mg in am, 30mg po qhs
Oxybutynin 5mg [**Hospital1 **] or tid PRN incontinence
Percocet 5mg po q6h PRN pain
Phentermine 37.5mg po daily
Valsartain 320mg po daily
Warfarin 6mg po daily
Calcium Carbonate Vitamin D3 600mg-400unit po bid
Ferrous sulfate 325mg po daily
Humalog SSI
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation once a day as needed for shortness of breath
or wheezing.
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
5. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
7. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Insulin Glargine 100 unit/mL Solution Sig: Ninety Five (95)
Subcutaneous at bedtime.
11. Morphine 15 mg Tablet Sig: One (1) Tablet PO twice a day:
15mg in am and 30mg in pm.
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
13. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO twice
a day as needed for incontinence.
14. Phentermine 37.5 mg Capsule Sig: One (1) Capsule PO once a
day.
15. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Warfarin 2 mg Tablet Sig: Seven (7) Tablet PO Once Daily at
4 PM: 14mg daily.
17. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
19. Insulin Sliding Scale
Please continue your previous insulin sliding scale with humalog
as before.
20. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO twice a
day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Fevers, elevated white blood cell count
Rule out Flu
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because of high fevers. You
were initially treated with antibiotics because of a concern for
a bacterial infection. You blood cultures had not grown
anything by the time of discharge.
Medication changes:
Your coumadin level was high initially so your dose was
decreased. However your level then became low. Please take
14mg of coumadin and have your INR checked on Friday ([**2143-6-7**]).
No other medication changes were made.
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:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], DPM Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2143-6-7**] 1:30
|
[
"079.99",
"285.9",
"V12.54",
"V58.67",
"705.83",
"278.01",
"493.90",
"707.8",
"584.9",
"585.2",
"427.31",
"403.90",
"276.2",
"338.29",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11589, 11646
|
5634, 7212
|
345, 352
|
11744, 11753
|
3852, 5611
|
12511, 12693
|
2853, 2921
|
9749, 11566
|
11667, 11723
|
9023, 9726
|
11777, 11998
|
2951, 3833
|
12018, 12488
|
285, 307
|
7225, 8997
|
380, 2267
|
2289, 2643
|
2675, 2819
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,009
| 126,068
|
45102
|
Discharge summary
|
report
|
Admission Date: [**2190-12-11**] Discharge Date: [**2190-12-13**]
Date of Birth: [**2112-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
unresponsive at HD
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 77 yo man with h/o longstanding HTN c/b ESRD, several
lacunar strokes, multivascular dementia with poor baseline
cognitive function, limited verbal ability and comprehension, as
well as poor memory, who presented with AMS today from his
outpatient dialysis center.
.
Per pt's wife and Neurology resident, pt had some agitation last
night, talking with his wife and pacing with walker. He finally
fell asleep around 3AM, awoke at 4AM for dialysis at 6:30,
slightly groggy but responding appropriately to his wife before
HD. Her received his usual dose of 50mg benadryl before
dialysis, and then slept through the entire dialysis, which is
unusual for him (last known "awake" time was 6:30AM). Following
dialysis, staff tried to wake him up with verbal and tactile
stim and he was unresponsive. Staff tried applying cold packs to
head, no response. BP was "high" and RR was 12 (other VS
unavailable). Wife tried to move his head which felt heavy and
stiff, and entire body looked stiff with no spontaneous mvmt. At
one point, wife tried to move him and he slapped her hand away,
thus wife thought he was "alright." However, was again
unresponsive, eyes closed just after this.
.
When EMS arrived, he had his eyes open and was looking around
initially, though unresponsive. In ER, still unresponsive, BG
found to be 49 - given 1amp d50, with no return to BL, thus CODE
STROKE called. Neuro arrival within 5 minutes, and initial NIHSS
score high in every category as pt unresponsive; TPA not given
as last well-time was 6:30AM (5.5 hrs ago) and not clear to be
stroke. Per Neuro recommendation, pt underwent head CT followed
by head MRI, both of which were unrevealing for etiology of his
AMS. He initially had 1mg Ativan given for possible Sz, and when
no response, he was loaded on IV dilaudid. Had bedside EEG in
the ER that did not show definite Sz activity, but Neuro
recommends continuing Dilantin. Also notable, pt had SBP in the
250s while in ED.
.
Per wife, the patient's baseline is: limited speech and
comprehension, walks with walker, brushes teeth and feeds self
but wife helps him with most other adls, including transfers. He
has some urinary and bowel incontinence at baseline. He has
complained of no (and wife has noticed no) f/c/cp/sob/uri
sx/gi/gu sx; he has chronic LBP and as usual took vicodin this
am. No visual, hearing, sp/sw problems, no new
weakness/numbness; has fallen (falls occ. at BL) but no head
trauma.
Past Medical History:
-ESRD related to HTN nephropathy
-s/p avf in both arms, R arm is functional
-HTN x >20 yrs
-Multivascular dementia
-BPH
-Chronic LBP with DJD, spinal stenosis
-Macrocytic anemia, unclear if from ESRD
Social History:
Retired plumber; no tob, etoh or drugs; lives with wife; has 2
children.
Family History:
No strokes or CAD
Physical Exam:
Vitals: T 97.0, HR 51, BP 151/84, RR 18, Sat 100% on 2LNC, UO
78cc/3h
Gen: initially sleeping and intermittently apneic, aroused to
touch, poorly responsive and not following commands, withdraws
to pain
HEENT: PERRL (5 to 3 mm), EOMI with approp tracking, mouth
closed and not opening for exam
Neck: turning head with no apparent discomfort; tunnelled line
into L SCV
CV: bradycardic, regular, +s4, no s3, no m/r
Lungs: CTA
Abd: thin, soft, NT (no grimace or withdrawal), ND, no HSM
Ext:
UE -- L pulsatile AVF without bruit or thrill, 2+ radial pulse;
R AVF with overlying bandage, with thrill and bruit, 2+ radial
pulse
LE -- thin, no edema, cool bilaterally but with 2+ DP pulses
bilaterally
Neuro:
a) MS: Unresponsive to verbal, opens eyes to tactile stim,
withdraws to pain, not following commands, nonverbal
b) CN: perrla 5->3; +blink to threat bilat; could not look in
mouth or test gag as teeth clenched shut
c) Sensorimotor: moving all 4 ext and neck, resisting extension
of arm for ABG
d) DTRs: 1+ biceps bilaterally, 1+ at knees bilaterally, toes
upgoing with Babinski bilaterally
Pertinent Results:
[**2190-12-11**] 10:43PM POTASSIUM-6.1*
[**2190-12-11**] 08:53PM GLUCOSE-81 UREA N-33* CREAT-8.8* SODIUM-138
POTASSIUM-6.5* CHLORIDE-99 TOTAL CO2-28 ANION GAP-18
[**2190-12-11**] 08:53PM ALT(SGPT)-19 AST(SGOT)-54* CK(CPK)-198* ALK
PHOS-68 TOT BILI-0.4
[**2190-12-11**] 08:53PM CK-MB-7 cTropnT-0.22*
[**2190-12-11**] 08:53PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-1.8
[**2190-12-11**] 08:53PM TSH-3.2
[**2190-12-11**] 08:53PM WBC-4.8 RBC-3.79* HGB-13.4* HCT-41.6 MCV-110*
MCH-35.3* MCHC-32.1 RDW-17.0*
[**2190-12-11**] 08:53PM PLT COUNT-148*
[**2190-12-11**] 08:53PM PT-11.7 PTT-29.3 INR(PT)-1.0
.
pCXR [**2190-12-11**]:
1. New retrocardiac opacity, which likely indicates pneumonia.
Atelectasis is a less likely diagnostic consideration.
2. Hypertensive configuration of the heart and aorta.
3. Indwelling dialysis catheter as above.
.
Brain MRI: No evidence of acute infarct.
MRA: Head MRA is somewhat limited by motion. There is no
evidence of vascular occlusion seen. There is diminished flow
signal intensity visualized in the intracranial arteries which
appears artifactual. The basilar artery flow void as well as the
basilar artery flow signal on source images is maintained.
IMPRESSION: Somewhat limited normal MRA of the head
.
head CT: No acute intracranial hemorrhage or mass effect. No
significant change from [**2190-9-27**].
.
EEG: This is an abnormal EEG in the waking and sleeping states
due to the low voltage slow posterior rhythm as well as bursts
of
bilateral frontal 4 Hz slowing. This suggests an encephalopathic
pattern which may be seen with medications or toxic metabolic
abnormalities.
.
pCXR: Mild CHF with left greater than right small pleural
effusions.
Brief Hospital Course:
MICU course:
- CT, MRI/MRA, EEG all negative for acute pathology. Etiology
of altered mental status thought to be multifactorial - 1)By
history patient took double of the usual dose of benadryl.
2)Patient found to be hypoglycemic. 3) Renal failure. 4)All
superimposed on baseline that per family is altered.
- Patient was intially started on dilantin but the etiology was
ultimately deemed not to be seizure. The patient should see his
behavioral neurologist, Dr. [**First Name (STitle) **], for whether he should
restart this medication.
- Plan to go to dialysis [**2190-12-13**] with possible removal of
tunneled catheter if dialysis through fistula is successful.
- Elevated potassium was treated with good effect with
kayexalate, insulin and D-50.
- Patient was incidentally found to have a retrocardiac opacity
but was not treated because of lack of fever and normal white
blood cell count.
- Home were held on admission, but were subsequently restarted
and the blood pressure remained stable.
# AMS: unclear etiology although possible precipitants include
hypoglycemia, seizure, altered BP; Neurology was consulted, EEG
was performed and showed no seizure. Head CT and MRI/A were
unremarkable. Benadryl/trazodone were held. Mental status
improved to baseline per his family. Trazodone was held. He
should try to avoid >25 mg at a time of benadryl. Blood sugars
returned to [**Location 213**].
.
# CV: Had slight TnT bump though with no change in ECG and known
ESRD; ruled out for MI, no CP/SOB.
# HTN: became very hypertensive to >200/100, not controlled on
home meds, so patient was changed to labetalol 400 mg tid in
addition to his norvasc for better BP control, his BP improved
to 140/90.
.
# ESRD: Had elevated Cr, K on admit. Dialyzed with improved K.
Will continue increased frequency of HD for a few days. Due for
another HD session the day after d/c. His fistula has matured as
was used for effective HD. He will need to follow up with Dr.
[**Last Name (STitle) 816**] as an outpatient to have his tunnelled HD cath removed. Pt.
did not want to stay in the hospital to have this removed. He
was restarted on his sensipar, renal caps, and fosrenal. He will
follow up with Dr. [**Last Name (STitle) 816**] and Dr. [**Last Name (STitle) **].
.
# Thrombocytopenia: plt count mildly low at 141k (recent bl
167k-190k) Follow up as an outpatient.
.
Medications on Admission:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lopressor 12.5 mg [**Hospital1 **]
3. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day). Disp:*120 Tablet, Chewable(s)*
Refills:*2*
4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [**6-24**]
hours as needed for agitation.
6. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day.
7. Trazodone 50 mg hs.
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
3. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [**6-24**]
hours as needed for agitation.
6. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Altered Mental Status
Hypoglycemia
End Stage Renal Failure
Hypertensive Urgency
Vascular Dementia
Discharge Condition:
stable
Discharge Instructions:
Please continue medications as listed below. Please follow up
for dialysis tomorrow. Please also follow up with Dr. [**Last Name (STitle) 816**] to
have your tunnelled catheter removed.
Followup Instructions:
1. Please call Dr.[**Name (NI) 1381**] office tomorrow to schedule a follow
up appointment to have your tunnelled catheter removed.
2. Please follow up with your nephrologist in the next week.
3. Please go for dialysis tomorrow.
4. Follow up with your PCP [**Last Name (NamePattern4) **] [**1-18**] weeks.
|
[
"724.5",
"403.91",
"437.0",
"585.6",
"428.30",
"276.7",
"290.40",
"438.9",
"281.9",
"780.97",
"250.80",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9535, 9541
|
6013, 8377
|
336, 343
|
9683, 9692
|
4289, 5541
|
9926, 10238
|
3143, 3162
|
8947, 9512
|
9562, 9662
|
8403, 8924
|
9716, 9903
|
3177, 4270
|
278, 298
|
371, 2813
|
5550, 5990
|
2835, 3036
|
3052, 3127
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,308
| 105,513
|
24323
|
Discharge summary
|
report
|
Admission Date: [**2165-7-28**] Discharge Date: [**2165-7-31**]
Date of Birth: [**2137-12-12**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
PT s/p single car MVC rollover
Major Surgical or Invasive Procedure:
L index finger partial amputation
Bedside debridement & irrigation of wound
History of Present Illness:
Pt was driving with EtOH on board and rolled her vehicle over,
suffered injuries to left digits and left shoulder and c spine
Social History:
EtOH
Physical Exam:
Pt was found to have L degloving injury at PIP of finger, neck
pain, and a left posterior shoulder laceration/abrasion
Pertinent Results:
[**2165-7-28**] 07:28AM WBC-13.6* RBC-3.66* HGB-11.4*# HCT-32.9*
MCV-90 MCH-31.1 MCHC-34.6 RDW-13.5
[**2165-7-28**] 02:05AM BLOOD ASA-NEG Ethanol-320* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2165-7-29**] 05:40AM BLOOD WBC-8.2 RBC-3.97* Hgb-12.2 Hct-35.3*
MCV-89 MCH-30.7 MCHC-34.5 RDW-13.3 Plt Ct-141*
[**2165-7-29**] 05:40AM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-136 K-4.0
Cl-101 HCO3-24 AnGap-15
[**2165-7-28**] 02:11AM BLOOD Hgb-14.7 calcHCT-44 O2 Sat-68 COHgb-4
MetHgb-0
Brief Hospital Course:
Patient was seen by plastics in ED, eval of finger suggested
that eventual amputation will be necessary C spine films showeda
R posterior lamina fracture with assoc transvers foramina
compression, pt was placed in a hard collar, Left shoulder films
were negative but Left shoulder was with large abrasion which
was treated with wet to dry and xeroform dressings.
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
2. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
4. Dressing supplies
Normal saline, sterile gauzes & kerlex dressing
Discharge Disposition:
Home With Service
Facility:
Community VNA of [**Location (un) 6981**]
Discharge Diagnosis:
s/p motor vehicle accident
L index finger amputation
L shoulder laceration
C5 vertebral fracture (R posterior lamina)
Discharge Condition:
Stable
Discharge Instructions:
Take medications as perscribed, wear cervical collar at all
times, follow up with orthopaedics and trauma surgery as
indicated below. Return to the Emergency Department if you have
high fevers, pain that is uncontrollable on your pain
medications. Follow Physical therapy recommendations as
indicated
Followup Instructions:
follow up with:
Plastic surgery clinic for your ultimate finger repair:
[**Telephone/Fax (1) 274**]
Orthopaedics: Dr. [**Last Name (STitle) 363**] in 2 weeks call ([**Telephone/Fax (1) 61627**] to
discuss your neck fracture
Trauma Clinic: call ([**Telephone/Fax (1) 29931**] for an appointment in 2 weeks
|
[
"E849.5",
"E816.0",
"880.20",
"305.01",
"V15.81",
"805.05",
"873.49",
"886.0",
"816.12",
"780.09",
"883.0",
"458.9",
"816.01",
"873.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"79.64"
] |
icd9pcs
|
[
[
[]
]
] |
2081, 2153
|
1266, 1630
|
345, 423
|
2315, 2323
|
754, 1243
|
2674, 2982
|
1653, 2058
|
2174, 2294
|
2347, 2651
|
615, 735
|
275, 307
|
451, 578
|
594, 600
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,043
| 124,645
|
32735
|
Discharge summary
|
report
|
Admission Date: [**2161-12-25**] Discharge Date: [**2162-1-12**]
Date of Birth: [**2087-12-14**] Sex: F
Service: MEDICINE
Allergies:
Albuterol
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Tachycardia/Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 73-year old female with a PMH of stable severe COPD
(on prednisone 20mg daily) presenting with worsening dyspnea and
tachycardia. She reports increased SOB X2 days with increased
nebulizer use at home with minimal improvment. Per EMS report
the pt had a rapid heart rate in 180s and was given cardizem. On
arrival to ER Initial vitals T 99.1, HR 118, BP 181/79, RR 28,
O2 sat 98% on FM. She was given methylprednisolone 125mg IV x1,
combivent neb x1, levofloxacin 750 PO x1, ASA 325mg X1, Tylenol
500mg X1, Mg sulfate 2g IV x1. CXR with no evidence of volume
overload, no clear infiltrate, flat diaphragms. She was placed
on CPAP with reports of increased comfort however her BP dropped
to 69 systolic, she was given 2L NS. After improvement in BP she
was again placed on Bipap with subsequent drop in BP to 80s.
Desired to r/o for PE with CTA however she was unable to lie
flat, so heparin gtt was started. Guaiac negative. ECG unchanged
from prior.
.
Current Vitals T 97, HR 112, BP 94/43, 27, comfortable sending
off CPAP.
.
On arrival to the ICU, patient feels that her breathing is
slightly better. She notes that her shortness of breath worsened
gradually. She notes a cough that has been productive of thick
white sputum for weeks, a low grade temperature at home with
some chills yesterday, but no other symptoms besides her
shortness of breath, including palpitations, chest pain, n/v/d,
abdominal pain, calf pain/swelling. No sick contacts. Received
the flu shot this season and pneumovax last year. She has been
taking Prednisone 20mg daily for 4 weeks per Dr. [**Last Name (STitle) 2168**].
Past Medical History:
1. COPD
2. Coronary Artery Disease s/p STEMI related to coronary
vasospasm
3. Congestive Heart Failure
- diastolic and systolic heart failure with EF 45%
4. Aortic Mural Thrombus
5. h/o Upper Extremity DVT associated with PICC line
6. Hypertension
7. Emphysema
- spirometry on [**2161-2-23**] with severe obstructive ventilatory
defect, FEV1/FVC 63% predicted
8. Hypercholesterolemia
9. h/o Cdiff colitis
10. Right upper lobe nodule
11. Compression Fractures
12. s/p cataract surgeries
Social History:
SOCIAL HISTORY:
Home: lives in a house with friends and family close by
Occupation: retired nurse [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) 4199**] Hospital
EtOH: Denies
Drugs: Denies
Tobacco: 60 PPY smoking history, quit 11 years ago
Family History:
Mother - died from [**Name (NI) 2481**] at the age of 75
Father - died with lymphoma and colon cancer at 80yo
Physical Exam:
Vitals: T: 97.5 BP: 93/47 P: 106 R: 25 O2: 95% on NC
General: Alert, oriented, moderate respiratory distress with
pursed lip breathing and accessory muscle use. Can almost finish
complete sentences
HEENT: Sclerae anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Poor air movement throughout, significantly prolonged
expiratory phase with scattered rhonchi, and upper airway
congestion
CV: tachycardic, normal S1 + S2, distant
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; scattered ecchymoses
Pertinent Results:
[**2161-12-25**] 09:30AM WBC-20.3*# RBC-4.71 HGB-13.7 HCT-41.2 MCV-88
MCH-29.0 MCHC-33.1 RDW-15.8*
[**2161-12-25**] 09:30AM NEUTS-90.3* LYMPHS-5.3* MONOS-4.0 EOS-0.2
BASOS-0.2
[**2161-12-25**] 09:30AM PLT COUNT-326
[**2161-12-25**] 09:30AM PT-12.1 PTT-25.2 INR(PT)-1.0
[**2161-12-25**] 09:30AM CK-MB-NotDone proBNP-269
[**2161-12-25**] 09:30AM cTropnT-0.01
[**2161-12-25**] 09:30AM CK(CPK)-25*
[**2161-12-25**] 09:30AM GLUCOSE-100 UREA N-22* CREAT-0.7 SODIUM-135
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15
[**2161-12-25**] 12:14PM LACTATE-1.4
Brief Hospital Course:
74 yo F with severe COPD admitted with COPD exacerbation
secondary to RSV bronchiolitis
.
# COPD exacerbation/RSV bronchiolitis - On admission the patient
was found to have RSV on nasopharyngeal aspirate. She was
treated supportively with stress dose steroids, Bipap and
frequent nebulizers. She was also given a 5 day course of
levaquin for possible secondary pneumonia. Given her persistent
leukocytosis she was also treated with ceftriaxone for a 5 day
course, stop date [**1-4**]. Was initiatlly given high does steroids
and tapered; however, she continued to require high doses
subsequently during her stay for fluxuating respiratory status
and thrombocytopenia (as below). Inital CT Chest with no clear
infilitrate, c/w severe emphysema. On [**2162-1-11**], her respiratory
status acutely worsened. CXR showed worsening right infiltrate.
Antibiotics were broadened to zosyn/levo. She required
intubation, but she was unable to be ventilated/oxygenated
properly. She subsequently expired on [**2162-1-12**].
# bacteremia: enterococcus faecium cultured from her blood on
[**2162-1-6**]. Vancomycin was added as per sensitivities.
.
# thrombocytopenia: her platelets dropped precipitously on
[**2162-1-5**] and she subsequently became more anemic. Heme/onc
consult was initiated. It was thought to be HIT vs ITP vs meds
vs infection-related drop in platelets. She was continued on IV
steroids until [**1-11**] when it was changed to 60mg po prednisone.
Possible offending agents were discontinued. Smears showed
little evidence of hemolysis, though her hapto and LDH were
consistent with hemolysis. She received platelet and pRBC
transfusions as necessary. CT for RP bleed was negative. Her
Adamts13 came back slightly low at 61. She underwent
plasmaphoresis for several days with no improvement in her plts.
.
# UTI: Patient with +UTI on UA, urine culture with yeast. Given
the patient had symptomatic dysuria, she was treated with
fluconazole for 10 day course.
.
# Tachycardia ?????? Occurred after Zopenex, improved with
Metoprolol. She was continued on metoprolol 12.5 TID and ativan
qhs prn.
.
# Coronary Artery Disease s/p STEMI related to coronary
vasospasm: continued aspirin. Metoprolol as above, continued
acei as tolerated (though was held during while on
plasmaphoresis).
Medications on Admission:
Alendronate 70 mg Tablet 1 Tablet(s) by mouth weekly
Atorvastatin [Lipitor] 40 mg Tablet 2 Tablet(s) by mouth daily
Fluticasone-Salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose Disk
with Device 1 puff inh twice a day [**2161-5-14**]
Ipratropium Bromide 0.2 mg/mL (0.02 %) Solution 1 neb inhalation
once a day
Lisinopril 5 mg Tablet 1 Tablet(s) by mouth daily
Montelukast [Singulair] 10 mg Tablet 1 Tablet(s) by mouth once a
day
Omeprazole 20 mg Capsule, Delayed Release(E.C.) 2 Capsule,
Delayed Release(E.C.)(s) by mouth once a day
Prednisone 10 mg Tablet 2 Tablet(s) by mouth once a day
Tiotropium Bromide [Spiriva with HandiHaler] 18 mcg Capsule,
w/Inhalation Device 1 cap(s) inh once a day
Trimethoprim-Sulfamethoxazole 400 mg-80 mg Tablet 1 Tablet(s) by
mouth daily
Verapamil 180 mg Cap,24 hr Sust Release Pellets 1 Cap,24 hr Sust
Release Pellets(s) by mouth once a day
Aspirin 81 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by
mouth once a day
Calcium-Cholecalciferol (D3) [Caltrate-600 Plus Vitamin D3]
600 mg-400 unit Tablet 1 Tablet(s) by mouth twice a day
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
RSV
COPD exacerbation
thrombocytopenia
anemia
bacteremia
Secondary:
1. COPD - spirometry on [**2161-2-23**] with severe obstructive
ventilatory
defect, FEV1/FVC 63% predicted
2. Coronary Artery Disease s/p STEMI related to coronary
vasospasm
3. Congestive Heart Failure
- diastolic and systolic heart failure with EF 45%
4. Aortic Mural Thrombus
5. h/o Upper Extremity DVT associated with PICC line
6. Hypertension
7. Hypercholesterolemia
8. h/o Cdiff colitis
9. Right upper lobe nodule
10. Compression Fractures
11. s/p cataract surgeries
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
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50,822
| 146,138
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36772
|
Discharge summary
|
report
|
Admission Date: [**2164-8-22**] Discharge Date: [**2164-9-14**]
Date of Birth: [**2112-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
abdominal distention and BRB on toilet paper
Major Surgical or Invasive Procedure:
1. EGD
2. Flex Sigmoidoscopy
3. Intubation
History of Present Illness:
52 y/o M with PMHx of etoh cirrhosis is transfered to MICU after
developing GIB.
.
He was initially admitted to ETS with increasing abdominal
distension and BRBPR on TP after using the bathroom. The plan
was for him to have paracentesis in the morning. His BRBPR
continued throughout the day (total of 8 episodes) and
apparently became more pronounced about one hr ago. His HCT was
17 from 32. His BP was 108/58. He has 2 pIVs prior to transfer.
He denies lightheadeness, chest pain, abdominal pain, nausea,
vomiting, hematemesis, or melena. He has a hisory of hemorrhoid.
Also history of UGIB with EGD showing G1 eso varix in [**2164-8-13**].
Dr [**Last Name (STitle) 696**] was contact[**Name (NI) **] and he is coming to scope the patient.
.
Recently he was admited to [**Hospital1 **] with BRBPR. He was treated with IV
protonix and an octreotide drip. He underwent flex sig which
revealed a large internal hemorrhoid and an EGD which revealed
erosions in the duodenum and Grade 1 varices were found in the
lower
esophagus. Also on that admission there was concern for SBP
given leukocytosis however a paracentesis was not performed [**2-6**]
coagulopathy. He was empirically treated with zosyn for 4 days
then transitioned to levoquin to complete a 7 day course to be
completed [**2164-8-15**].
.
Past Medical History:
ETOH cirrhosis
s/p bilateral knee replacements [**2-6**] OA
Chronic GIB [**2-6**] internal hemorrhoids
Leg fracture 25years ago
Grade 1 esophageal varices seen in [**9-/2163**] (grade 1 on EGD
[**2164-8-13**])
bleeding duodenal ulcer
Social History:
Currently disabled. Lives with wife and 16 [**Name2 (NI) **] daughter. Drank
[**1-6**] -1 pint of vodka daily for many years until quitting [**7-30**] [**2164**]. Non-smoker. Never used IVD. No tattoos
Family History:
Dad died of ETOH cirrhosis
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, 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, diffuse tender to plapation, distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: pitting [**Last Name (un) **] to thigh, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Skin: diffuse jaundice
EXT: 2+ pitting edema to knees. scars on bilateral knees.
NEURO: A+Ox3. No asterixis
DERM: No rashes
Pertinent Results:
[**2164-8-22**] 06:55AM BLOOD WBC-16.4* RBC-3.50* Hgb-10.2* Hct-32.7*
MCV-93 MCH-29.2 MCHC-31.3 RDW-18.9* Plt Ct-185
[**2164-8-23**] 07:48AM BLOOD Hct-21.8*
[**2164-8-23**] 10:11AM BLOOD WBC-22.3* RBC-3.51*# Hgb-10.0*#
Hct-30.7*# MCV-87# MCH-28.4 MCHC-32.5 RDW-17.5* Plt Ct-171
[**2164-9-14**] 05:25AM BLOOD WBC-13.1* RBC-3.03* Hgb-8.9* Hct-28.0*
MCV-92 MCH-29.3 MCHC-31.7 RDW-22.1* Plt Ct-152
[**2164-9-9**] 06:45AM BLOOD Neuts-87* Bands-0 Lymphs-8* Monos-4 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2164-8-22**] 06:55AM BLOOD PT-20.8* PTT-45.0* INR(PT)-1.9*
[**2164-8-23**] 03:38AM BLOOD PT-26.6* PTT-53.6* INR(PT)-2.6*
[**2164-9-14**] 05:25AM BLOOD PT-19.8* PTT-39.9* INR(PT)-1.8*
[**2164-8-24**] 08:42AM BLOOD Fibrino-140*
[**2164-8-22**] 06:55AM BLOOD Glucose-102 UreaN-25* Creat-0.8 Na-132*
K-4.4 Cl-107 HCO3-15* AnGap-14
[**2164-8-23**] 05:04AM BLOOD Glucose-152* UreaN-36* Creat-3.0* Na-134
K-5.9* Cl-114* HCO3-10* AnGap-16
[**2164-9-6**] 05:15AM BLOOD Glucose-107* UreaN-28* Creat-0.8 Na-134
K-4.4 Cl-102 HCO3-23 AnGap-13
[**2164-9-10**] 06:30AM BLOOD Glucose-107* UreaN-45* Creat-1.6* Na-134
K-5.0 Cl-102 HCO3-22 AnGap-15
[**2164-9-14**] 05:25AM BLOOD Glucose-145* UreaN-46* Creat-1.2 Na-133
K-5.0 Cl-103 HCO3-21* AnGap-14
[**2164-8-22**] 06:55AM BLOOD ALT-29 AST-98* AlkPhos-154* TotBili-37.0*
[**2164-8-26**] 04:00AM BLOOD ALT-24 AST-68* AlkPhos-75 TotBili-24.4*
[**2164-8-29**] 05:25AM BLOOD TotBili-32.5*
[**2164-9-3**] 05:15AM BLOOD TotBili-30.9*
[**2164-9-5**] 05:20AM BLOOD ALT-23 AST-54* AlkPhos-119* TotBili-30.4*
[**2164-9-6**] 05:15AM BLOOD TotBili-30.7*
[**2164-9-9**] 06:45AM BLOOD AlkPhos-154* TotBili-36.1*
[**2164-9-12**] 05:35AM BLOOD AlkPhos-124* TotBili-24.6*
[**2164-9-14**] 05:25AM BLOOD TotBili-22.1*
[**2164-9-14**] 05:25AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1
[**2164-8-22**] 06:55AM BLOOD IgG-1828*
[**2164-8-22**] 11:27AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2164-8-22**] 11:27AM BLOOD Smooth-NEGATIVE
[**2164-8-24**] 04:11AM BLOOD Lactate-2.0
[**2164-8-24**] 04:11AM BLOOD freeCa-1.15
[**2164-8-29**] 11:34PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2164-8-29**] 11:34PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.002
[**2164-8-25**] 04:20AM URINE RBC-92* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
[**2164-8-23**] 07:36PM ASCITES WBC-53* RBC-163* Polys-27* Lymphs-31*
Monos-0 Plasma-1* Mesothe-2* Macroph-38* Other-1*
[**2164-8-29**] 03:52PM ASCITES WBC-155* RBC-488* Polys-2* Lymphs-34*
Monos-46* Mesothe-13* Macroph-5*
EGD [**2164-8-22**]:
Esophageal varices
Blood in the stomach
Blood in the duodenal bulb and second part of the duodenum
A large visible vessel was seen in the proximal duodenum and
appeared to be the source of bleeding. This vessel likely
represents vessel in an ulcer base, and less likely a duodenal
varix. (injection, thermal therapy)
Abd U/S [**8-22**]:
Hepatic cirrhosis with secondary findings of portal hypertension
including
splenomegaly, ascites, and patent umbilical vein. Patent
hepatic vasculature. Patent main portal vein demonstrating
hepatopetal
flow.
Brief Hospital Course:
52 year-old man with PMHx of etoh cirrhosis transferred to MICU
after developing GIB and noted to have acute anemia,
leukocytosis and elevated INR.
# GIB: Patient presented with abdominal distention and BRB on
toilet paper. He was stable on admission to the floor but later
developed BRBPR on several occasions throughout the night. He
was found to be hypotensive and with a Hct of 17 from 30 on
admission. He was transfered to the MICU where he was intubated
for airway protection and underwent EGD and was found to have a
visible vessel that was thought to be either a variceal or a
vessel within a duodenal ulcer. He was started on octreotide
and pantoprazole, and he was transfused 15u PRBC, 7u FFP, 1 bag
of platelets, and 1u Cryoprecipitate. A right IJ catheter ([**Location (un) 109**])
was also placed and right a-line were also placed. He was
hypotensive during periods of acute bleeding and required IVFs
to maintain his blood pressure. He was successfully extubated
on [**8-24**] and subsequently transfered to the floor. On the floor
patient had about 4 episodes of small amount of BRBPR that
resolved on [**8-26**]. His BP and Hct remained stable on the floor
and he had no more episodes of UGIB until the week of discharge.
On [**2164-9-10**], patient was noted to have BRBPR again. Hematocrit
was stable, but do to original presentation, there was concern
for repeat UGIB. Flex Sigmoidoscopy showed internal hemorrhoids
and rectal ulcer, not actively bleeding, but with brown stool
above. BRBPR improved over the next 2 days without intervention
with intermittant BRBPR with BM's. Hematocrit was monitored and
stable through discharge on [**2164-9-12**].
# Acute kidney injury: Patient's renal function worsened acutely
as a result of his massive UGIB. His Cr increased from baseline
of 0.8 to 3.0. This was thought to be due to both ATN, in the
setting of hypoperfusion of the kidneys, and a possible
component of HRS. He was started on octreotide/midodrine/albumin
to treat empirically for HRS. His renal function improved and
his Cr ultimately went back to his baseline. After stability
inhis creatinine over a few days, he was started on low dose
lasix and spironolactone. These were increased as tolerated to
discharge does. On discharge, renal function was at baseline.
# Leukocytosis: Patient had an elevated WBC on admission of 16,
that was thought to be due to his ESLD initially. After his
massive UGIB his WBC increased even more to a high of 23. He
was started empirically on Zosyn for SBP in the setting of this
leukocytosis. A diagnostic paracentesis was done that ruled out
SBP. An infectious work up was done but BCx, UCx, peritoneal
fluid Cx and C.diff test were (-). Upon transfer to the floor he
was switched to ciprofloxacin empirically, which was continued
until all his Cx were (-).
# EtOH Hepatitis/Cirrhosis: Patient has hx of alcoholic
cirrhosis with grade 1 varices, last drink 1 month prior to
presentation. His presentation was consistent EtOH hepatitis
with Tbili 37 and INR 1.9. He was initially treated with
prednisone but only received one dose as he developed an UGIB on
the night of admission. Once his UGIB was undercontrol and his
renal function was improving he was transfered to the floor. On
the floor his Tbili and INR remained elevated. He was not
restarted on prednisone given his UGIB but pentoxifyline was
started. As a result of his ESLD he developed large tense
ascites and underwent IR guided medium volume paracentesis where
they took out 3.5L. After 1 week on pentoxifyline with no
improvement, Mr. [**Known lastname 24049**] was started on Prednisone 40mg daily for
expected one month course. Two days after starting prednisone,
Mr. [**Known lastname 24049**] started having BRBPR with stable hematocrit. Flex
sigmoidoscopy revealed internal hemorrhoids and rectal ulcers
with brown stool above, so this was sufficient to account for
the bleeding. Total bilirubin began to decrease on the
prednisone and at one week of therapy the decision was made to
discharge him home to complete a one week course of steroid
therapy. Mr. [**Known lastname 24049**] was to have outpatient lab work and
follow-up in the Liver Center for determination of steroid taper
after the one-month course.
Medications on Admission:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day) as needed for itching.
Disp:*60 Capsule(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*0*
4. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1800 ML(s)* Refills:*2*
7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*0*
9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 21 days.
Disp:*42 Tablet(s)* Refills:*0*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day) for 21 days.
Disp:*42 Tablet, Chewable(s)* Refills:*0*
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily) for 21 days.
Disp:*42 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
Please check CBC, LFT's (including total billirubin),
PT/PTT/INR, and basic metabolic panel (including potassium and
creatinine) on [**2164-9-17**], [**2164-9-20**], [**2164-9-24**] and fax results to PCP.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
Primary Diagnosis:
1. Alcholic Hepatitis
2. Duodenal Ulcer vs. Duodenal Varices with Upper GI bleed
3. Internal Hemorrhoids
4. Respiratory Failure
5. Hepatorenal Syndrome
Discharge Condition:
Hemodynamically stable. Tolerating food. Ambulating.
Discharge Instructions:
You were admitted to the hospital due to blood in your stool and
worsening abdominal distension. Your bleeding became severe
while you were in the hospital and you were transferred to the
intesive care unit (ICU). While in the ICU, they looked in your
stomach and intestine and found a bleeding vessel in the first
part of your intestine. The vessel was clipped and injected
with medications to stop the bleeding. You required blood
products due to your massive blood loss. You were also placed
on a machine to help you breathe while you were in the ICU. Due
to your bleeding, you kidney function declined. You were put on
medicine to help your kidney function return to normal. You
also were started on steroids to help your liver heal.
Additionally, medicines were given to get excess fluid out of
your body.
It is important that you not drink any more alcohol when you
leave the hospital. The alcohol has caused damage to your liver
that has predisposed you to bleeding in your gastrointestinal
tract. Additionally, your skin has turned yellow becuase your
liver is unable to process poisons properly in your body. This
should improve over time, however if you continue to drink, you
will likely experience repeat bleeding episodes that you may die
from. Please consider joining AA or another support group to
help you quit drinking alcohol. If you drink again, there is a
high likelihood that you would die.
You have been started on steroids, to be continued for 3 weeks
after your discharge. You must go to the appointment arranged
for you at the Liver Center to discuss tapering the dose of
steroids after the month of treatment.
It is very important that you have [**3-7**] bowel movements per day.
If you dont, there is a high chance that you will become very
confused. This is because your liver isnt breaking down waste
products in your blood. Lactulose helps get these toxins out of
your body and is incredibly important for you to take.
Changes in Medication:
CHANGE Ursodiol 300 mg by mouth to three times daily (was twice
daily)
CHANGE Pantoprazole 40 mg by mouth to twice daily (was once
daily)
START Lactulose 30 mL by mouth twice a day
START Spirinolactone 50 mg by mouth daily
START Furosomide 30 mg by mouth daily
START Prednisone 40 mg by mouth daily for 21 days
START Calcium Carbonate 500 mg by mouth twice a day for 21 days
START Vitamin D 800 units by mouth once a day
If you start to have increasing blood in your stool, vomitting
(with or without blood), uncontrollable bleeding from any site,
abdominal pain, nausea, confusion, shortness of breath, chest
pain, decreased urine output, worsening yellow of your skin or
any other symptom that concerns you, please contact your PCP,
[**Name10 (NameIs) **] [**Hospital1 18**] Liver Center, call 911 or go immediately to the
nearest emergency room for treatment.
Followup Instructions:
Please follow-up with your PCP within one week of discharge from
[**Hospital1 18**]. An appointment has been made for you with the Liver
Center at [**Hospital1 18**] on the following date:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2164-10-3**] 8:30
|
[
"276.1",
"571.2",
"303.91",
"285.1",
"455.0",
"276.7",
"288.60",
"572.3",
"571.1",
"584.5",
"569.41",
"276.2",
"572.4",
"532.40",
"458.9",
"456.21",
"789.59",
"782.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"45.24",
"54.91",
"38.91",
"96.71",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
12380, 12454
|
6069, 10340
|
364, 409
|
12669, 12726
|
2937, 6046
|
15628, 15973
|
2233, 2261
|
10931, 12357
|
12475, 12475
|
10366, 10908
|
12750, 15605
|
2276, 2918
|
280, 326
|
437, 1740
|
12494, 12648
|
1762, 1998
|
2014, 2217
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,476
| 199,622
|
53235
|
Discharge summary
|
report
|
Admission Date: [**2139-12-5**] [**Month/Day/Year **] Date: [**2139-12-5**]
Date of Birth: [**2057-5-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Bactrim / Nsaids
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 82 yo female w/ bronchiectasis, CHF and COPD who
presents with an acute change in mental status (became
nonverbal). On EMS arrival to her home, she was found to be
cyanotic and in respiratory distress. Was placed on NRB with
sats to 90s. Family states she had a sore throat yesterday, but
no cough or SOB that they noted. Also mention in records of ear
pain and odynophagia last night, as well as chills.
In the ED, initial VS: T 98.7 75/39 79 20 80s RA -> high 90s
NRB. Placed on BiPAP, satting 100%. Patient told EMS she did not
want to be intubated. ED paged her pulmonologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
re: intubation, and he said patient would not want to be
intubated; family also agrees. Her PCO2 on BiPAP was 110 with pH
7.05 so settings were increased from [**9-22**] to 15/8 with better Vt
(repeat ABG/lactate pending). Family unsure re: central lines,
DNR status. CXR with increased RUL infiltrate and ?dilated
bowel, also ?UTI, so given levofloxacin, metronidazole,
vancomycin, cefepime to include Pseudomonas given
bronchiectasis. She received 1.5 L of NS. Head, abdominal CT
performed to look for other sources of infection. Noncon CT head
and abd unremarkable. Current VS: 80/paced 98/60 28 96%BiPAP. On
2nd L IVF, on norepi 0.08 peripherally. Mental status improving.
She was given 1 L NS on the floor.
Note that remaining parts of hx (PMHx, Meds, SHx, FHX) are per
records given acuity of patient's presentation and treatment.
Past Medical History:
#CAD - Cath ([**3-/2134**]) - LMCA and LCx, no disease; LAD: proximal
and mid vessel 30% stenoses; RCA - mild luminal irregularities
Pacemaker/ICD ([**Company 1543**] Sigma SDR303 B pacemaker), in [**1-/2132**]
#Atrial fibrillation, status post AVJ ablation and DDD pacer
#Congestive heart failure (EF 30% in [**2135**])
#MV repair and TVR ([**4-/2132**])
#Bronchiectasis with presumed pseudomonal colonization ([**Month (only) 404**]
[**2135**] and treated with ceftazidime and azithromycin): Previously
suffered exacerbations in [**Month (only) **] and [**2135-8-19**] that were
treated with meropenem/ciprofloxacin and ceftazidime as
outpatient
#Depression
#Hyperparathyroidism
#Pan-sensitive E.coli UTI
#DJD
Social History:
Lives in [**Location (un) 55**]. She worked as a lecturer on Egyptology
at the MFA in [**Location (un) 86**]. Husband is deceased. She lives with her
son and has an aid most days of the week. Has three sons, [**Name (NI) **],
[**Name (NI) **] and [**Name (NI) **]. Quit smoking 30 years ago, had a 5 pack year
history. Previously, she drank one drink/day but no ETOH now for
many years.
Family History:
Her father and mother are both deceased. Her father had HTN. Her
mother had [**Name (NI) 19917**] disease and died as an elderly woman. There
is a negative family history of colon cancer, breast cancer,
diabetes, and premature coronary artery disease. She has three
natural children who are alive and well and one brother who is
alive and well. She also has a 17 year old granddaughter
recently diagnosed with melanoma.
Physical Exam:
VS: 96.9 93 103/47 20 100% on BPAP 15/8, FiO2 50%
Gen: in severe respiratory distress on BPAP, unable to speak
HEENT: EOMI, bruise on left maxilla [**1-20**] to recent MOHS
Neck: No JVD, no thyromegaly, no LAD
CVS: RRR, no MRG
Pulm: diffuse coarse rhonchi, + retractions, labored breathing
Abd: +BS, NTND, No HSM
Extrem: no c/c/e
Skin: no rashes
Neuro: Aox3, appropriate
Pertinent Results:
[**2139-12-5**] 02:00PM BLOOD Type-ART pO2-140* pCO2-110* pH-7.05*
calTCO2-33* Base XS--3 Intubat-NOT INTUBA
[**2139-12-5**] 03:45PM BLOOD pO2-70* pCO2-71* pH-7.19* calTCO2-28 Base
XS--2
[**2139-12-5**] 06:19PM BLOOD Type-[**Last Name (un) **] pO2-21* pCO2-105* pH-7.07*
calTCO2-32* Base XS--5
[**2139-12-5**] 12:11PM BLOOD Glucose-93 Lactate-4.8* Na-140 K-7.6*
Cl-97* calHCO3-30
[**2139-12-5**] 12:35PM BLOOD Lactate-5.7* K-4.9
[**2139-12-5**] 03:45PM BLOOD Lactate-1.7
CXR [**2139-12-5**]: Stable appearance of the lungs since [**2139-4-4**].
CT head [**2139-12-5**]: No acute intracranial pathological process, or
overt change from prior study. MRI scanning is more sensitive
than CT imaging in detecting acute brain ischemia.
CT abd/pelvis [**2139-12-5**]:
1. Limited exam without oral or IV contrast, but no evidence of
intraabdominal catastrophe.
2. Moderate bibasilar bronchiectasis.
3. Significant vascular calcifications.
4. Left renal hypodense lesion, likely a simple renal cyst.
Brief Hospital Course:
Patient presented with an acute change in mental status with
hypercapnic respiratory distress. Appeared to be in setting of
septic shock with potential sources being PNA and UTI. She was
initially admitted on BPAP with pressure settings of 15/8.
Initially, ABG showed improved ventilation and acidemia,
although repeat ABG in the ICU showed worsening CO2 retention
and acidemia despite high levels of pressure support (20/8). She
was continued on broad antibiotics with
vanco/cefepime/levofloxacin/ metronidazole and received 125mg IV
methylprednisolone. She had arrived on peripheral
norepinephrine, but was transitioned to IVF boluses when the PIV
infusing norepinephrine was lost. Family meeting was held with
her 3 sons and they wished to observe for improvement in the
next few hours before deciding on how aggressive to treat her,
but agreed to DNR/DNI, no CVC and no Aline at that time. Her BP
continued to trend down to SBP in 70s with minimal UOP, and IVF
were stopped given O2 sat 90% on 100% FiO2. Her RR was in
40s-60s initially, and she received a dose of 1mg IV morphine
for symptom control. After about 4 hrs from admission, her RR
trended down to 10-12 suggesting she was unable to maintain
appropriate ventilation. Her family then agreed that comfort was
the priority and prn morphine was ordered; the patient expired
shortly after and autopsy was declined.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs by mouth every four (4) to six (6) hours as needed
for cough/wheezing
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth q
week
CITALOPRAM [CELEXA] - 20 mg Tablet - 3 Tablet(s) by mouth once a
day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff inhaled twice a day rinse after use
FUROSEMIDE [LASIX] - 20 mg Tablet - 0.5 (One half) Tablet(s) by
mouth once a day and increase as directed by Dr [**Last Name (STitle) **]
LISINOPRIL - 5 mg Tablet - [**12-20**] Tablet(s) by mouth once a day
LORAZEPAM - 0.5 mg Tablet - [**12-20**] Tablet(s) by mouth qhs as
needed
for sleep
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
SPIRONOLACTONE - 25 mg Tablet - [**12-20**] Tablet(s) by mouth once a
day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day
WARFARIN [COUMADIN] - 1 mg Tablet - Take up to 3 tablets by
mouth
once a day or as directed by [**Company 191**] Anti-Coag
CALCIUM CITRATE-VITAMIN D3 - (OTC) - 315 mg-200 unit Tablet - 3
Tablet(s) by mouth once a day
GUAIFENESIN [MUCINEX] - (OTC) - 600 mg Tablet Sustained Release
- 2 Tablet(s) by mouth twice a day prn
MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Tablet -
1 Tablet(s) by mouth once a day
[**Company **] Medications:
Expired
[**Company **] Disposition:
Expired
[**Company **] Diagnosis:
Septic shock
Hypercapnic respiratory failure
Bronchiectasis
[**Company **] Condition:
Expired
[**Company **] Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2139-12-7**]
|
[
"995.92",
"038.0",
"486",
"V45.01",
"593.2",
"V49.86",
"494.0",
"562.10",
"785.52",
"518.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4863, 6239
|
328, 334
|
3845, 4840
|
7888, 8062
|
3014, 3435
|
6265, 7865
|
3450, 3826
|
267, 290
|
362, 1859
|
1881, 2594
|
2610, 2998
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,368
| 194,102
|
16981
|
Discharge summary
|
report
|
Admission Date: [**2121-1-26**] Discharge Date: [**2121-2-10**]
Date of Birth: [**2050-9-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
seizure s/p intubation for airway protection
Major Surgical or Invasive Procedure:
intubation, hemodialysis
History of Present Illness:
70 yo woman with hypertension, presents as a transfer from OSH,
intubated, s/p first seizure in the setting of elevated BPs.
*
History is per daughter/son/husband.
*
The patient is a 70 y.o. female with h/o htn, PVD s/p L common
carotid to subclavian bypass, MCA aneurysm - declined
intervention in past, who presents s/p first seizure. She was in
her usual state of health (fairly active at baseline,
independent of ADLs, drove to attended her grand daughter's
gymnastics event day PTP) until 3 weeks prior to admission when
she began experiencing new onset headaches which she described
as bilateral pressure behind the eyes. She also experienced
malaise and generalized weakness. Denied visual changes or
nausea. Despite her family's urging she refused to seek medical
attention at that time. One week after the onset of her HA's
she went to her PCP who thought that she had sinusitis and thus
prescribed an abx and a decongestant. She self d/c'ed the abx
soon after since it was ineffective but has been taking the
decongestant per daughter. 11 days ago, she went to the beauty
parlor and after standing up her legs "buckled." She felt light
headed and dizzy and her legs collapsed. Someone caught her as
she fell so that her head did not hit the ground. Was not
incontinent of bowel or bladder. She did not allow an ambulance
to be called. Since then she has c/o progressive
weakness/malaise such that she spent a great deal time in bed
with a cold compress on her head in dark room. She saw her PCP
4 days ago where her BP was low and thus he thought that her
weakness was [**2-13**] hypotension and thus d/c'ed nifedipine. Since
then her HA's have worsened such that she is unable to sleep.
She also c/o eye burning. When her daughter saw her yesterday
she appeared pale, weak with red puffy eyes. Today her headache
was "unbearable" so family took her to [**Hospital 1474**] hospital. There,
her BP was 240/110. She was given labetolol 20mg at 7:40am, and
then at 7:53am she had a "grand mal seizure" lasting 3 minutes.
There were no dips in her BP or HR just before the seizure. (BP
remained elevated in the 200's, HR 88-104). Prior to seizure she
was given SLNT 0.4 mg , 1 inch nitro paste, labetalol 20 mg IV x
T, tylenol, zofran 4 mg IV. Just prior to the seizure she
complained of bilateral vision loss. She was given 2mg IV
ativan, and intubated with succ, lido, etom, propofol and vec at
8am. She was loaded with dilantin 1gram, and transfered to [**Hospital1 18**]
for neurosurgical eval (has a known aneurysm).
In ED given 90 meq K, ceftriaxone 2 gm, acyclovir 700 mg IV,
vancomycin 1 gm IV, ampicillin 2 gm IV x T.
*
Other interesting history is that plavix was discontinued 2
months ago after her HCT dropped and she was found to be occult
blood positive at an OSH. There she was transfused, no source
of bleeding to explain the drop could be found - EGD showed mild
gastritis, c'scope did not reveal a source. No capsule
endoscopy was performed. She has no h/o stroke, seizure.
*
On review of systems, the pt's daughter, husband and son deny
recent fever or chills. No night sweats. Her daughter reports a
five pound wt loss along with a dry cough of unclear duration.
Denies 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. No focal weakness, facial asymmetry,
slurred speech.
*
Past Medical History:
PMH:
- Admitted to [**Hospital1 1474**] in [**Month (only) **] with GI bleeding for which
her plavix was stopped. Source of GI bleeding is unclear.
- [**2118**] developed severe claudication in her left upper extremity
with loss of pulses in her left upper extremity. An arteriogram
was performed which showed a long occlusion of the left
subclavian artery starting at the aortic arch with heavy
circumferential calcification making it inappropriate for
stenting. s/p left common carotid to subclavian bypass.
- right mca aneurysm incidentally found during the above workup,
has not bleed or given her any problems in the past
- HTN - labile and difficult to control
- PVD s/p stent right leg
- COPD, smoker
- diverticulitis?
- + "arrhythmia" per family, details not known- per records, h/o
atrial fibrillation but no other documentation re coumadin etc.
PMD states that there is no known history of AF and no history
of coumadin
- no h/o kidney problems per family
- no known history of COPD per PMD and family
*
Social History:
Social Hx:
+ tob many ppd x many years, may have quit approx 3 months
ago. No etoh. No drugs. House wife. Lives at home with
husband. Supportive family - son, [**Name (NI) **] [**Name (NI) 47777**] cell
[**Telephone/Fax (1) 47778**]. Daughter [**Name (NI) **] -cell [**Telephone/Fax (1) 47779**].
Family History:
Family Hx:
mom with a stroke at old age and dm and CAD/MI. Father died of
cancer at a young age. Sister with [**Name2 (NI) **], s/p CABG, brother with
CVA.
Physical Exam:
Physical Exam:
Vitals: T:95.7 P:77 R:17 BP: 126/53 SaO2: 100% on VT =
450/40%/16
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP , No papilledema per neuro's
exam
Neck: supple, bilateral cartid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, ? pelvic mass or
sacrum
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.
Neurologic:
Able to follow commands, good strength, able to raise both legs
high of the bed. Tracks,
Pertinent Results:
LABORATORY DATA:
OSH labs:
WBC = 11.7, HCT = 40.0, RDW = 17, PLT = 216,
*
EKG:
Admission ECG:
Rate = NSR, 65, LAD, approx -30, PR = 200ms, QT > 0.5 RR
interval, QTC = 476 msec, TWI in V5 and V6, 1mm ST elevations in
V2, V3, ST depressions in V5 and V6. TWI and STE not present in
ECG at [**Hospital1 1474**].
ADMISSION LABS:
[**2121-1-26**] 08:00PM LACTATE-1.8
[**2121-1-26**] 07:45PM CK(CPK)-84
[**2121-1-26**] 07:45PM CK-MB-NotDone cTropnT-<0.01
[**2121-1-26**] 07:45PM URINE HOURS-RANDOM UREA N-481 CREAT-61
SODIUM-20
[**2121-1-26**] 04:10PM GLUCOSE-117* UREA N-41* CREAT-2.7* SODIUM-139
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2121-1-26**] 04:10PM CK(CPK)-84
[**2121-1-26**] 04:10PM CK-MB-NotDone cTropnT-<0.01
[**2121-1-26**] 12:16PM COMMENTS-GREEN TOP
[**2121-1-26**] 12:16PM LACTATE-4.1*
[**2121-1-26**] 12:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-70*
GLUCOSE-78
[**2121-1-26**] 12:00PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-[**Numeric Identifier 43616**]*
POLYS-75 LYMPHS-22 MONOS-3
[**2121-1-26**] 10:55AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2121-1-26**] 10:55AM URINE RBC->50 WBC-[**3-16**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2121-1-26**] 10:55AM URINE GRANULAR-0-2
[**2121-1-26**] 10:32AM COMMENTS-GREEN TOP
[**2121-1-26**] 10:20AM GLUCOSE-153* UREA N-44* CREAT-2.8*#
SODIUM-140 POTASSIUM-2.5* CHLORIDE-104 TOTAL CO2-21* ANION
GAP-18
[**2121-1-26**] 10:20AM ALT(SGPT)-17 AST(SGOT)-32 CK(CPK)-66 ALK
PHOS-89 AMYLASE-86 TOT BILI-0.3
[**2121-1-26**] 10:20AM LIPASE-55
[**2121-1-26**] 10:20AM CK-MB-NotDone cTropnT-<0.01
[**2121-1-26**] 10:20AM PHENYTOIN-13.1
[**2121-1-26**] 10:20AM [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2121-1-26**] 10:20AM WBC-13.4* RBC-4.18* HGB-11.9* HCT-34.4*
MCV-82 MCH-28.5 MCHC-34.7 RDW-17.2*
[**2121-1-26**] 10:20AM NEUTS-88.6* LYMPHS-8.3* MONOS-2.6 EOS-0.2
BASOS-0.4
[**2121-1-26**] 10:20AM ANISOCYT-1+ MICROCYT-2+
[**2121-1-26**] 10:20AM PT-11.5 PTT-21.8* INR(PT)-0.9
[**2121-1-26**] 10:20AM SED RATE-46*
MICRO DATA:
Negative (blood, urine, sputum, csf, stool cultures)
IMAGING:
Admission CTA:
IMPRESSION:
1. No evidence of acute intracranial hemorrhage. Please note,
however, that
by history, the patient's symptoms have persisted for
approximately three
weeks. If the patient had leakage from the aneurysm weeks ago,
the blood would be iso- to hypodense on this CT, and may not be
visible.
2. Similar appearance of known 3-mm middle cerebral artery
aneurysmon the right on these preliminary images. Final
reformatted images are pending. When these become available,
final assessment and comparison of this aneurysm will be
performed.
Admission CXray:
IMPRESSION: Appropriate position of endotracheal and feeding
tube. No acute cardiopulmonary process. Extensive aortic
calcification
Admission MRI/A:
IMPRESSION:
No definite evidence of acute infarct noted.
No abnormal enhancing lesions noted.
Questionable focal atrophy is noted in the occipital lobes
bilaterally, this appears to be unchanged since the prior
examination.
MR [**First Name (Titles) 4058**] [**Last Name (Titles) 4059**] normal flow in the anterior and
posterior circulation. The previously noted aneurysm in the
right middle cerebral artery bifurcation appears to be unchanged
since the prior examination. MR [**First Name (Titles) 36062**] [**Last Name (Titles) 4059**] normal
flow in all the major venous sinuses.
Renal U/S [**1-26**]:
IMPRESSION:
1. Echogenic kidneys which could be consistent with chronic
interstitial disease.
2. No hydronephrosis or stones.
3. Patent renal vasculature on the right side. Limited
evaluation of the left renal vasculature. If there is a high
clinical suspicion then MR angiography would be recommended.
Echo [**1-28**]:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets appear structurally normal with good leaflet excursion.
No aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Preserved global and regional biventricular systolic
function. Mild mitral regurgitation.
VQ scan [**1-29**]:
IMPRESSION: Low likelihood ratio for pulmonary embolism.
Findings are consistent with COPD.
Bubble study Echo [**1-30**]:
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
2. On rest contrast echocardiography, an intrapulmonary shunt is
not present.
CT Airway [**1-31**]:
IMPRESSION:
1. Bilateral moderate pleural effusions and bilateral lower lobe
atelectasis and/or pneumonia.
2. Multifocal pneumonia--right middle lobe, lingula and
apicoposterior segment of right upper lobe.
3. Secretions in the right lower lobe and segmental bronchi and
in the left main bronchus. Given the amount of secretions, a
small endobronchial lesion cannot be excluded.
4. Moderate tracheobronchomalacia, at the level of the carina,
right bronchus intermedius and right lower lobe bronchus.
5. Severe atherosclerotic calcification of the entire aorta,
coronary, superior mesenteric, left subclavian and innominate
arteries.
6. Atrophic left kidney with a 2.2-cm cyst.
Bilat LENI [**1-31**]:
IMPRESSION: There is no evidence of DVT
MRI/A abdomen [**2-2**]:
IMPRESSION:
1. High-grade stenosis within the proximal aspect of the left
renal artery.
2. High-grade stenosis at the origin of the celiac artery.
3. Moderate-severe stenosis of the proximal superior mesenteric
artery. The [**Female First Name (un) 899**] is not visualized.
4. Evidence for a stent within the right common iliac artery,
which limits evaluation of this vessel.
5. The proximal aspect of the left common iliac artery is not
visualized. It is not clear whether this represents artifact
from the patient's right common iliac stent or an area of
stenosis.
CT head [**2-4**]:
IMPRESSION:
New acute infarcts in the posterior cerebral, vertebral and
basilar artery territories. Basilar arterial thrombosis should
be considered. In addition, small hypodensities in the right
centrum ovale which also could represent recent infarctions.
There is edema narrowing the fourth ventricle, but no
hydrocephalus at this time. MRI/MRA evaluation should be
considered. The findings were discussed at 9:50 p.m. with Dr.
[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 3646**].
US R SC artery [**2-4**]:
IMPRESSION: No evidence of pseudoaneurysm or AV fistula in the
imaged right subclavian vessels.
MRI/A [**2-5**]:
IMPRESSION: Multiple evolving infarctions including large
bilateral cerebellar hemispheres, bilateral occipital lobes, and
right centrum ovale. Abnormal high-signal subarachnoid CSF of
unclear etiology, but can be seen in meningitis.
IMPRESSION: Decreased flow in the right vertebral and posterior
inferior cerebellar artery. Superior cerebellar arteries not
visualized.
EEG [**2-6**]:
FINDINGS:
ABNORMALITY #1: Throughout the recording background rhythm was
slow and
disorganized, typically remaining at 3-4 Hz in most areas.
ABNORMALITY #2: There were several bursts of brief periods of
suppression of the background in all areas for up to one to two
seconds.
There were also some bursts of generalized slowing.
ABNORMALITY #3: There were additional high voltage sharp waves
evident
bilaterally and independently on the two sides, particularly in
left
fronto-temporal areas and in the right temporal region, some
with
maximum emphasis at T4. There were no simple spike or sharp and
slow
wave complexes.
CXR [**2-6**]:
IMPRESSION: Stable findings on portable chest examination of
intubated patient.
EKG [**2-8**]:
Sinus bradycardia. Borderline prolonged Q-T interval. Borderline
left
ventricular hypertrophy by voltage in the precordial leads.
Compared to the previous tracing of [**2121-1-31**] no diagnostic
change.
PLACEMENT OF DIALYSIS CATHETER:
IMPRESSION: Successful placement of a right IJ dialysis catheter
with the tip in the right atrium. The line is ready for use.
IMPRESSION: Successful placement of a 23 cm tip to cuff dialysis
catheter through the right internal jugular vein. The tip in the
right atrium and the line is ready for use.
CT HEAD NON-CONTRAST [**2-9**] 12:41pm:
IMPRESSION: New acute development of hydrocephalus since [**2-4**], [**2121**]. Progression of extensive bilateral occipital lobe and
bilateral cerebellar hemisphere infarctions.
CT HEAD [**2-9**] 20:31:
IMPRESSION: Decreased ventricular size, status post right
frontal shunt catheter placement. Evolving bilateral occipital
and cerebellar hemisphere infarcts.
CT HEAD [**2-10**]:
FINDINGS: Again seen is hydrocephalus, which has worsened
slightly since the prior examination. The right-sided frontal
ventriculostomy catheter is again seen, with essentially
unchanged position. Slightly increased intraventricular blood is
seen, possibly from manipulation of the catheter.
Again seen is diffuse hypodensity within the posterior fossa as
well as the occipital horns, consistent with infarction. In
addition, there is obliteration of the posterior fossa cisterns
and fourth ventricle, indicating severe posterior fossa mass
effect. This is not significantly changed. There is no evidence
of new hemorrhage. There is no new midline shift. Fluid is seen
within the hypopharynx, consistent with secretions.
IMPRESSION: Worsening hydrocephalus. Unchanged posterior fossa
mass effect and infarction of the bilateral cerebellar and
occipital lobes.
STUDIES FROM PRIOR HOSPITALIZATIONS:
*
MRI/MRA [**10-16**]:
IMPRESSION: Accounting for differences in technique, stable
appearance of right MCA bifurcation aneurysm
*
Echo [**2117**]
EF = 60%, trace MR
*
Colonoscopy [**12-16**]
Internal hemorrhoids
Severe diverticular dz
*
Carotid US- [**2118**]
IMPRESSION: Calcific heterogeneous bilateral ICA plaque, that on
the right associated with a 40 to 59% stenosis, that on the left
associated with an approximately 70% stenosis
*
[**7-15**] Arterial CTA
middle cerebral artery bifurcation aneurysm is again identified.
On the CTA examination the best estimated luminal dimension is 3
mm,
*
Brief Hospital Course:
BRIEF OVERVIEW:
This 70 yo woman with multiple stroke risk factors (HTN,
smoking, arrythmia, aneurysm), with recent treated sinus
infection presented with markedly elevated BP at OSH after weeks
of HA and developed a GTC seizure. She was intuabted for airway
protection and transferred to [**Hospital1 18**] where she remained intubated
and sedated. CT and MRI head showed stable appearance of a
known 3mm L MCA aneurysm. On [**1-27**] the patient was extubated w/o
difficulty. She had a brief episode of atrial fibrillation that
did not recur after being started on amiodarone. She was
transferred to the floor, where she developed repeated hypoxic
respiratory distress and was readmitted to the MICU the same
day. She continued to have periods of intermittent hypoxia - V/Q
scan, plain films, and CT scans in addition to ENT evaluation
revealed PNA, which was treated, likely COPD and developing
pulmonary edema. The patient was re-intubated on [**2-1**]. She
underwent dialysis on [**2-2**] where she experienced an SBP drop to
the 80's. The patient's blood pressure remained labile and she
was found to have a change in her neuro exam after a period of
hypotension. Subsequent CT/MRI imaging of her brain revealed
posterior circulation watershed infarction with a few ischemic
areas in the anterior circulation. BP was aggressively managed
using pressors and antihypertensives. On [**2-9**] neurologic exam
showed loss of corneal reflex and head CT showed acute
development of hydrocephalus. She was seen by neurosurgery and
ventriculostomy drain was placed at the bedside with CSF sent
for culture. Despite this intervention, the hydrocephalus
continued to worsen and after discussion with the patient's
family, goals of care were changed to comfort, the patient was
extubated and died thereafter.
*
HOSPITAL COURSE BY PROBLEM:
*
Stroke: The patient has had labile BP for some time (see below).
At this hospitalization she was initially hypertensive and
controlled with labetolol gtt, but after some days, the patient
also developed periods of relative hypotension. Notably, with
HD on [**2-2**] SBP decreased to 80's and on night of [**2-5**] SBP
decreased into 100's. The pt was subsequently noted to have
decreased movement of her left side. CT scan revealed watershed
infarcts primarily affecting the posterior circulation,
especially the cerebellum. The neurology service was consulted.
Given the patient's PVD and appearance of scan, the etiology
was thought to be hypoperfusion with watershed scans. Read c/w
L>R PCA/MCA territory and some L ACA/MCA territory. On final
read, MRA showed no PICA nor SCA - this raised the question of
embolism, however low flow would also make these disappear on
MRA. The final consensus was that the stroke was, indeed, due
to watershed infarcts from relative hypotension. [**Name2 (NI) **] 81 was
continued. SBP parameters were 150-170 (pt required both
pressors and antihypertensives to remain in this range.) HD was
continued while watching pressures carefully. Clinically the pt
evolved such that on [**2-7**] pupils became non-reactive and corneal
on L disappeared. Doll's eye's reflex was also noted to be
absent (pathologic) when turning head to L, but normal when
turning head to right. This suggested some brainstem
involvement. However, pt continued to breathe spontaneously on
pressure support ventilation, so that the stroke was thought
likely to have involved only more cranial brainstem areas. At
that time the pt was also unresponsive, and it was thought that
if the stroke involved the RAS, then it could account for a
large portion of her MS changes. At that time, the issue of
family meeting and addressing goals of care was broached (until
this time the family had continued to elect for aggressive
treatment of the [**Hospital **] medical problems, understanding that there
had been numerous setbacks throughout her hospital course. It
was their feeling that she would not have wanted long-term life
support.). At that point, the neurology service favored waiting
for major decisions until after weekend, which would provide
more time to observe the clinical course so as to better
prognosticate. On [**2-9**], the pt developed irregular respiration
and had a repeat head CT that showed hydrocephalus, new compared
to last imaging. Neurosurgery was consulted and placed a
bedside ventriculostomy, which appeared to be working correctly
and in the proper place, however on [**2-10**], the pt had a CT that
showed worsening hydrocephalus. No surgical intervention was
possible. The patient's family made the decision to withdraw
care on [**2-10**] and the patient died thereafter.
*
MS Changes: The patient was initially intubated and sedated.
The following day she was extubated successfully. Some days
thereafter she was reintubated and sedated. However, after her
stroke, she was noted to be poorly responsive, even when
sedation was discontinued. This depression in MS was not
thought to be likely c/w stroke alone (though may have been a
large part of the cause as the brainstem was likely compressed
to some degree, which may have affected the RAS and later
hydrocephalus developed, which could have caused bialteral
cerebral dysfunction). Multifactorial: uremia, infection, vent,
sedation, inactivity. Encephalopathy.
Initially, it was hoped that continued hemodialysis might help
clear the patient's mental status. EEG showed triphasics on L
side c/w encephalopathy, diffuse slowing, sharps. C/W infection,
metabolic, toxic. Uremia was a highly suspicious cause. Neuro
service, consulted after the CT showed watershed stroke as
above, recommended LP to r/o infection. This LP was delayed on
[**2-7**] due to HTN to 220's and was avoided thereafter to avoid
herniation as the patient had developed hydrocephalus. Once
hydrocephalus was seen on CT and neurosurgery was consulted, a
ventriculostomy was placed and CSF was obtained for GS and Cx,
which were negative.
*
HTN: THe patient had a long history of labile blood pressure,
but predominantly hypertension that was difficult to control.
She had known severe PVD s/p bypass of L SC and stenting of R
iliac artery. However, she had never been evaluated for RAS.
On exam she had a prominent abd bruit to the left of the
umbilicus. Renal US was equivocal as the L was poorly
visualized. The pt was unstable for MRI abd for many days but
when she was stabilized, the study revealed severe proximal L
sided RAS. Dr. [**First Name (STitle) **] was contact[**Name (NI) **] regarding future stenting,
however the patient was not stable at any point during this
hospitalization for such a procedure and died prior to
discharge.
********At this hospitalization, the patient's blood pressure
was extremely labile. In the inital days of hospitalization the
patient had routinely elevated blood pressures requiring a
labetolol drip to maintain BP 140-160's. With initiation of HD
the pt had a decrease in BP to 80's. On the night of [**2-5**] the
pt had a decrease in BP to SBP of 100's and was subsequently
found to have posterior circulation watershed infarction as
above. Thereafter, both pressors and antihypertensive gtt were
used to maintain BP 150-170.
*
Acute renal insufficiency (Acute on Chronic Kidney Disease):
Baseline 1.9 per PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] to be due to HTN. high protein in
UA suggested longstanding dysfxn. At this hospitalization, her
creatinine on arrival was found to be 2.8 on admission and rose
to 4.1 prior to initiation of hemodialysis on [**2-2**]. The patient
had urine electrolytes that were equivocal and had positive
eosinophils. The patient had rising creatine and decreasing
urine output despite aggressive fluid resuscitation over the
period from admission until [**2-1**]. Renal U/S was equivocal for
RAS at that time. The renal service was consulted for
assistance with diagnosis and treatment, especially given the
patient's hypoxia, worsening pulmonary edema, and continuing
oliguria. (Later, MRI would reveal high grade stenosis at the
proximal portion of the L renal artery.) The renal service
thought the ARF to be multifactorial and ddx to include contrast
nephropathy from her CTA, prerenal state, decreased forward
flow, embolic dz, or acute hypertensive injury in setting of
RAS. On [**2-2**], HD was initiated and BP decreased to 80 systolic.
HD was then held for some days and re-initiated around [**2-5**]
without decrease in blood pressure at that time. Return of
renal function was thought to be unlikely from the time of
initiation of hemodialysis.
*
Respiratory distress:
On [**1-27**] the patient was extubated w/o difficulty. She was
transferred to the floor, where she developed repeated hypoxic
respiratory distress and was readmitted to the MICU the same
day. She continued to have periods of intermittent hypoxia and
had a V/Q scan read as low probability on [**1-29**]. It was c/w some
COPD. The pt was also found to have a pneumonia on CXR that was
treated with ceftriaxone and vancomycin. Subsequently the pt
had an ENT evaluation for any vocal cord swelling contributing
to her respiratory distress - not thought to be contributing.
Multiple cxr suggested some component of pulmonary edema as well
as CXR. CT airways revealed no dynamic large airway collapse.
The patient was re-intubated on [**2-1**]. Echo showed preserved EF
and echo with contrast showed no intrapulmonary shunt and
essentially ruled out intracardiac shunt. The patient had one
episode of atrial fibrillation with albuterol administration on
the second day of her hospitalization and was started on
amiodarone without recurrance of AF. Hypoxic respiratory
distress at that time was thought to be due to shunt physiology
from PNA, COPD, and pulmonary edema. Initially ventilator
settings were difficult to optimize as the patient had a very
long expiratory phase and continued to have hypoxia. Due to
rising creatinine and increasing fluid status, the renal team
was consulted and the patient underwent dialysis on [**2-2**] with
some decrease in hypoxia. On [**2-2**], the patient was also found
to be briefly hypotensive due to autopeeping on the ventilator -
prolonged expiratory phase made ventilator settings difficult to
manage, however with careful monitoring and management, further
autopeeping was prevented. Neither ventilation nor oxygenation
were problem[**Name (NI) 115**] thereafter. The patient remained intubated for
airway protection until [**2-10**] when goals of care were changed to
comfort and she was extubated and subsequently died.
*
CV:
CAD: The patient had no known ischemia, though pt certainly had
asx CAD based on the presence of severe PAD as outlined in the
PMH.
Pump: Echo showed nml LV, 1+MR, no systolic nor diastolic CHF.
The patient had no history of CHF. Bubble study showed no
intrapulmonary shunt. The final read of the bubble study left
open the question of intracardiac shunt, but informal
discussions with the cardiology service suggested that
intracardiac shunt based on the bubble study echo was extremely
unlikely.
Rhythm: AF in setting of albuterol at this hosp stay. Loaded
with amio and sinus since. The patient was then started on PO
amiodarone and had no further episodes of atrial fibrillation at
this hospitalization. Given the patient's history of recent
GIB, the pt was never anticoagulated.
*
Prophylaxis:
The patient was initially intubated and sedated. She was
maintained on PPI for GI prophylaxis. Initially she was not on
heparin prophylaxis because of her history of GI bleed. When
hypoxic respiratory distress recurred after extubation and PE
was entertained, SQ heparin was begun at that time and
maintained throught the remainder of her hospitalization. Bowel
regimen was maintained as needed. Blood pressure was
aggressively managed throughtout her hospital stay using both
antihypertensives and pressors as above.
*
*Code Status: The patient's code status was full throughout most
of her hospitalization but was changed to DNR/DNI and CMO after
her herniation event.
Medications on Admission:
Meds in ED:
Labetalol 20 mg
Nitro SL
Zofran 4 mg
Tylenol
Propofol gtt
Potassium Chloride 90mEq Packet 2 [**Last Name (LF) 47780**], [**First Name3 (LF) 6177**]
Ampicillin Sodium 1 g Vial 2 [**Last Name (LF) 47780**], [**First Name3 (LF) 6177**]
Vancomycin HCl 1g Frozen Bag 1 [**Last Name (LF) 47780**], [**First Name3 (LF) 6177**]
CefTRIAXone 1g Frozen Bag 2 [**Last Name (LF) 47780**], [**First Name3 (LF) 6177**]
*
Admission Meds [**First Name8 (NamePattern2) **] [**Hospital1 1474**] d/c summary [**2120-12-17**]
Lopressor 75 mg po tid
Protonix 40 mg po qd
nifedipine 60 mg po qd
isosorbide mononitrate 30 mg po qd
plavix 75 mg po qd- d/c'ed in the setting of GI bleed
[**Month/Day/Year **] 81 mg po qd
Lipitor 40 mg po qd
pepcid AC at bed time
Metamucil
*
Allergies:
PCN- confirmed with family- life threatening reaction as a child
-
Coedine - family not aware
Percocet - family not aware of this
Discharge Medications:
The patient died at this hospitalization.
Discharge Disposition:
Expired
Discharge Diagnosis:
Posterior circulation watershed infarct, tonsillar herniation,
renal artery stenosis, acute on chronic renal failure requiring
HD, hypoxic respiratory distress, pulmonary edema, COPD, seizure
disorder, hypertensive emergency, hypotension, history of GI
bleed, pneumonia
Discharge Condition:
The patient died after goals of care were changed to comfort
measures during this hospitalization.
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2121-3-5**]
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20,064
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Discharge summary
|
report+addendum
|
Admission Date: [**2117-1-8**] Discharge Date: [**2117-1-22**]
Date of Birth: [**2068-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Bental/Asc Ao replacement #28 Gelweave/AVR #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
History of Present Illness:
48 y/o male who presented in [**10-1**] with acute onset of chest
pain radiating to back of neck with N&V. CT scan showed Type 1
aortic dissecting aneurysm involving thoracic and abd. aortas,
exteding to prox. aspect of left iliac artery. Previous hx is
relevant for thoracic/abd aorta replacement in 03. He presented
on [**12-16**] with DOE since [**10-1**] and back pain. The cardiac cath
showed an aneurysmal dilatation of the proximal third of the
aorta, below the previous graft, along with significant root
dilatation and aortic regurgitation. The pt. was then scheduled
for an aortic valve and root replacement.
Past Medical History:
Type A Aortic dissection [**2111**] & repair w/tube
graft(thoracic/abd) [**3-30**]; s/p emergent asc. aorta repair 04
CVA w/ residual rt sided hemiparesis
HTN
^chol
GERD
anemia
Social History:
Lives in [**Location 620**] with family. Currently not working. Quit
smoking 5 yrs ago after 15 yr pk hx. Pt. denies ETOH drinking.
Family History:
Non-contributory
Physical Exam:
VS: Ht.: 6'2" Wt.: 216 BP: 108/85 HR: 58
General: Sitting in bed in NAD
Resp: CTAB
CV: RRR, S1S2 with 3/6 SEM and radiation to carotids
GI: Soft, flat, NT/ND +BS
Neuro: A&O x 3, appropriate with R hemiparesis
Ext: warm, well-perfuses, - edema, - varicosities
Pulses: 1+ throughout
Brief Hospital Course:
Pt. was scheduled to be a same day admit following his surgery
but was found to have an elevated INR and had to be admitted and
delayed until a lower INR. On [**2117-1-10**] pt. was given one dose of
Vitamin K and scheduled for the OR the next day. On [**2117-1-11**] pt.
had a stable INR and was brought to the operating room where he
underwent a Redo Ascending Ao replacement (and Bentall
procedure) w/ a #28 Gel weave graft. Along with an AVR w/ a #23
[**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]. Please see surgical note for full details. Pt.
tolerated the procedure well. Total CPB time was 210 minutes
with a XCT of 142 minutes. Pt. was brought to the CSRU in stable
condition with a MAP 80, CVP 12, PAD 15, [**Doctor First Name 1052**] 22, and a HR of 80
NSR. He was being titrated on Nitro, Epi, and propofol when
transferred.
On Post-Op day #1, propofol was weaned. NMB reversed and pt. was
weaned off ventilation. After extubation, pt was awake, alert
and oriented and had no new deficits(r-sided hemiparesis
pre-op). Pt. was now on Nipride and that was planned to be
weaned.
POD #2 pt. had no new events but was still being titrated on
Nipride. Anticoagulation started today.
POD #3, pt. was transfused 1 unit of PRBC due to low HCT (25).
Still in CSRU secondary to not being able to titrate off
Nipride. Chest tubes were removed and Foley replaced.
POD #4, HCT increased to 29.1. Pt. had increased DOE though the
day with a transient drop in SBP after Lopressor (80's). Neo was
started. An echo was performed which showed a small pericardial
effusion. CXR showed L. pleural effusion. Suture over CT site
due to bleeding.
POD #5 Neo was weaned.
POD # 6 pt. had PO2 in 90's and was receiving O2 via open face
tent.
POD #7, repeat CXR performed yesterday revealed increased L
pleural effusion. A pigtail catheter was placed over guidewire
into left chest which immediately drained 550 cc. Weaned mask to
nasal cannula since oxygenation improved.
POD #8, CT d/c'd. Later that night pt. was oozing from l. chest
tube sight with resolution after stitch placement. Pt. was
transferred to telemetry floor.
POD #9 & 10: Hemodynamically stable. Pt. is now awaiting INR to
increase and still needs an increase and strength and activity
before being discharged home. Cont. to receive Coumadin.
POD #11, pt doing well and was d/c'd home with VNA services and
INR will be checked on [**1-23**] and [**1-25**] with results sent to Dr.
[**Last Name (STitle) 30197**].
D/C PE:
VS: 99.5 75 SR 120/60 22
Neuro: alert, oriented with r-side hemiparesis
Pulm: CTAB
Cardiac: RRR
Sternum: + Bledding from pacer site, -Erythema
Abd: soft, NT/ND +BS
Ext: warm, -c/c/e
Medications on Admission:
1. Lopressor 25mg [**Hospital1 **]
2. Diovan 160mg [**Hospital1 **]
3. Enalapril 20mg qd
4. HCTZ 25mg qd
5. Nifedical 30mg [**Hospital1 **]
6. Protonix 40mg qd
7. Pravachol 20mg qd
8. Tizanidine 4mg qd
9. Gemfibrizol 600mg [**Hospital1 **]
10. FeSO4 325mg qd
Discharge Medications:
1. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. 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*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. 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*
9. 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*
10. Warfarin Sodium 2 mg Tablet Sig: as directed Tablet PO once
a day: goal INR 2.5-3
pt to take 5 mg Sat and Sun then inr check and as directed.
Disp:*100 Tablet(s)* Refills:*0*
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: pt may resume
after d/c.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
S/P Redo Asc. & Bentall Ao replacement #28 Gelweave/AVR #23 [**First Name8 (NamePattern2) **]
[**Male First Name (un) 923**]
Type A Aortic dissection [**2111**] s/p repair w/tube
graft(thoracic/abd) [**3-30**]; s/p emergent asc. aorta repair 04
CVA (stroke) w/ residual rt sided hemiparesis
Hypertension
Hypercholesterolemia
GERD/Acid reflux
Anemia
Discharge Condition:
good
Discharge Instructions:
KEEP WOUNDS CLEAN AND DRY. OK TO SHOWER, NO BATHING OR SWIMMING.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
[**Last Name (NamePattern4) 2138**]p Instructions:
wound clinic in 1 week
Dr [**Last Name (STitle) 30197**] in [**12-31**] weeks and for INR checks as directed
Dr [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2117-3-15**] Name: [**Known lastname 5423**],[**Known firstname 5424**] Unit No: [**Numeric Identifier 5425**]
Admission Date: [**2117-1-8**] Discharge Date: [**2117-1-22**]
Date of Birth: [**2068-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 674**]
Addendum:
Lab results. Please refer to discharge summary for full hospital
details.
Pertinent Results:
[**2117-1-9**] 05:45AM BLOOD WBC-6.9 RBC-4.73 Hgb-10.8* Hct-34.9*
MCV-74* MCH-22.8* MCHC-31.0 RDW-12.9 Plt Ct-291
[**2117-1-14**] 03:15AM BLOOD WBC-13.2* RBC-3.25* Hgb-8.3* Hct-24.9*
MCV-77* MCH-25.4* MCHC-33.2 RDW-14.9 Plt Ct-161
[**2117-1-8**] 08:00AM BLOOD PT-14.7* PTT-23.3 INR(PT)-1.4
[**2117-1-11**] 09:39PM BLOOD PT-9.4* PTT-31.3 INR(PT)-0.6
[**2117-1-11**] 09:39PM BLOOD Plt Ct-178
[**2117-1-21**] 06:50AM BLOOD Plt Ct-570*
[**2117-1-22**] 06:35AM BLOOD PT-19.3* PTT-73.4* INR(PT)-2.3
[**2117-1-9**] 05:45AM BLOOD Glucose-91 UreaN-21* Creat-0.9 Na-137
K-3.9 Cl-103 HCO3-28 AnGap-10
[**2117-1-20**] 07:05AM BLOOD Glucose-104 UreaN-24* Creat-1.0 Na-133
K-4.6 Cl-99 HCO3-25 AnGap-14
[**2117-1-9**] 05:45AM BLOOD ALT-8 AST-14 AlkPhos-61 TotBili-0.4
[**2117-1-13**] 06:25AM BLOOD ALT-35 AST-80* AlkPhos-45 Amylase-386*
[**2117-1-9**] 11:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2117-1-9**] 11:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2117-3-15**]
|
[
"401.9",
"441.01",
"280.9",
"996.71",
"E878.1",
"424.1",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.22",
"35.95",
"99.04",
"36.99"
] |
icd9pcs
|
[
[
[]
]
] |
8646, 8840
|
1762, 4438
|
297, 410
|
6726, 6732
|
7587, 8623
|
1423, 1441
|
4747, 6252
|
6354, 6705
|
4464, 4724
|
6756, 6911
|
6962, 7568
|
1456, 1739
|
238, 259
|
438, 1058
|
1080, 1258
|
1274, 1407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,642
| 154,927
|
3741
|
Discharge summary
|
report
|
Admission Date: [**2168-2-12**] Discharge Date: [**2168-2-27**]
Date of Birth: [**2090-12-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Horse Blood Extract / Fentanyl
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
agitation, urosepsis, resp failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
77F PMH HTN, osteoarthritis, R total hip 10yrs ago, depression
was vacationing in bermuda until [**2168-2-3**], returned home, did not
feel well on the night of return, tired, "did not seem self,"
appeared confused, acting strangely. C/O extremie thirst, no CP,
no SOB, no fevers, no URI-like sx, no nausea, no vomiting, no
dysuria. MS seemed worse on the next am with increased agitation
and confusion, incoherence, emotional changes, so brought to
[**Hospital 16843**] Hospital on [**2-5**]. Lyme negative, [**Doctor First Name **] negative. At LH,
dx'd with arf (cr 3.3) baseline 1.1-1.3, dx'd to have a e.coli
uti (10-15wbc, 3+ bacteria) (later found to be quinolone
resistant). BCx eventually grew out ecoli, resistant to
quinolones as well. The patient was started on abx (given levo
in the ed, then changed to cefazolin, then changed to ctx).
Improving MS on the 4th, but then in the afternoon agitated, +
restless, low sats, very emotionally upset, c/o abdominal and
back pain, moved bowels, got back into bed, but was agitated and
found to be hypoxic with sats in the low 80s abg 7.35/24/48/13
on 5L NC, intubated, xferrerd to ICU. HTN 140s-170s-->xferred to
ICU, ecoli in urine found to be R quinolones and sulfa,
sensitive to cephs and pcn. Started on heparin gtt, head ct neg.
CXR showed bilat fluffy infiltraes, concern for ARDS, concern
for PE (V/Q not done, could do CTA due to renal failure), placed
on NRB, satting 96%. Bcx x 2 from [**2-5**] GNRs (later to be found
E.coli).
.
Resp failure was attributed to ards, pt subsequentally intubated
on [**2168-2-8**]; started on versed+MSO4 for sedation, patient was
generally unresponsive, not following commands. Cr improved to
2.4 on [**2-8**]. Pt was tx'd with ctx. On [**2-9**]; pt was on cpap, doing
well, mental status improving. Echo performed [**2-9**]; normal LV fx,
small pericardial effusion. Pt was extubated on [**2-10**], within
12hrs required re-intubation for inability to protect airway.
She was doing well from resp mechanics point of view. Mental
status worsened, patient was more delirious with psychomotor
agitation, moving all 4 extremities at full strength, not able
to interact. Mutliple attemps were made to sedate the patient,
including propofol, which resulted in HTN, so it was stopped,
haldol, versed, ativan. She remained agitated, writhign in bed;
unresponsive to ativan. [**2-11**] CXR poor quality cxr, could not r/o
nosocomial pna, ID ocnsulted. The patient was started on vanc
1gm IV q 24 for hosp acquired PNA, zosyn 3.375 IV q 6 hrs were
started for urosepsis. She was also receiving lopressor 5mg IV q
4hrs for HTH, Morphine and ativan. Neuro consult was obtained
and dx'd pt with toxic metabolic encephalopathy [**1-8**] urosepsis
and resp failure. Psych consulted, dx'ed acute delirium,
recommended celexa and haldol PRN. Pt was never LP's and MRI was
not obtained.
Past Medical History:
HTN
osteoarthritis
hyperlipidemia
s/p hip replacement 10 yrs ago
s/p ccy 2 yrs ago
depression
DJD
Social History:
pt most likely a smoker, hides it from husband, husband not sure
how much she smokes. 2 glasses of wine q night. lives at home
with husband. usually functions at a very high level
Physical Exam:
PE: T: 99.7 BP: 80-160/42-70 HR: 116 RR: 25 O2 %100 on CPAP+ PS
[**7-10**].
Gen: agitated, psychomotor delirium not following commands
HEENT: very dry muc membranes. pupils reactive to light.
NECK: Supple, No LAD, No JVD. Large bulky thyroid on left.
Patient acutely agitated, unable to complete full neuro exam.
CV: tachycardic, nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, mild bibasilar crackles. soft exp sounds
ABD: + bowel sounds. Soft, ND. NL BS. No HSM. multiple bruises
on abdomen
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: diffuse echymoses.
NEURO: psychomotor agitation.
Pertinent Results:
[**2168-2-14**] CXR: AP chest compared to [**2-12**] and 10:
Left lower lobe atelectasis is largely cleared. Mild pulmonary
edema has developed at the right lung base although heart size
is normal and there is no mediastinal vascular engorgement. No
pleural effusion or pneumothorax seen. ET tube, left subclavian
line, and nasogastric tube are in standard placements
respectively.
.
[**2168-2-15**] MR HEAD: 1) No evidence of infarction or other acute
process to explain the patient's symptoms.
2) Faint 2-mm contour abnormality off the left ICA at the
expected takeoff of the left opthalmic artery, seen only on the
reformatted MIP images, thought most likely to be artifactual.
If further workup is clinically indicated, a CT angiogram would
better assess this finding.
.
[**2168-2-18**] ABD U/S: Unremarkable abdominal ultrasound.
.
[**2168-2-20**] CXR: The cardiac silhouette is stable. There is
unchanged mild pulmonary edema. There is unchanged small right
pleural effusion with a new left small pleural effusion. There
is no pneumothorax.
.
[**2168-2-23**] ECG: Sinus rhythm
Atrial premature complex
Probable left atrial abnormality
Modest nonspecific T wave changes
Since previous tracing of [**2168-2-19**], sinus tachycardia absent,
delayed R wave
progression less prominent and ST-T wave changes decreased
.
FROM OSH:
[**2-11**] labs: wbc 12.8, hct 27.2, plt 314, 17% bands
INR: 1.0
ESR: 76-->110
chem 7 [**2-11**]
144
3.6
109
24
49
2.1(1.7 lowest it was at OSH)
.
alb 2.1
.
iron 40
tibc 289
.
bnp 1670 [**2168-2-7**]; decreased to 121 on [**2-11**]
.
LFTs [**2-10**] ([**2-5**])
t bili 0.4
alp 106
alt 31 (78)
ast 31 (133)
.
CE's negative
.
CXR: [**2-12**] [**Hospital1 18**]: retrocardiac opacity, increased vascular
markings R lung.
.
abg's: [**2-9**]: 7.43/27/102/18 FIO2 0.5/PEEP 10
.
Cx results:
blood [**2-5**] (4/4 bottles): ecoli ([**Last Name (un) 36**] to amp and cephazolin, R to
levo/cipro, [**Last Name (un) 36**] to zosyn, gent bactrim)/gpc's on gram stain.
.
still isolating gpc's seen on gram stain.
.
[**2168-2-5**] urine: ecoli: same resistance as above.
.
IMAGING:
From OSH: CXR: [**2168-2-9**]: new airspace disease in LLL
[**2168-2-10**]: improved aeration in lung fields. no infiltrates
appreciated
[**2168-2-8**]: significant improvement in interstitial and alveolar
opacities
[**2168-2-7**]: diffuse bilateral airspace disease
[**2168-2-5**]: CXR: normal
.
[**2168-2-7**]: CT head. normal.
.
[**2168-2-6**] abd us: intrahepatic dilatation. prominent CBD (can be
seen after surgery). kidneys ok.
.
Echo: small pericardial effusion; preserved ef (no report, just
per notes).
Brief Hospital Course:
1) DELERIUM:
On initial presentation, the patient was very agitated. This
improved throughout admission especially after extubation in
ICU. However, she remained confused and not at her baseline.
Both neurology and geriatrics were consulted. Workup did not
reveal any organic cause and it was felt delerium was secondary
to acute illness and ICU hospitalization. MRI was essentially
normal. An LP was never performed as pt's mental status
improved. Her mental status was improving slowly but
progressively. She was started on zyprexa to prevent agitation
with success. This can be slowly weaned as her delerium
improves. Based upon discussion with PCP and family, there was
a possiblity of pre-existing underlying dementia which may
explain severity of delerium, but this will need to be formally
evaluated after delerium improves. Her outpt meds which
included morphine, bupropion were eliminated.
.
2) SEPSIS:
See HPI for prior course. Pt had resistant E. coli in urine
culture and completed a 14d course of antibiotics with
meropenem. There was no recurrence of infectious signs or
symptoms after completion of antibiotics.
.
3) RESPIRATORY FAILURE:
Likely multifactorial with question of ARDS secondary to sepsis.
After second extubation in ICU and completion of vanco for
pneumonia, pt's respiratory status was stable and normal.
.
4) ABNORMAL LFTs:
Pt had mildly elevated transaminases and alk phos. She had no
abdominal pain and imaging did not show any hepatobiliary
pathology. Hepatitis serologies were normal. It may have been
secondary to sepsis. Pt continued to have mild transaminitis
and should have rpt LFTs in [**12-8**] weeks to assure normalization.
.
5) HTN:
Well controlled on home dose of atenolol.
Medications on Admission:
atenolol 100 p qd
buproprion ER 100 po bid
morphine sulfate 15mg 1 tab po bid
fluoxetine 20 mg 3 tabs daily
cyclobenzaprine 10mg 1 tab tid
protonix 40 po bid
celebrex 200 [**Hospital1 **] prn
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
3. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16844**] Hospital - [**Location (un) 1157**]
Discharge Diagnosis:
PRIMARY:
Urosepsis
Respiratory failure
Delerium
[**Hospital 7502**] hospital-acquired
.
SECONDARY:
Hypertension
Depression
Osteoarthritis
Discharge Condition:
Good--vital signs stable.
Discharge Instructions:
1. Take medications as prescribed.
2. Follow up as below.
3. You can call Dr. [**Last Name (STitle) **] or physician at rehab if you have any
fevers, pain, shortness of breath, worsening confusion.
Followup Instructions:
1. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2983**] Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2168-3-29**]
10:00, Memory Clinic
2. Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP) to schedule a follow-up
appointment once you leave rehab. [**Telephone/Fax (1) 4775**].
|
[
"486",
"038.42",
"401.9",
"349.82",
"V43.64",
"790.5",
"995.92",
"518.81",
"787.91",
"715.90",
"293.0",
"707.03",
"305.1",
"584.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9555, 9638
|
6850, 8589
|
340, 353
|
9820, 9848
|
4212, 6827
|
10097, 10438
|
8832, 9532
|
9659, 9799
|
8615, 8809
|
9872, 10074
|
3586, 4193
|
266, 302
|
381, 3251
|
3273, 3372
|
3388, 3571
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,866
| 147,338
|
11953
|
Discharge summary
|
report
|
Admission Date: [**2198-12-11**] Discharge Date: [**2198-12-31**]
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: This is an 81 year old female
with a history of rheumatic heart disease with known mitral
regurgitation, mitral stenosis and aortic insufficiency. The
patient has a three year history of frequent congestive heart
failure exacerbations requiring intubation. The patient was
admitted three days prior to admission at [**Hospital1 346**] to [**Hospital6 33**] with
congestive heart failure exacerbation. The patient had known
mitral regurgitation and coronary artery disease. The
patient was transferred to [**Hospital1 188**] for mitral valve replacement and coronary artery
bypass graft.
PAST MEDICAL HISTORY:
1. Chronic atrial fibrillation.
2. History of multiple gastrointestinal bleeds secondary to
arteriovenous malformation.
3. Questionable history of transient ischemic attacks.
4. Congestive heart failure.
5. Pulmonary hypertension.
6. Coronary artery disease.
7. Status post percutaneous transluminal coronary
angioplasty in [**2195**].
8. Gout.
ALLERGIES: Penicillin. Questionable allergy to Vancomycin
thought to be due to redman syndrome.
PREOPERATIVE MEDICATIONS:
1. Lasix 40 mg p.o. q.d.
2. Allopurinol.
3. Captopril 25 mg p.o. b.i.d.
4. Carafate.
5. Iron.
LABORATORY DATA: On admission, white blood cell count 6.0,
hematocrit 27.5, platelet count 262,000. Sodium 143,
potassium 3.8, chloride 104, bicarbonate 33, blood urea
nitrogen 37, creatinine 0.9, glucose 112. Digoxin level was
0.5.
HOSPITAL COURSE: The patient was taken to the operating
room on [**2198-12-13**], with Dr. [**Last Name (STitle) 1537**] for mitral valve replacement
with a #25 [**Last Name (un) 3843**]-[**Doctor Last Name **] valve and coronary artery
bypass graft times one with saphenous vein graft to OM.
Please see operative note for further details. In the
operating room by Transesophageal Echocardiogram, the
patient's ejection fraction was found to be greater than 55%
with mild to moderate tricuspid regurgitation and mild aortic
insufficiency. The patient was transferred to the Intensive
Care Unit on Dobutamine infusion and Neo-Synephrine infusion.
In the Intensive Care Unit, the patient was continued on the
Dobutamine and Neo-Synephrine. Cardiac output was monitored
by thick equation due to the patient's history of tricuspid
regurgitation. On postoperative day number one, the patient
was weaned and extubated from mechanical ventilation. The
patient had developed oliguria with rising blood urea
nitrogen and creatinine, treated with Bumex, Diuril and
Lasix. The patient was placed on a Dopamine infusion with
subsequent increase in urine output.
On [**2198-12-16**], postoperative day number three, the patient
required reintubation due to elevated carbon dioxide and
respiratory acidosis. The patient had been attempted on
BiPAP ventilation which subsequently failed and required
intubation. After intubation, the patient was noted to have
a moderate amount of secretions. Sputum culture was sent
which subsequently was positive for Hemophilus influenzae.
The patient's course was changed over a wire to a triple
lumen catheter. Dobutamine was weaned to off with an
adequate cardiac index.
On [**2198-12-16**], the patient underwent bronchoscopy which showed
thick copious secretions. The patient underwent
bronchoscopies on consecutive days, [**2198-12-17**], [**2198-12-18**], which
gradually showed improving amounts of secretions and after
antibiotics were then started.
On [**2198-12-17**], the patient was started on enteral feeds. The
patient's blood urea nitrogen and creatinine peaked at 76 and
1.5. The patient had required multiple red blood cell
transfusions for decreasing hematocrit with no obvious source
of bleeding. The patient continued on Dopamine infusion for
oliguria and the patient's mechanical ventilation was weaned
to CPAP.
On [**2198-12-18**], the patient was transferred from the CSRU to the
Surgical Intensive Care Unit service. The patient had been
started on Amiodarone for atrial fibrillation which
subsequently resulted in bradycardia. On [**2198-12-21**], the
patient was noted to have bilateral pleural effusions for
which bilateral chest tubes were placed with resolution of
effusions. The patient was weaned and extubated from
mechanical ventilation after the patient required aggressive
pulmonary toilet requiring multiple respiratory treatments
with Albuterol.
The patient was transferred to the floor on [**2198-12-23**]. Later
that evening, the patient was emergently intubated for
hypoxia and increased work of breathing. The patient was
transferred back to the Surgical Intensive Care Unit. The
patient required restarting of Dopamine infusion due to
bradycardia. Sputum culture from [**2198-12-23**], and [**2198-12-24**],
showed gram positive cocci which subsequently grew in culture
Methicillin resistant Staphylococcus aureus. The patient was
started on Vancomycin. Infectious disease consultation was
obtained.
Chest tubes were removed on [**2198-12-25**]. Dopamine infusion was
discontinued on [**2198-12-25**], and needed to be restarted due to
bradycardia. Electrophysiology consultation was obtained and
it was decided to discontinue the Amiodarone with thought
that perhaps the patient's atrial fibrillation with decreased
ventricular response was due to Amiodarone and perhaps the
patient would need a permanent pacemaker placed.
On [**2198-12-27**], the patient underwent percutaneous tracheostomy
placement and percutaneous endoscopic gastrostomy placement
by Dr. [**Last Name (STitle) **], a #8 tracheostomy tube. Bronchoscopy at
that time showed minimal secretions. On [**2198-12-28**], a PICC
line was attempted for intravenous antibiotics. Chest x-ray
showed that the tip of the catheter is in the midsubclavian
vein. It seemed that this intravenous was adequate for
intravenous antibiotics but inadequate for anything requiring
central infusion such as TPN.
The patient over the next several days underwent slow
ventilatory wean awaiting placement in rehabilitation
facility. On [**2198-12-30**], the patient developed an episode of
faster heart rates than previously, heart rates in the 70s to
one hundred teens. CKs were sent to rule out myocardial
infarction. The first CK was 8 and the second CK was 10.
On [**2198-12-31**], electrophysiology was again consulted regarding
the potential need for permanent pacemaker. It was decided
that the patient should complete a full two week course of
Vancomycin for her Methicillin resistant Staphylococcus
aureus pneumonia and the patient should be discharged to
rehabilitation and follow-up with electrophysiology clinic
regarding the need for permanent pacemaker.
Electrophysiology also requested echocardiogram to rule out
endocarditis as a result of bradycardia. It is scheduled the
afternoon of [**2198-12-31**]. After that, the patient will be
cleared for discharge to rehabilitation facility.
CONDITION ON DISCHARGE: Temperature maximum 98, pulse 76,
atrial fibrillation, blood pressure 123/58, respiratory rate
25. The patient is mechanically ventilated via tracheostomy.
Ventilator settings are CPAP, 40% FIO2, PEEP 5, pressure
support of 5. The patient has moderate thick tan secretions
requiring q6hour suctioning. The patient is awake, alert and
neurologically intact and conversant. The heart is
irregularly irregular. The extremities are warm and well
perfused. The lungs are coarse breath sounds bilaterally.
Breath sounds decreased on the left greater than the right.
Abdomen positive bowel sounds, percutaneous endoscopic
gastrostomy site is clean and dry. The abdomen is soft,
nontender, nondistended. The patient is having bowel
movements. The patient's weight on [**2198-12-29**], is 56 kilograms
which is at her preoperative weight. Sternal incision is
clean and dry. Steri-Strips are intact. There is no
erythema or drainage. The sternum is stable. Right lower
extremity upper medial thigh vein harvest site, Steri-Strips
are intact, incision is clean and dry without erythema or
drainage. Left lower extremity medial ankle shows an old
scar. The patient reports this is a previous ulcer with a
previous skin graft. Skin graft site is seen at the left
lower extremity upper thigh. The patient has 1 to 2+ pitting
edema in her lower extremities.
LABORATORY DATA: White blood cell count 13.3, hematocrit
27.8, platelet count 309,000. Sodium 145, potassium 4.3,
chloride 112, bicarbonate 29, blood urea nitrogen 71,
creatinine 0.9, glucose 126. Vancomycin peak 38.7, trough
24.1.
The patient has an evaluation by speech and swallowing
service pending. The patient has a transthoracic
echocardiogram pending.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Colace 100 mg p.o. b.i.d.
3. Albuterol MDI two puffs q4hours.
4. Heparin 5000 units subcutaneous b.i.d.
5. Vancomycin one gram intravenous q24hours, last dose
[**2199-1-10**].
6. Tylenol 650 mg p.o., PR q4-6hours p.r.n.
7. Dulcolax suppository one PR q.d. p.r.n.
8. Fleets enema one PR q.d. p.r.n.
9. Nystatin Powder to groin t.i.d. and p.r.n.
10. Prevacid 30 mg p.o. q.d.
11. Tube feeds via percutaneous endoscopic gastrostomy full
growth Promote with Fiber at 55 cc/hour.
All medications are to be given via the percutaneous
endoscopic gastrostomy tube. The patient is to not receive
any Coumadin for her atrial fibrillation due to her history
of multiple gastrointestinal bleeds due to her arteriovenous
malformations.
DISCHARGE STATUS: The patient is to be discharged to
rehabilitation facility in stable condition.
DISCHARGE DIAGNOSES:
1. Chronic atrial fibrillation.
2. Status post mitral valve replacement with
[**Last Name (un) 3843**]-[**Doctor Last Name **] valve.
3. Postoperative respiratory failure with Methicillin
resistant Staphylococcus aureus pneumonia.
4. Questionable history of transient ischemic attacks.
5. Congestive heart failure.
6. Pulmonary hypertension.
7. Coronary artery disease, status post percutaneous
transluminal coronary angioplasty in [**2195**].
9. Gout.
10. Postoperative renal insufficiency.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2198-12-31**] 14:41
T: [**2198-12-31**] 15:18
JOB#: [**Job Number 36169**]
|
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icd9cm
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47,683
| 116,642
|
50222
|
Discharge summary
|
report
|
Admission Date: [**2159-3-16**] Discharge Date: [**2159-3-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known lastname 80294**] is an 84 y/o M with history of recent CHF exacerbation
following hospitalizatin for sepsis who presents to the hospital
with increasing LE edema and dyspnea. This morning, he developed
acute shortness of breath, and was brought to the hospital by
ambulance. He denied any other symptoms such as fever, cough, or
chest pain. In the ED, Initially, he was satting 97% on RA but
tachypneic to 30s. BPs 118/83 initially, now 111/74. He was
started on nitro gtt, and received hydralazine 5mg IV as well.
He also received a dose of vancomycin and zosyn for possible
infectious precipitant. He is anticoagulated for a history of
DVT, and his present INR is 4.4. He also received 60mg PO K for
a potassium of 3.4. CXR showed volume overload. He then received
80mg IV lasix putting out only 500cc (home 80), put on bipap. He
was trialed off bipap and looked okay by numbers but was still
felt to be tenuous and was placed back on bipap for transfer.
.
Cardiac review of systems is notable for + orthopnea,
longstanding. On review of symptoms, he denies any prior history
of stroke, TIA, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
compiled from prior discharge summary:
Multiple Myeloma - treated at DF currently, on dexamethasone
DVT x 2, on coumadin
Valvular heart disease (MODERATE MR)
Hyperlipidemia
BPH
Constipation
Hypertension
Plantar fasciitis
Severe leg pain
appendectomy and tonsillectomy as a child
a kidney stone removed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] in [**2146**]
cholecystectomy by Dr. [**Last Name (STitle) **] in [**2153-9-17**]
Cardiac Risk Factors: Dyslipidemia, Hypertension
Cardiac History: No h/o CABG or revascularization
Percutaneous coronary intervention: none
Pacemaker/ICD: None
Social History:
He does not smoke nor drink. Smoked < 1 year when young. He is
married, has a son and a daughter. [**Name (NI) **] used to run a sportswear
factory.
Family History:
His father died at 90 of cancer in the brain and his mother at
52 of breast cancer.
Physical Exam:
Initially, he was satting 97% on RA but tachypneic to 30s. BPs
118/83 initially, now 111/74
GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**5-22**], and BLE [**5-22**] both proximally and distally. No pronator
drift.
Reflexes were symmetric. [**Last Name (un) **] going toes.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
At discharge, pt satting mid 90s on room air, walking with
assist with only faint bibasilar rales
Pertinent Results:
Admission Labs [**2159-3-16**]
WBC-6.0 RBC-3.36* Hgb-11.5* Hct-33.7* MCV-100* MCH-34.3*
MCHC-34.2 RDW-15.1 Plt Ct-265#
PT-41.1* PTT-33.5 INR(PT)-4.4*
Glucose-117* UreaN-21* Creat-1.3* Na-140 K-3.4 Cl-99 HCO3-33*
AnGap-11
ALT-12 AST-21 CK(CPK)-75 AlkPhos-50
CK-MB-NotDone proBNP-5767* cTropnT-0.05* CK-MB-NotDone
cTropnT-0.06*
Phos-2.8 Mg-2.0
Other Labs
[**2159-3-20**] Lactate-1.1
[**2159-3-21**] Cortsol-19.0
[**2159-3-19**] Glucose-124* UreaN-17 Creat-1.6* Na-143 K-3.7 Cl-92*
HCO3-46* AnGap-9
[**2159-3-21**] Glucose-108* UreaN-28* Creat-1.8* Na-141 K-3.2* Cl-92*
HCO3-45* AnGap-7*
[**2159-3-24**] Glucose-108* UreaN-36* Creat-1.4* Na-138 K-2.5* Cl-88*
HCO3-43* AnGap-10
[**2159-3-25**] Glucose-109* UreaN-37* Creat-1.5* Na-135 K-3.2* Cl-89*
HCO3-38* AnGap-11
[**2159-3-26**] Glucose-104 UreaN-38* Creat-1.7* Na-137 K-2.7* Cl-87*
HCO3-41* AnGap-12
[**2159-3-17**] PT-43.2* PTT-35.3* INR(PT)-4.8*
[**2159-3-18**] PT-44.2* PTT-35.6* INR(PT)-4.9*
[**2159-3-24**] PT-26.3* PTT-28.1 INR(PT)-2.6*
[**2159-3-25**] PT-34.6* PTT-31.1 INR(PT)-3.6*
[**2159-3-26**] WBC-8.2 RBC-3.63* Hgb-12.5* Hct-35.3* MCV-97 MCH-34.5*
MCHC-35.4* RDW-14.2 Plt Ct-292
Urine Studies
[**2159-3-21**] 11:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2159-3-21**] 11:25PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2159-3-21**] 11:25PM URINE RBC-[**6-27**]* WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
Micro Data
Blood cx x 4 NGTD
urine cx 10-100K yeast
Imaging
CXR [**2159-3-16**] FINDINGS: AP semi-upright portable chest radiograph
is obtained. There is persistent cardiomegaly with central
pulmonary vascular congestion and relative indistinctness of the
hilum. Bilateral pleural effusions are again noted with fissural
fluid noted on the right. Mediastinal contour is grossly stable
and difficult to accurately assess on this portable AP chest
radiograph. No pneumothorax is seen. Bibasilar atelectasis is
also stable. Osseous structures are unchanged.
IMPRESSION: Mild CHF with bilateral pleural effusions.
TTE [**2159-3-17**] The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is dilated with depressed free wall
contractility. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. Moderate to severe (3+) mitral
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion. If clinically
indicated, a transesophageal echocardiographic examination is
recommended to assess mitral valve morphology, exclude a
vegetation, and better evaluate severity of mitral
regurgitation.
IMPRESSION: Dilated left ventricle with normal global systolic
function. Dilated and at least mildly hypokinetic right
ventricle. Mild aortic regurgitation. Moderate to severe mitral
regurgitation. Severe pulmonary hypertension. Compared with the
prior study (images reviewed) of [**2159-2-15**], LV is more dilated.
Mitral regurgitation severity has increased, and pulmonary
pressure is more severe. Findings discussed with Dr. [**First Name (STitle) 4135**] at
1410 hours on the day of the study.
[**2159-3-23**] CXR FINDINGS: In comparison with the study of [**3-21**], there
may be some continued improvement in the mild pulmonary edema.
Enlargement of the cardiac silhouette persists. Progressive
decrease in the pleural effusions, especially on the right. Mild
bibasilar atelectasis persists.
ECG [**2159-3-18**] The rhythm appears to be atrial fibrillation with a
moderate ventricular response and occasional ventricular ectopy.
Right bundle-branch block. Compared to the previous tracing of
[**2159-3-16**] atrial fibrillation has appeared. Clinical correlation
is suggested.
ECG [**2159-3-17**] Sinus rhythm. Left atrial abnormality. Right
bundle-branch block. Compared to the previous tracing of [**2159-3-16**]
no diagnostic interim change.
Brief Hospital Course:
Assessment and Plan
84 y/o gentleman with history of diastolic CHF and hypertension
who presents with acute CHF exacerbation initially requiring
non-invasive ventilation as well as new 3+MR now improved
satting mid 90s after aggressive diuresis.
.
# ACUTE ON CHRONIC DIASTOLIC CONGESTIVE HEART FAILURE - Pt was
admitted with acute on chronic diastolic heart failure
decompensation with [**Date Range 113**] on admission showing worsening moderate
to severe MR [**Name13 (STitle) 104756**] with [**2159-1-18**]. He had no evidence of
new ischemia by ECG or biomarkers. Diuresis with lasix IV
boluses was initially limited by low BPs with SBPs in 70s-80s
but BP improved throughout hospital course as he was diuresed
with lasix gtt. He tolerated approximately 3L negative per day
and his renal function improved with diuresis. Lasix gtt was
transitioned to torsemide 80mg PO BID and metolazone with goal
1L negative per 24 hr period. He bumped his creatinine on day of
discharge from 1.7 to 2.3, so regimen was downtitrated to
torsemide 60mg PO BID with no metolazone. He was also restarted
on lisinopril 5mg PO daily for heart fialure and low dose beat
blocker metoprolol 12.5 PO BID. He will continue on this for
outpatient regimen. His dry weight at time of discharge was 94
kg on floor standing scale. He had been 92kg on CCU scale on day
prior to discharge. His admission weight was 106kg. His SBP was
80s-90s at discharge which is likely his baseline. He was
mentating well and was asymptomatic with SBP 80s-90s.
.
# MR: New 3+ MR [**First Name (Titles) **] [**Last Name (Titles) 113**] concerning for ischemic MR vs volume
overload. Continued diuresis as above and attempted to optimize
medical management as patient does not want surgery or any
invasive procedures.
.
# H/O DVT ON ANTICOAGULATION: Coumadin initially held due to
supratherapeutic INR but then restarted at home doses. INR again
supratherpaeutic on [**2159-3-26**] so will likely need adjustment of
home regimen as outpatient. Goal INR [**2-20**].
.
# MYELOMA: Have been holding dexamethasone secondary to fluid
overload
.
# CHRONIC KIDNEY DISEASE: Creatinine trended up through
admission likely from heart failure and decreased renal
perfusion as well as diuresis. Creatinine bump on [**2159-3-26**] likely
related to starting low dose ACE as well as reaching limit of
diuresis. Started on low dose aceI as above. Will need follow up
of renal function as well as electrolytes after discharge and
has repeat labs this week.
.
# HEMATURIA: Likely from elevated INR. He tolerated removing
foley and was voiding without difficulty at discharge. He
should follow up with urology and primary care as an outpatient.
.
# BPH/Bladder spasms- Patient started on pyrimidine 100mg PO TID
for 3 days which improved spasms. Continued finasteride.
.
# FEN : Pt with hypokalemia while being diuresed. He required
daily to [**Hospital1 **] potassium repletion and potassium levels will need
to be closely followed on discharge. He was also discharged on
standing low dose potassium repletion.
.
# CODE DNR/DNI , confirmed with patient and daughter
Medications on Admission:
1. Finasteride 5 mg dailu
2. Gabapentin 100 mg TID
4. ** STOPPED Tamsulosin 0.4 mg qHS
5. Calcitrate-Vitamin D 315-200 mg-unit [**Hospital1 **]
6. Docusate Sodium 100 mg [**Hospital1 **]
7. Folic Acid 0.5 mg Daily
8. Citalopram 40mg PO daily
9. Warfarin 4mg daily
11. Furosemide 80 mg daily
12. Acetic Acid - 2 % Solution - half cc in ears twice a day
13. ** STOPPED- Dexamethasone - 40mg qMonday
14. Famotidine - 20 mg [**Hospital1 **]
15. Tylenol
16. ASA b325mg PO daily
17. CHLORHEXIDINE GLUCONATE - 2 % Liquid - mouth wash twice a
day
19. MULTIVITAMINS WITH MINERALS
20. SENNA - 8.6 mg Tablet - 2 Tablet [**Hospital1 **]
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Calcium 500 + D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
6. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for constipation.
9. Gabapentin 100 mg Capsule Sig: Three (3) Capsule PO once a
day.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day.
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
13. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Please check INR, Chem-7 and Hct on thursday [**2159-3-29**] and call
results to Dr. [**Last Name (STitle) 713**] at [**Telephone/Fax (1) 719**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart failure
Hematuria
Chronic Kidney Disease Stage 3
Multiple myeloma
Discharge Condition:
stable
Discharge Instructions:
You were admitted with congestive heart failure that was making
your legs swell and causing shortness of breath. We changed some
of your medicines to help your heart work better. You also had
some blood in your urine that was from the foley catheter
placement. This should resolve on it's own. Please call Dr.
[**Last Name (STitle) 713**] if you have trouble urinating and talk to her about
seeing a urologist. Your coumadin level was 3.4 on [**3-27**] so your
coumadin was held. Please check it again on Thursday [**2159-3-29**]. Do
not start taking your coumadin again until Dr. [**Last Name (STitle) 713**] or Dr. [**Name (NI) 11723**] tells you to.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to [**2150**] mg sodium diet
Fluid Restriction: about [**6-24**] cups of fluid per day.
,
Medication changes:
1. Your Lisinopril was restarted at a very low dose
2. Metoprolol 12.5 mg twice daily: to help you heart pump better
3. Torsemide 80 mg twice daily: to replace the Furosemide to get
rid of fluid.
4. Potassium: to take every day to replace the potassium lost
from the torsemide
5.Stop taking your Furosemide
6. Please do not take your warfarin until after you get your INR
checked on [**2159-3-29**].
.
Please call Dr.[**Name (NI) 3733**] if you have any trouble breathing,
swelling in your legs, dizziness, feeling very thirsty,
palpitations or chest pain.
.
I have talked to Dr. [**Last Name (STitle) 713**] and Dr.[**Name (NI) 3733**], they agree to
defer a pulmonology work-up for now. These appts have been
cancelled.
Followup Instructions:
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time:
Friday [**3-30**] at 1:40pm. [**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**].
.
Heart Failure Clinic: Tuesday [**4-17**] at 2:30pm with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] NP [**Hospital Ward Name 23**] [**Location (un) 436**].
.
Primary Care:
Dr. [**First Name8 (NamePattern2) 712**] [**Name (STitle) 713**] Phone: [**Telephone/Fax (1) 719**] Date/time: [**2159-4-12**]
09:00am, [**Hospital Unit Name **], [**Location (un) 448**].
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icd9cm
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22,453
| 106,162
|
23118
|
Discharge summary
|
report
|
Admission Date: [**2107-12-10**] Discharge Date: [**2107-12-15**]
Date of Birth: [**2043-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
found unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
63yo man with history of hypertension, hyperlipidemia, and
bipolar disorder found on bathroom flor prone and incontinent of
urine/stool. Initially, he was arousable to verbal stimuli with
eye opening and incomprehensible verbal response. Vitals at
this point were 102/64, 90, 24, and 96%. There was a question
of right facial asymmetry. Hereafter, there was decreasing
level
of mental status with no response to verbal or pain.
In ED, vitals were 101.2, 98, 70/30, 20, and 100% on NRB. After
2L NS bolus, blood presure increased to 110. Narcan was given
with no effect. He was intubated with etomidate and
succinylcholine. He was given 50mg of charcoal by OG tube. He
was given vanco, ceftriaxone, and flagyl. Neosynephrine was
started with BP from 99/54 to105/57.
Discussion with his sister confirms the history and also adds
that he has had 3-4 months of leg cramps for which he has been
taking quinine. She also states that she counted all his pills
at home and that these were accurate.
Past Medical History:
-hypertension
-bipolar disorder, no h/o suicidal ideation or attempts
-hypercholesterolemia
-no known history of CAD
-GERD
-hip surgery one year ago
Social History:
-lives with 37 yo son (who has MR)
-wife in [**Name (NI) **] with [**Name (NI) 5895**]
- 45 pckXyear smoking history
- no etoh or drugs
Family History:
no family history of DM or CAD
Physical Exam:
101.2, 86, 137/67, 27, 100% on
AC (500X16, 0.5, 5)
gen: intubated, responding to voice, squeezing hands
heent: pupils equal, reactive
strabismus with outward/downward deviation of right eye
CV: RRR, no m/r/g
resp: CTA bilaterally
abd: soft, NT, good bowel sounds
extr: 2+ pitting edema bilaterally
petechial rash at bilateral heels/lower extremities
Pertinent Results:
[**2107-12-10**] 11:00AM CEREBROSPINAL FLUID (CSF) PROTEIN-47*
GLUCOSE-71
[**2107-12-10**] 11:00AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1*
POLYS-10 LYMPHS-90 MONOS-0
.
[**2107-12-10**] 07:01AM TYPE-ART TEMP-38.4 PO2-259* PCO2-35 PH-7.35
TOTAL CO2-20* BASE XS--5
[**2107-12-10**] 07:01AM LACTATE-1.1
[**2107-12-10**] 07:01AM O2 SAT-97 CARBOXYHB-0.3 MET HGB-1.5
.
[**2107-12-10**] 07:15AM GLUCOSE-135* UREA N-16 CREAT-0.8 SODIUM-138
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-21* ANION GAP-11
CALCIUM-7.0* PHOSPHATE-2.7 MAGNESIUM-1.8
.
[**2107-12-10**] 07:15AM ALT(SGPT)-25 AST(SGOT)-35 ALK PHOS-60
AMYLASE-303* TOT BILI-0.6 ALBUMIN-2.8* [**2107-12-10**] 07:15AM
LITHIUM-LESS THAN
[**2107-12-10**] 07:15AM VALPROATE-5*
[**2107-12-10**] 05:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
.
[**2107-12-10**] 05:30AM ALT(SGPT)-13 AST(SGOT)-14 CK(CPK)-15* ALK
PHOS-36* AMYLASE-205* TOT BILI-0.3
[**2107-12-10**] 05:30AM LIPASE-344*
.
[**2107-12-10**] 05:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
.
[**2107-12-10**] 05:30AM WBC-8.4 RBC-3.78* HGB-12.0* HCT-34.5* MCV-91
MCH-31.7 MCHC-34.8 RDW-13.8 PLT COUNT-310
[**2107-12-10**] 05:30AM NEUTS-62 BANDS-3 LYMPHS-15* MONOS-15* EOS-0
BASOS-0 ATYPS-3* METAS-2* MYELOS-0
[**2107-12-10**] 05:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
.
[**2107-12-10**] 05:30AM PT-14.0* PTT-27.4 INR(PT)-1.2
.
[**2107-12-10**] 06:23PM SED RATE-72*
CTA:
1. No evidence of pulmonary embolism.
2. Small amount of opacity at both lung bases representative of
either atelectasis or infiltrate.
ct a/p:
1) Dependent atelectasis/consolidation. This could represent
aspiration.
2) Cholelithiasis without evidence of cholecystitis.
3) Probable simple cyst in the kidney.
4) Periportal adenopathy.
ct spine:
IMPRESSION: No evidence of cervical spine fracture.
ct head w/o contrast:
1) No intracranial hemorrhage or mass effect.
2) Small vessel ischemic change.
cxr: Satisfactory positioning of the ET tube. No pneumothorax.
Patchy atelectasis in the left lower lobe. Pneumonia cannot be
excluded.
MR HEAD W/O CONTRAST, MRA BRAIN W/O CONTRAST, MRA
CAROTID/VERTEBRAL W/O CONTRAST:
1. No evidence of acute stroke.
2. Nonspecific hyperintensity in the periventricular white
matter most likely due to chronic small vessel infarction.
3. The MRA of the brain and neck are markedly limited by motion.
For further evaluation of the extracranial carotids, a carotid
ultrasound is recommended.
TTE:
1. The left atrium is mildly dilated. The left atrium is
elongated.
2 Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The ascending aorta is mildly dilated. The aortic arch is
mildly dilated.
5.The aortic valve leaflets (3) are mildly thickened. There is
mild aortic
valve stenosis. No aortic regurgitation seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7.There is no pericardial effusion. There is an anterior space
which most
likely represents a fat pad, though a loculated anterior
pericardial effusion
cannot be excluded.
MICRO:
negative urine, blood and csf cultures; ruled out for influenza
by negative direct antigens a and b. viral culture preliminarily
also negative.
Brief Hospital Course:
63 yo male w/ pmhx htn, hyperlipidemia, restless legs, bipolar
d/o found to have altered mental status and fever of unclear
etiologies, hypotension and mild pancreatitis, status post
extubation, having NSVT's while in ICU.
ICU course:
During ICU course, he defervesced, was extubated, weaned off
levophed, and antibiotics were discontinued. Workup for syncope,
seizure, stroke, meningeal or other infections negative to date.
TTE and viral cultures ordered and were pending. ICU course c/b
two episodes of asymptomatic NSVT. Transferred to floor on
hospital day #3.
Overall Hospital course, by problem:
1. Altered Mental Status/Unresponsiveness: An extensive workup
was begun in the ICU. Quinine was considered a possible
etiology as this can lead to prolonged QTc interval. However,
he had a normal EKG and has no known history of cardiac disease.
He was ruled out for an MI. His TTE showed only mild AS.
Infectious etiology was considered. He had a lumbar puncture
with CSF showing normal protein and glucose and 1 WBC and 1 RBC.
Blood, CSF, and urine cultures remained negative. He was ruled
out for influenza by direct antigen testing and his viral
cultures were preliminarily negative. Neurology was consulted.
A neurologic workup included a negative head MRI and MRA,
although the latter was limited by his motion. His depakote
level was low, although per his VA psychiatrist, his level the
week before was 40s. He had an EEG which was obtained while he
was on propofol that did not show lateralizing or epileptiform
abnormalities. The propofol was turned off during EEG and there
was a slight increase in the background activity. Neurology did
not believe that a seizure was responsible for his initial
state. His tox screen was positive only for benzodiazepenes.
It is possible that a benzo overdose may have led to his altered
mental status although per his sister, all his pills are
accounted for at home. A metabolic workup revealed initially
profound hypocalcemia and hypokalemia. At TSH and free T4 were
normal; however his PTH was slightly elevated which is
consistent with a calcium deficiency. It is possible that
hypocalcemia was a cause of a neurologic disturbance or
undetected seizure as he appeared symptomatic from the
hypocalcemia with a reported history of muscle cramps.
Malabsorption and malnutrition were considered given his low
albumin. However his calcium rose appropriately with
supplementation and his coagulation profile was normal. He did
appear initially dehydrated, with hypotension responding to
fluids. This could have led to a syncopal event but does not
explain the prolonged and profound altered mental status.
Although we are still unclear as to the cause of his change in
mental status, we presume that it is the result of some sort of
metabolic insult. His mental status has improved significantly.
However he still appears mildly delerious. He is hypomanic at
times, reports tearfulness, and per nursing is at times
inappropriate verbally. It is unclear what his baseline is
however. We are holding his quinine, as well as his olanzapine
and depakote.
2. NSVT: He had two episodes of asymptomatic NSVT while his
electrolytes were not fully repleted while in the ICU. He has
no known history of CAD and ruled out for MI by serial cardiac
enzymes. He had an echo that showed normal ventricular function
without wall motion abnormalities.
3. Hypotension: This was likely hypovolemic as he responded to
fluid boluses
and was then weaned from the neosynephrine. After pressors were
weaned, he remained normotensive and required no further IVF
boluses. It is also possible that he was overmedicated with
atenolol. He reportedly had an urgent care visit at the VA
recently for hypotentsion with a pressure of 90/30s. We kept
him off atenolol and his blood pressure remained normotensive.
4. Pancreatitis: This may have been a medication side effect
from valproic acid. Per his VA psychiatrist, he had a level in
the mid 40's the week prior to admission.
[**Last Name (un) **] score on presentation was low (< 2) which was consistent
with mild pancreatitis with low risk of mortality. His
pancreatic enzymes continued to trend downward, and he remained
free of any abdominal pain. He was able to tolerate po's
without difficulty after being extubated.
5. Petechial rash on bilateral lower extremities: He was not
thrombocytopenic. A vasculitis was considered as a potential
etiology; Dermatology was consulted, and felt that these changes
represented stasis changes secondary to his venous insufficiency
rather than vasculitis; decided against biopsy. The rash
resolved on its own.
6. bipolar disorder: Previously on Zyprexa and depakote. These
were held on presentation, and psychiatry was consulted for
recommendations regarding re-instituting these medications after
he was successfully extubated and alert/oriented. They
recommended that he remain off these until his delerium
completely resolves.
7. Diarrhea/LLQ pain-He had mild left lower quadrant pain and
watery black guaiac negative diarrhea. A CT did not show
diverticulitis or other potential source of pain/fever. Other
possibilities include infectious gastroenteritis/colitis from a
bacterial or viral etiology. It was thought that diarrhea is
from activated charcoal given in ED. This resolved on its own.
He was given one dose
8. Fever-no cultures have been positive so far. He appears to be
defervescing. There was a question if this is truly from an
infectious etiology as he does not appear to be symptomatic
other than with diarrhea, which is new in comparison to the
fever. Atelectasis or chemical pneumonitis [**1-24**] to aspiration
during his fall could be possible, however the latter without an
elevation in his white count is not usual. It could be that he
had an accounted for viral illness, that appears to be resolving
on its own.
9. Venous stasis-likely chronic; leg elevation was done with
good resolution.
10. leg cramps-He was no longer symptomatic once calcium was
repleted.
11. anemia-folate, b12 levels are normal. Low iron in setting of
low transferrin and TIBC with elevated ferritin does not provide
a clear etiology. This could be conssistent with anemia of
chronic disease. He is currently hemodynamically stable, with
hematocrit stable and guaiac negative. We would transfuse for
HCT <28; he has no h/o CAD but likely has COPD given 45py
smoking history. He may need outpatient colonoscopy given his
age. We started an iron supplement.
10. Fluids, Electrolytes, Nutrition-much of his initial
presentation may be attributable to dietary deficiencies. We
repleted his electrolytes and put him on an MVI, calcium and
vitamin D supplements. We encouraged him to drink plenty of
water and maintained him on a cardiac healthy diet. He was kept
on an insulin sliding scale.
Medications on Admission:
-depakote
-omeprazole 20 qD
-atenolol 50 qD
-quinine 325 qD
-simvastatin 40 qD
-gemfibrozl 600 [**Hospital1 **]
-olanzapine 10 HS
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: qs Injection
ASDIR (AS DIRECTED): USE RISS.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
Unresponsiveness requiring intubation, now resolved.
Delerium of unknown etiology
Hypocalcemia
Hypokalemia
Hypophosphatemia
Hypoalbuminema
Anemia
Bipolar disorder
Hypertension
Hypercholesterolemia
GERD
Discharge Condition:
stable, afebrile
Discharge Instructions:
You are being transferred to continue acute medical care at [**Hospital 10050**] [**Hospital6 **].
Followup Instructions:
continue acute medical and psychiatric care at [**Hospital 1268**] [**Hospital 59525**].
|
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48,297
| 103,539
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52363
|
Discharge summary
|
report
|
Admission Date: [**2163-6-21**] Discharge Date: [**2163-7-2**]
Date of Birth: [**2098-8-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
SOB, Fever
Major Surgical or Invasive Procedure:
Aline, central line
History of Present Illness:
Ms. [**Known lastname 108231**] is a 64 yo F w/ h/o pulm fibrosis after radiation
for Hodgkins, esophageal candidiasis, GERD, ? adrenal
insufficiency (orthostatic hypotension at PCP last wk when
dropped pred), esophageal HSV, SVT, unprovoked PE on coumadin
who presented to her PCP today [**Name Initial (PRE) **]/ 2D SOB and cough productive of
greenish brown sputum which is worse than her baseline. The
cough is assoc with left sided sharp 7/10 chest pain x1d. Pt
also reports nausea this am and vomiting mucus no blood after
albuterol. + chills, subj fevers, lightheaded, HA, weakness.
Recent PNA [**1-19**].
.
Has chronic SOB since [**1-19**] on pred taper. No hemoptysis.
.
In the ED, initial vs were: T 99.9 P 118 BP 120/49 R O2 sat
100%. Access 2 PIVs (18/20). Got 3 LNS, vanc 1gm, levo, aspirin,
tylenol. EKG diffuse ST depressions, improved since starting
fluids, initial troponin negative. CXR perimediastinal fibrosis
unchanged, incr linear opacities in apices bilat with nodular
opacities in RLL c/w multifocal PNA. CTA no PE, bilateral tree
and [**Male First Name (un) 239**] with RML consolidation. INR subtherapeutic 1.6.
.
Prior to transfer from the ED, vitals: T 99.5 P 110 BP 105/49 R
23 100% on BIPAP FIO2 100%, PEEP 5, PSV 8. Diffusely wheezy,
tachycardic. Pt waiting for a bed on [**Hospital Ward Name **] when HR rose to
140s, RR to 30, BP 120/80 and started BIPAP, got SL NTG, rpt CXR
without flash, started on ceftri as well (had already gotten
levo and vanco).
.
On arrival to the ICU, pt acknowledge feeling like she was
"drowning" in ED, but since starting BiPAP much improved.
Decreased SOB. Denies HA/CP/N/V/D/C.
.
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:
-Reactive airways disease/Pulmonary Fibrosis
-Pneumonia [**2162-12-12**], CAP tx with levofloxacin. Cx's neg.
-Hodgkin's disease stage 2 in '[**22**] treated with total body
radiation
-Functional Asplenism s/p radiation treatment
-Radiation induced ovarian failure s/p total hysterectomy and
estradiol therapy
-Hypothyroidism
-Supraventricular tachycardia
-GERD
-?Coronary vasospasm
-Pulmonary emoblism in '[**54**] on longterm low-dose Coumadin
-Right chest lentigo
-H/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**]/HSV esophagitis in setting of being on steroids
-Outpatient question of adrenal insufficiency with
lightheadedness with decreasing steroids
Social History:
Patient is married and lives in [**Location 1514**], MA with her husband.
She works as an administrator at a private high school. She is
independent and performs ADLs without limitation. Physically,
she has difficulty climbing stairs and participating in sports
due to her radiation-induced lung fibrosis. She drink EtOH
socially on the weekendsremote tobacco history in college but
no current use, , no ilicit drug use.
Administrator in high school, rare alcohol, no tobacco, daily
cup caffeine
Family History:
No family history of lung or cardiac diseases.
Mother: [**Name (NI) 2481**]
Maternal GM: Uterine cancer
Physical Exam:
General Appearance: Well nourished, No acute distress, No(t)
Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: bases b/l)
Abdominal: Soft, Non-tender, b/l papular rash below both breasts
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**2163-6-21**] 08:12PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2163-6-21**] 08:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2163-6-21**] 08:12PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2163-6-21**] 04:07PM LACTATE-2.0
[**2163-6-21**] 04:00PM GLUCOSE-112* UREA N-27* CREAT-1.2* SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
[**2163-6-21**] 04:00PM ALT(SGPT)-27 AST(SGOT)-32 CK(CPK)-41 ALK
PHOS-135* TOT BILI-0.6
[**2163-6-21**] 04:00PM LIPASE-17
[**2163-6-21**] 04:00PM CK-MB-NotDone cTropnT-<0.01
[**2163-6-21**] 04:00PM IRON-10*
[**2163-6-21**] 04:00PM calTIBC-308 FERRITIN-157* TRF-237
[**2163-6-21**] 04:00PM WBC-21.3*# RBC-3.37* HGB-10.4* HCT-30.1*
MCV-89 MCH-30.9 MCHC-34.6 RDW-14.5
[**2163-6-21**] 04:00PM NEUTS-85* BANDS-3 LYMPHS-2* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2163-6-21**] 04:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2163-6-21**] 04:00PM PLT SMR-HIGH PLT COUNT-486*
[**2163-6-21**] 04:00PM PT-18.0* PTT-26.6 INR(PT)-1.6*
CTA CHEST: 1. No evidence of pulmonary embolism or aortic
dissection.
2. Tree-in-[**Male First Name (un) 239**] nodular opacities in both lungs, most pronounced
in the
superior segment of the right lower lobe, compatible with a
small airways
infectious or inflammatory process.
3. Partial collapse of the right middle lobe.
4. Paramediastinal fibrotic changes secondary to radiation, with
neighboring
traction bronchiectasis.
TTE [**2163-6-22**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basl to mid septal
hypokinesis to akinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the report of the prior study (images unavailable
for review) of [**2155-12-16**], regional LV systolic dysfunciotn is
new.
Brief Hospital Course:
# Respiratory Failure - Mrs. [**Known lastname 108231**] was admitted to the ICU
due to hypoxia and tachypnea on presentation to the ED. PE was
ruled out by CTA, which also showed RLL pneumonia with tree [**First Name8 (NamePattern2) **]
[**Male First Name (un) 239**] opacities throughout lungs. In ED, she acutely worsened in
setting of tachycardia, thought likely secondary to flash
pulmonary edema. She was given diuretics, placed on BiPap with
some improvement, however ultimately required intubation for
hypoxic respiratory failure. She was admitted to the ICU. She
was treated for her pneumonia. She was intermittantly
hypotensive, requireing pressors. She was extubated after 24
hours with steady improvement in her oxygen requirement over the
course of her admission. Blood pressure was closely monitored
to avoid repeat flash pulmonary edema. On dishcarge, she was
breathing comfortably on room air.
# Pneumonia- Atypical distribution on CT with a RLL
consolidation. She was started on Vancomycin and Zosyn. ID was
consulted. While intubated, bronchoscopy was performed which
showed thick secretions, but no other pathology. Cultures were
taken and all were negative to date at time of discharge. Per
ID, antibiotic regimen was changed to Ceftriaxone given no
positive cultures. She was treated with Ceftriaxone for planned
10 day course. Oxygen requirement improved throughout
admission. Mrs. [**Known lastname 108231**] was discharged on a 2 day course of
Levoquin to complete a 10 day antibiotic course.
# Chest pain/NSTEMI - Mrs. [**Known lastname 108231**] presented with persistant,
pleuritic chest pain over lateral left chest in setting of
pneumonia on CT. EKG in the ED with SD depressions, first set
of cardiac enzymes were negative. Repeat enzymes in the ICU
were positive for troponin > 0.1 and she was started on
treatment for NSTEMI.
She was placed on high dose aspirin, beta-blocker, ace-inhibitor
and statin. Heparin was not given as she was
theapeutic/supratherapeutic on INR. Her EKG returned to
baseline. Cardiac catheterization was done after improvement in
acute infection. Catheterization showed diffuse coronary artery
disease; no internvention was done. Mrs.[**Known lastname 108232**]
[**Name (STitle) 10708**] was discontinued due to continued orthostatic
hypotension and restarting should be readdressed as an
outpatient. Aspirin, plavix, atorvostatin and metroprolol were
continued on discharge.
# Orthostatic Hypotension- Reportedly manifest as orthostasis
and lightheadedness over several weeks as patient tried to self
taper her prednisone that she has been on since last bout of PNA
in [**12-20**] - concern for adrenal insufficiency. She was given
stress dose steroids in the ICU and returned to outpatient dose
of prednisone (3 mg/day) after completion. Two days prior to
discharge, Mrs. [**Known lastname 108231**] experienced asymptommatic hypotension
in the morning that responded to small IV bolus. She continued
to hypotensive to systolic 80's the next two days. Cortisol
stimulation test was normal (however, patient was on prednisone
at the time). Patient was discharged on admission dose of
prednisone (3 mg). Salt in her diet was liberalized and patient
was discharged on Florinef with plans to follow-up with her PCP.
# Anemia - Anemia below baseline on admission, stable throughout
admission. Iron studies, B12 and folate normal. Transfused 1
unit PRBCs with no side effects.
# History of PE - Mrs. [**Known lastname 108231**] continues outpatient warfarin
for prophylaxis after PE approximately 10 years ago. She became
supratherapeutic during admission and this was held. Coumadin
was continued to be held in anticipation of cardiac
cathterization. After catheterization, coumadin was restarted.
After discharge, home VNA was arranged and INR checks will be
called into [**Hospital3 **] [**Hospital3 271**].
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs INH every four to six hours as needed for cough
ATENOLOL - 50 mg Tablet - 1 (One) Tablet(s) by mouth every day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 inhalation twice a day - RINSE MOUTH AFTER EACH
USE
LEVOTHYROXINE [SYNTHROID] - 112 mcg Tablet - 1 (One) Tablet(s)
by
mouth every day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
PREDNISONE - 2-3 mg daily
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth at bedtime
WARFARIN - 5 mg on Tuesday nights, 2.5 mg every other night.
CALCIUM CARBONATE-VITAMIN D3 500 mg (1,250 mg)-400 unit [**Hospital1 **]
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcium Carbonate-Vitamin D3 500 mg(1,250mg) -400 unit Tablet
Sig: One (1) Tablet PO once a day.
5. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO Once Daily at 4
PM: As directed by your PCP/coumadin clinic. Change dose as
instructed after coumadin/INR checks.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Hypotension
Respiratory Failure
Heart Attack - NSTEMI
Anemaia
Orthostatic Hypotension
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 shortness of breath and
determined to have pneumonia. Due to your pneumonia and
difficulty breathing, you were briefly put on a machine to
breath for you. You also briefly required medications to
maintain your blood pressure. Antibiotics were continued
throughout your admission and you will need to take one dose of
antibiotics after discharge to complete the treatment for
pneumonia for which you were treated with an 11 day course. You
also suffered a small heart attack during your hospitalization.
You were started on medication for this and had a cardiac
cathterization that showed coronary artery disease, but no
intervention was required. Your blood pressure was low at times
and it is felt that you have orthostatic hypotension. You
recieved one blood transfusion to treat your low blood count.
You are being started on a medication to help your blood
pressure. It is important that you follow-up with the
specialist appointmnents arranged for you.
CHANGES IN MEDICATION:
START Metoprolol 12.5 mg twice a day
START Plavix 75 mg daily
START Atorvastatin 80 mg daily
START Aspirin 325 mg daily
START Fludrocortisone 0.1mg daily
START Levofloxacin 750mg daily
STOP Atenolol
Please continue all other medications as previously prescribed.
Followup Instructions:
The following appointments have been arranged for you:
Department: [**Hospital3 249**]
When: TUESDAY [**2163-7-12**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11917**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This is a follow up of your hospitalization. You will be
reconnected to your primary care physician after this visit.
Department: DIV OF ALLERGY AND INFLAM
When: TUESDAY [**2163-7-19**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: CARDIAC SERVICES
When: FRIDAY [**2163-7-22**] at 3:20 PM
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
*We are working on a follow-up appointment for you in the
Pulmonary department. The office will contact you with an
appointment. If you do not hear from them or have questions,
please contact them at ([**Telephone/Fax (1) 3554**].
|
[
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"414.01",
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"428.0",
"285.9",
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"518.81",
"458.0",
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"427.89",
"V12.51",
"511.9",
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93",
"88.56",
"96.71",
"96.04",
"37.22",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13005, 13011
|
6860, 10769
|
325, 346
|
13170, 13170
|
4396, 6837
|
14637, 16017
|
3651, 3756
|
11526, 12982
|
13032, 13032
|
10795, 11503
|
13321, 14614
|
3771, 4377
|
275, 287
|
2042, 2422
|
374, 2024
|
13051, 13149
|
13185, 13297
|
2444, 3121
|
3137, 3635
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,190
| 115,624
|
31041
|
Discharge summary
|
report
|
Admission Date: [**2128-4-30**] Discharge Date: [**2128-5-23**]
Service: CARDIOTHORACIC
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2128-4-30**] Cardiac Catheterization
[**2128-5-4**] Thrombin Injection of Right Groin Pseudoaneurysm
[**2128-5-5**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending,
with vein grafts to obtuse marginal and posterior descending
artery
[**2128-5-17**] Cardioversion
History of Present Illness:
This is an 85 yr old male with CRI (baseline creat 1.8-2.3) who
was admitted to [**Hospital 46**] Hosp with a NSTEMI last month (medically
managed) and was then readmitted to [**Hospital 46**] Hosp with chest pain
on [**2128-4-26**]. He had squeezing sub-sternal CP intermittently for 2
weeks (both at rest and with exertion). The CP was associated
with SOB. He ruled in again for MI with trop reportedly 0.15,
ck??????s were negative. ETT reportedly revealed a reversible
inferior posterior defect. He is on coumadin for hx of DVT,
which has been on hold, and INR on [**2128-4-29**] was 1.5. He was pain
free at rest but has had chest pain when getting oob to the BR,
which has resolved with ntg SL and oxygen at [**Hospital 46**] Hosp.
Creatinine was up to 2.3. He was hydrated just prior to transfer
to the [**Hospital1 18**] for cardiac catheterization and further management
of his coronary artery disease. On admission, he was pain free.
Past Medical History:
Coronary artery disease with Recent MI
Chronic Renal Insuffiency
History of Deep Vein Thrombosis
Atrial Fibrillation
Hypertension
Hyperlipidemia
Social History:
Significant for the absence of current tobacco use. There is no
history of alcohol abuse.
Family History:
Brother in 50's with CAD.
Physical Exam:
VS: T 97.8 BP 119/73 HR 73 RR 18 O2 96% RA
Gen: WDWN male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 6cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Very distant heart sounds, irregular. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi anteriorly.
Abd: Soft,nt, obse, +BS. 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:
[**2128-4-30**] 01:56PM BLOOD WBC-7.4 RBC-4.16* Hgb-13.9* Hct-40.4
MCV-97 MCH-33.4* MCHC-34.4 RDW-13.7 Plt Ct-149*
[**2128-4-30**] 01:56PM BLOOD PT-16.4* INR(PT)-1.5*
[**2128-5-5**] 01:18PM BLOOD Fibrino-332
[**2128-4-30**] 01:56PM BLOOD Glucose-141* UreaN-30* Creat-1.6* Na-136
K-4.4 Cl-104 HCO3-25 AnGap-11
[**2128-4-30**] 01:56PM BLOOD ALT-17 AST-21 AlkPhos-46 TotBili-0.7
[**2128-4-30**] 01:56PM BLOOD %HbA1c-5.8
[**2128-5-2**] 06:50AM BLOOD CK-MB-3
[**2128-4-30**] Cardiac catheterization: Selective coronary angiography
of this right dominant system revealed three vessel disease. The
LMCA had a distal 30% lesion. The LAD was moderately calcified
with a 30% ostial stenosis and an 80% lesion in the mid-vessel
just after the take off of a major D2 branch, which had diffuse
plaquing. The D1 branch had a proximal 80% stenosis. The LCx had
a 90% lesion in the proximal AV groove and a 40% lesion
distally. The was a major OM3 branch with a proximal 70%
stenosis. The RCA was diffusely diseased throughout with a 50%
mid-vessel stenosis and 60-70% stenosis in the PDA. There was a
major AM branch with a 60% lesion. Moderate diastolic left
ventricular dysfunction.
[**2128-5-3**] TTE: Preserved global left ventricular systolic
function(LVEF approximately 55%). Right ventricular cavity
enlargement but with good free wall function. No AI. Trivial
MR. [**First Name (Titles) **] [**Last Name (Titles) **].
[**2128-5-4**] Carotid Ultrasound: Less than 40% stenosis involving the
internal carotid arteries bilaterally.
[**2128-5-4**] Groin Ultrasound: Right groin pseudoaneurysm measuring
up to 2.8 cm at site of previous right femoral puncture.
[**2128-5-15**] Abdominal CT Scan: Findings consistent with colonic
ileus. Short segment of narrowed ileum with mild wall
thickening. The appearance raises concern for a neoplastic
process, for which further evaluation is recommended. Multiple
bilateral cystic lesions in the kidneys, not fully characterized
here. Although these most likely represents simple cysts, this
appearance could be evaluated by ultrasound if clinically
indicated.
Brief Hospital Course:
On admission, Mr. [**Known lastname **] [**Last Name (Titles) 1834**] cardiac catheterization
which revealed severe three vessel coronary artery disease. He
was pretreated with Plavix. Given his chronic renal
insufficiency, LV gram was deferred and echocardiogram was
obtained which showed preserved global left ventricular systolic
function. In anticipation for cardiac surgical intervention,
Plavix was discontinued. Additional workup included cartoid
ultrasond which found minimal disease of the internal carotid
arteries. Cardiac catheterization was complicated by a right
common femoral artery pseudoaneurysm which was successfully
treated with thrombin injection on [**5-4**]. He otherwise
remained pain free on medical therapy. He had bouts of
paroxsymal atrial fibrillation preoperatively for which he was
maintained on Amiodarone and Heparin.
On [**5-5**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting surgery. For surgical details, please see seperate
dictated operative note. Following the operation, he was brought
to the CSRU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated. He continued to
experience periods of atrial fibrillation/flutter which was
initially treated with beta blockade and Amiodarone. Given
persistent atrial arrhythmias associated with hypotension, the
EP service was consulted. Amiodarone was continued while
Metoprolol was temporarily discontinued in hopes to improve
hemodynamics. Warfarin was also resumed with a temporary Heparin
bridge. Successful cardioversion was performed on [**5-17**], but
he returned to atrial fibillation within several days. A second
electrical cardioversion was attempted, but was also
unsuccessful. It was recommended that he remain on Amiodarone
at discharge with anticoagulation indefinitely.
His renal function declined in the early postoperative period.
His creatinine peaked to 3.8 on postoperative day ten. He did
not experience oliguria. The renal service was consulted and
attributed his acute on chronic renal failure to acute tubular
necrosis secondary to hypotension. Despite significant rise in
creatinine, there was no indication for dialysis. Over the
remaineder of his hospital stay, his renal function slowly
improved. He also experienced some hypernatremia which was
treated with free water.
His postoperative course was also complicated by an
ileus/colonic pseudobstruction. He was temporarily made NPO and
required placement of nasogastric and rectal tubes. With the
above measures and aggressive bowel regimen, his
pseudobstruction gradually resolved. His diet was slowly
advanced and by discharge, he was tolerating a regular diet.
He was also noted to have a sternal click associated with
sternal drainage. He was placed on strict sternal precautions
with close observation of his sternal incision. At discharge,
his sternal drainage had resolved although he continued to have
a click.
By post-operative day seventeen he was ready for discharge to a
rehabilitation facility.
Medications on Admission:
CURRENT MEDICATIONS (on transfer):
Asa 81mg qd
Ntg paste 1 inch
Imdur 60mg qd
Lopressor 100mg [**Hospital1 **]
Protonix 40mg qd
Lipitor 5mg qd
MVI qd
Glucosamine 2000mg qd
HCTZ 12.5mg qd, recently held due to rising creatinine
Ambien 5mg qhs prn
MEDS (home, [**Last Name (un) 5487**] doses):
HCTZ
Metoprolol
Coumadin
Glucosamine
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center - [**Location (un) 3320**]
Discharge Diagnosis:
Coronary artery disease - s/p CABG
Acute MI
Postop Colonic Pseudo-obstruction(Olgilvie's syndrome)
Postop Sternal Drainage
Postop Acute on Chronic Renal Insuffiency
Right Groin Pseudoaneurysm - s/p Thrombin Injection
History of Deep Vein Thrombosis
Atrial Fibrillation/Flutter - s/p Cardioversion
Hypertension
Hyperlipidemia
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. Warfarin should be monitored closely and
adjusted for goal INR between 2.0 - 3.0. Pre-admission his
coumadin was followed by his cardiologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
[**Location (un) 3320**], Mass ([**Telephone/Fax (1) 73314**].
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**4-15**] weeks, call for appt ([**Telephone/Fax (1) 11763**]
Dr. [**Last Name (STitle) 5310**] in [**2-14**] weeks, call for appt ([**Telephone/Fax (1) 73315**]
Dr. [**Last Name (STitle) 12246**] in [**2-14**] weeks, call for appt ([**Telephone/Fax (1) 73316**]
Dr. [**Last Name (STitle) **] from electrophysiology in 1 month, call for an
appointment ([**Telephone/Fax (1) 22784**]
|
[
"410.72",
"414.01",
"272.4",
"411.1",
"V12.51",
"997.2",
"496",
"427.31",
"401.9",
"593.9",
"442.3",
"250.00",
"560.89",
"427.32",
"276.0",
"584.5",
"997.4",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"89.60",
"36.12",
"99.61",
"99.29",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9368, 9447
|
4891, 7931
|
238, 574
|
9816, 9823
|
2770, 4868
|
10418, 10838
|
1839, 1866
|
8312, 9345
|
9468, 9795
|
7957, 8289
|
9847, 10395
|
1881, 2751
|
188, 200
|
602, 1547
|
1569, 1716
|
1732, 1823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,746
| 155,603
|
48107
|
Discharge summary
|
report
|
Admission Date: [**2131-8-22**] Discharge Date: [**2131-8-28**]
Date of Birth: [**2055-3-16**] Sex: M
Service: MEDICINE
Allergies:
Paxil / Haldol / Zyprexa / Risperdal / Ambien
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
# Ataxia
# Anemia
# Delirium
Major Surgical or Invasive Procedure:
# Intubation
# Esophagogastroduodenoscopy
History of Present Illness:
76M h/o demyelinating disease NOS (question MS), seizure d/o,
dementia NOS (question Alzheimer'[**Initials (NamePattern5) **] [**Last Name (NamePattern5) 309**] body disease),
bipolar d/o, and HTN, admitted from [**Hospital3 **] facility for
unsteady gait.
.
Neurology consult was able to speak with pt's facility Cadbury
Commons ([**Telephone/Fax (1) 101435**]), and much of the HPI was derived from
their note & ED notes. Per report, pt had not been sleeping
much for the past few days, and had been very restless at night.
During the evening prior to admit, pt stood up at dinner,
became dizzy, looked pale and diaphoretic, and almost fell.
Personnel reported pt's gait was "off." On the day of admit, at
lunch, pt again became dizzy, BP 150/80, pulse 90. Pulse
increased to 120 after pt walked briefly. Pt also reported to
be "not acting like himself." Pt reportedly pleasant with staff
in general.
.
In the [**Name (NI) **], pt found to be ataxic on exam, with other cerebellar
testing unremarkable. Guaiac mildly positive ([**11-21**] slides).
Vitals normal, afebrile. WBC slightly elevated at 13 and hct
26, decreased from 38 one year ago. UA negative. CT head
showed no bleed or mass. It was felt that the pt should be
admitted for further workup of his ataxia and anemia. When this
was communicated to the pt, he reportedly became very agitated
and, at some point, reportedly assaulted one of the ED nurses.
Because of this agitation, pt received haldol 5 mg and lorazepam
2mg. The pt initially calmed down, then became more agitated,
requiring lorazepam IV 3mg and 4-point leather restraints.
Following administration of haldol, it was learned that pt has
had previous paradoxical reactions to this and other psych
medications in the past.
.
Pt noted to be somnolent after receiving lorazepam with SaO2 to
80s when lying flat and not on BiPAP. However, pt. became also
intermittently agitated, becoming hypertensive and tachycardic.
.
ROS: Unable to assess when pt. arrived in MICU, though pt
frequently reported need to urinate and associated discomfort.
Past Medical History:
Neurologic/psychiatric
# Demyelinating disease NOS (question MS)
# Seizure d/o
# Dementia NOS (question Alzheimer'[**Initials (NamePattern5) **] [**Last Name (NamePattern5) 309**] body disease)
# Bipolar d/o
# Aspergers syndrome
# Restless leg syndrome
.
GI
# C. diff colitis ([**2128-6-20**])
# Bowel incontinence daily
.
GU
# BPH
.
Pulmonary
# OSA with no current CPAP at home
.
Musculoskeletal
# R hip fracture ([**2128-3-20**])
# R arm fracture ([**2128-3-20**])
.
Cardiac
# Heart murmur NOS
# Chronic diastolic dysfunction
Social History:
# Personal: Divorced. Lives in [**Hospital3 **] facility Cadbury
Commons, [**Hospital1 8**] MA, with active involvement of social worker
[**Name (NI) 2127**] [**Name (NI) **], tel. [**Telephone/Fax (1) 101436**]. HCP daughter [**Name (NI) 37193**] living in
[**Name (NI) 2784**]: [**Name (NI) 101437**] [**Telephone/Fax (1) 101438**], home 011-49-[**Telephone/Fax (1) 101439**], cell [**Telephone/Fax (3) 101440**].
# Professional: Retired math professor.
# Tobacco: None
# Alcohol: None
# Recreational drugs: None
Family History:
Noncontributory
Physical Exam:
VS: T 95.7, HR 98, BP 114/56, RR 18, SaO2 99 (4LNC)
Gen: NAD, intermittently severly agitated and trying to get out
of bed. Yelling that he wants to urinate.
HEENT: NCAT
****CV, respiratory: Deferred due to severe agitation****
Ext: No c/c/e.
Neuro: Moves all extremities, strength intact in all major
muscle groups
Skin: Pink, warm, no rashes
Pertinent Results:
Notable admission labs:
.
[**2131-8-22**] 02:46PM WBC-13.8*# RBC-2.98*# HGB-9.1*# HCT-26.3*#
MCV-88 MCH-30.5 MCHC-34.6 RDW-13.6
[**2131-8-22**] 02:46PM NEUTS-90.7* LYMPHS-5.9* MONOS-3.1 EOS-0.2
BASOS-0.1
[**2131-8-22**] 02:46PM CK(CPK)-76
[**2131-8-22**] 02:46PM CK-MB-5 cTropnT-<0.01
[**2131-8-22**] 02:46PM ASA-NEG ETHANOL-NEG CARBAMZPN-7.4
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2131-8-22**] 07:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
Notable studies:
.
# CHEST (PA & LAT) [**2131-8-22**] 4:49 PM
No radiographic evidence of pneumonia. No change from [**Month (only) **]
[**2127**].
.
# CT HEAD W/O CONTRAST [**2131-8-22**] 2:56 PM
1. No evidence of intracranial hemorrhage.
2. Findings consistent with age-related involutional change.
3. Chronic microvascular ischemic changes.
.
# MR HEAD WITHOUT AND WITH CONTRAST AND MRA BRAIN, [**2131-8-24**]
Evidence of chronic small vessel ischemia. No evidence of
hemorrhage or infarction.
.
# EGD [**2131-8-23**]
Blood in the pre-pyloric region. Below clot spurting blood was
noted. Whether this lesion represents an ulcer or Dieulafoy's
lesion is not entirely clear due to poor visibility. 2
resolution clips were applied and hemostasis was achieved.
Small hiatal hernia. Otherwise normal EGD to second part of the
duodenum.
Brief Hospital Course:
76M h/o demyelinating disease NOS (question MS), seizure d/o,
dementia NOS (question Alzheimer'[**Initials (NamePattern5) **] [**Last Name (NamePattern5) 309**] body disease),
bipolar d/o, and HTN, admitted from [**Hospital3 **] facility for
unsteady gait upon standing and altered mental status, both
likely [**12-22**] to active GIB.
.
# GI bleed: Pt noted to have 10 point hct decrease within the
last year (hct = 19), as well as black tarry stool upon transfer
to MICU. Pt intubated for urgent EGD [**8-23**]; clipped bleeding
lesion in prepyloric area. Pt received 7 units PRBCs and 1 unit
FFP; started on pantoprazole PO BID indefinitely until otherwise
notified by primary care provider and GI specialists. H. pylori
negative. HCT remained stable throughout the rest of hospital
course. Pt instructed to submit outpatient labwork for hct to
Dr. [**First Name (STitle) 908**] on Friday, [**2131-8-31**]. EGD outpatient
appointment arranged.
.
# Unsteady gait: Considered likely [**12-22**] GIB as CT and MRI/MRA
head were negative, pt demonstrated no other focal neurological
signs, and no infectious source was identified. Pt noted to be
deconditioned per PT. Psychiatry consult considered
polypharmacy to be unlikely contributor to preadmission unsteady
gait. Neurology consult agreed with diagnosis of orthostasis
[**12-22**] GIB, but recommended an [**Month/Day (2) **] as an outpatient to r/o possible
abnormal electrical activity. Pt considered ambulating well by
PT and OT, with PT arranged 2x weekly. [**Month/Day (2) **] and neurology
outpatient follow-up arranged.
.
# Altered mental status: AMS considered likely [**12-22**] GIB per
psychiatry consult, with agitation in the ED [**12-22**] reaction to
haloperidol. Question of underlying [**Last Name (un) 309**] body disease given
pt's paradoxical haloperidol reaction. Psychiatry consult
recommended quetiapine PRN for agitation, with total daily dose
limited to 400mg. Pt also restarted on home dose of trazodone
QHS. Pt received 1:1 sitter. AMS improved, with resolved
agitation and improved reception to verbal redirection and
calming. Psychiatry outpatient follow-up arranged.
.
# Bipolar disorder: Pt managed with quetiapine PRN, total dose
limited to 400mg daily, and home regimen of donepezil 5 mg PO
HS. Psychiatry outpatient follow-up arranged.
.
# Seizure d/o NOS: Pt continued on home regimen of levetiracetam
1000mg PO QHS and carbamazepine XR 400 mg PO BID. Neurology
outpatient follow-up arranged.
.
# HTN: Pt's home regimen of valsartan 40mg daily was held during
this admission given GIB. Pt was instructed to follow-up with
new PCP to determine when to restart BP medications.
.
# OSA: Pt received BiPAP overnight as tolerated. Pt's home
regimen of modafinil 150mg daily was held during this admission
given pt's agitation. Pt was instructed to follow-up with
outpatient providers to determine when to restart modafinil.
.
# Osteopenia: Pt's home regimen of alendronate 70mg qweekly was
held during this admission.
.
# Depression: Pt continued on home regimen of duloxetine 90 mg
PO daily and trazodone 150 mg QHS. Psychiatry outpatient
follow-up arranged.
.
# Dementia: Pt continued on home regimen of donepezil 5 mg
daily. Psychiatry outpatient follow-up arranged.
.
# BPH: Pt continued on home regimen of tamsulosin 0.8mg PO HS.
.
# Full code
Medications on Admission:
Carbamazepine XR 400 [**Hospital1 **]
Levetiracetam 1000 QHS
Trazodone 150 mg QHS
Duloxetine 90 mg QAM
Donepezil 5 mg daily
Aspirin 81 mg daily
Valsartan 40 mg daily
Tamsulosin 0.8 mg daily
Alendronate 70 mg Q week
MVI 1 tab daily
Vitamin D 800 untis daily
Modafinil 150 mg daily
.
Allergies: Paxil, Zyprexa, Haldol, Risperdal, and Ambien all
cause paradoxical effects
Discharge Medications:
1. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: Two
(2) Tablet Sustained Release 12 hr PO BID (2 times a day).
2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Levetiracetam 250 mg Tablet Sig: Four (4) Tablet PO QHS (once
a day (at bedtime)).
7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed
for in am.
8. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
CADBURY COMMONS
Discharge Diagnosis:
Primary diagnosis
.
# GI bleed
# Acute mental status change [**12-22**] GI bleed
.
Secondary diagnosis
.
# Multiple sclerosis
# Seizure disorder NOS
# Bipolar disorder
# Alzheimer's
# Asperger's syndrome
# Depression
# Hypertension
# Obstructive sleep apnea
# Benign prostatic hypertrophy
Discharge Condition:
All vital signs stable with adequate ambulation and mental
status
Discharge Instructions:
You came to the hospital because you had a change in mental
status and you were unsteady on your feet. We found that you
had a GI bleed. We clipped the bleeding vessel in your stomach,
but we had to intubate you (put a tube in your airway) to help
you breathe during that procedure.
.
We believe your blood loss could have caused you to be unsteady
on your feet and contributed to your mental status changes.
Your bleeding was NOT because of Helicobacter pylori infection,
as our lab results show that you are negative for this bacterial
infection.
.
We have given you a new medication for the bleeding in your
stomach:
# For your stomach: Pantoprazole 40mg twice daily. Continue
taking this medication until your primary care provider or GI
specialist tells you to stop.
.
We have STOPPED three of your medications:
# Because you were bleeding, we have temporarily stopped your
aspirin 81 mg daily. Do not restart this until after your
second esophagogastroduodenoscopy (EGD) confirms that you are
still no longer bleeding. Talk to your primary care doctor
about whether to restart the aspirin.
.
# Because you were bleeding, we temporarily stopped your
valsartan 40 mg daily, which you take for your blood pressure.
Talk to your primary care doctor about when to restart your
valsartan.
.
# Because you were agitated, we stopped your modafinil. Talk to
your psychiatrist about when to restart this.
.
Otherwise, we have not changed any of your medications.
.
It will be important to have two follow-up procedures:
# Esophogastroduodenoscopy: This will be important to see if you
are still bleeding in the stomach. We have made an appointment
for you (see below).
.
# Electroencephalogram: This will be important to see if you
have abnormal brain activity which may have contributed to your
unsteady gait. We have made an appointment for you (see below).
.
It will be important to follow up with your doctors. We have
listed your appointments below.
.
Also, you should have your red blood cell levels checked on
Friday, [**8-31**]. We have written a laboratory order for
that. Please fax those results to Dr. [**First Name4 (NamePattern1) 2795**] [**Last Name (NamePattern1) 908**], the GI
doctor who worked with you, at fax ([**Telephone/Fax (1) 101441**].
.
If you experience any dizziness, changes in your walking, or
changes in your mental status, or if you notice black, tarry
stools, please go immediately to the emergency room and call
your GI doctors (their names are listed below).
Followup Instructions:
You should follow up with these doctors:
.
# Your primary care provider:
[**Name10 (NameIs) **] have a new patient appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], tel.
[**Telephone/Fax (1) 250**], on Monday, [**9-3**], 9:40 am. **IT WILL BE VERY
IMPORTANT THAT Ms. [**First Name (Titles) **] [**Last Name (Titles) **] YOU TO THIS APPOINTMENT**, as
this is the first time Dr. [**Last Name (STitle) **] is meeting you.
.
# Your sleep neurologist:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2131-9-3**] 11:30 (Please note that this is the same day
as your appointment with Dr. [**Last Name (STitle) **].)
.
# Your psychiatrist:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] FORESTER, Phone:[**Telephone/Fax (1) 101442**],
Date/Time:[**2131-9-12**] at 11:00am, [**Hospital 11786**] Hospital, [**Street Address(2) 100235**], [**Location (un) 10059**] [**Numeric Identifier 80357**]
.
# Routine [**Numeric Identifier **]:
Dr. [**Last Name (STitle) **] would like you to complete this [**Last Name (STitle) **] study of your
brain activity before your appointment with him.
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 19105**] or [**Telephone/Fax (1) 5285**], Date/Time:
[**2131-9-18**] 1:00, at [**Hospital Ward Name **] 5
.
# Your epilepsy neurologist:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5285**]
Date/Time:[**2131-9-20**] 11:30, [**Hospital Ward Name **] 5
.
# Your repeat EGD:
You have a repeat EGD with Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] and [**First Name4 (NamePattern1) 2795**]
[**Last Name (NamePattern1) 908**] (tel [**Telephone/Fax (1) 463**]) on Tuesday, [**10-9**], at 7 am.
Please arrive at the [**Hospital Ward Name 1826**] Lobby at the Main Entrace of the
[**Hospital1 18**] [**Hospital Ward Name 516**], [**Location (un) 830**]. Do not eat after
midnight on the day of your EGD, and do not drink anything four
hours prior to arrival.
.
# Your urologist:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2131-12-24**] 2:00
Completed by:[**2131-8-28**]
|
[
"578.9",
"E939.2",
"276.51",
"293.0",
"785.59",
"340",
"296.80",
"E947.9",
"553.3",
"458.0",
"299.80",
"693.0",
"280.0",
"331.0",
"781.2",
"600.00",
"780.39",
"733.90",
"401.9",
"V15.88",
"294.10",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"99.04",
"93.90",
"96.04",
"99.07",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10058, 10100
|
5362, 6966
|
335, 379
|
10432, 10500
|
3985, 3993
|
13051, 15397
|
3589, 3606
|
9138, 10035
|
10121, 10411
|
8745, 9115
|
10524, 13028
|
3621, 3966
|
267, 297
|
407, 2488
|
4009, 5339
|
6981, 8719
|
2510, 3039
|
3055, 3573
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,381
| 151,521
|
10650
|
Discharge summary
|
report
|
Admission Date: [**2192-11-6**] Discharge Date: [**2192-11-6**]
Date of Birth: [**2120-9-15**] Sex: F
Service: NEUROLOGY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
Intubation and Extubation
History of Present Illness:
Pt is a 72 yo female with h/o metastatic breast CA(currently
undergoing chemo/XRT), HTN, chronic CA-related pain who is
transferred from an OSH with ICH/SAH. She has fallen several
times in the past few days by report. She also fell at least
twice on day before admission. She developed a hematoma
periorbitally on the right during one fall ~24 hours ago. Then,
she fell again and her husband was unable to get her up. At this
point, it is unclear whether the ambulance was called, or
whether
her daughter who is a nurse arrived, but she was then taken to
[**Hospital **] Hospital. In reviewing their notes, she was sedate but
arousable there. Her pupils were also described as equal and
reactive at 3 mm bilaterally. There, she was found to have a
large ICH with subarachnoid blood and ventricular extension. She
had an INR>8 at that time. She had a nasal airway placed,
received cerebyx 1 g IV, Vit K 1 mg SQ, FFP, and Ativan 1 mg IV.
She was then transferred here. It is unclear what her exact
mental status, level of arousability was upon transfer from OSH,
but she was awake and agitated for some of her time there. It
appears she may have been slightly worsened before transfer, but
unclear from notes.
In the ED here, she was described and unarousable when she
arrived(unclear of pupils). She was intubated, given Proplex and
Mannitol 140 mg IV. She was then continued on propofol here. A
repeat CT scan revealed similar picture to the OSH scan(have
only
seen report of that CT scan). She has a focus of hemorrhage in
the right frontotemporal white matter with extension to all of
her ventricles. She also has hydrocephalus with temporal [**Doctor Last Name 534**]
enlargement and a large amount of blood in the 4th ventricle,
likely causing obstruction. She has a right frontal contusion
that is separate from her largest area of bleeding. She also has
subarachnoid blood present fairly diffusely. It is unclear
whether any metastases are present and she has no known brain
mets. Since arrival here, she has been unresponsive and without
meaningful neurologic function.
ROS:Unable
Past Medical History:
PMH:
-HTN
-Stage 4 breast CA. Mets to lung/liver/iliac crests. Currently
undergoing chemo/XRT. Just completed palliative XRT to iliac
crests in hopes of providing pain relief. On coumadin for
port-a-cath patency.
-Chronic Pain related to cancer
-Known cavernous angiomas. On MRI from [**2187**], lesions appear to
be
scattered in left cerebral hemisphere.
Social History:
Pt lives with her husband. [**Name (NI) **] children live in the area. She
is undergoing treatment for her metastatic CA. Unknown
tobacco/EtOH status
Family History:
Unknown
Physical Exam:
Exam:Vitals:81, 122/55, 14, 100% on vent
Gen:Intubated and unresponsive.
HEENT:Intubated. C-collar in place.
CV: RRR, Nl S1 and S2, 2-3/6 sys murmur
Lung: Clear to auscultation bilaterally ant/lat
Abd:Soft.NT/ND
Neurologic examination:
Mental status: Intubated and unresponsive. Propofol was off for
~10 minutes when we examined her. She received Vecuronium ~2 hrs
prior to exam. No response to calling her name or painful
stimuli.
Cranial Nerves:
Pupils fixed and dilated bilaterally. On right 8 mm, on left [**5-29**]
mm. No reactive to light. Corneal reflexes not present. No eye
movements present.
Reflexes:Gag reflex not present. Unable to do Doll's eye due to
C-collar. DTRs 2+ in br, biceps, patellar bilaterally. Trace in
triceps bilat. Toes up bilaterally with toe [**Doctor Last Name 6671**] bilaterally.
Motor:
Normal to decreased tone throughout. She is moving feet/ankles
spontaneously, but not purposefully. She has triple flexion to
painful stimuli in legs bilaterally. She does not move her UEs
to
painful stimuli.
She does withdraw her feet to touch, but appears to be triple
flexion.
Pertinent Results:
[**2192-11-6**] 07:15AM BLOOD WBC-5.2# RBC-2.61*# Hgb-9.8* Hct-26.8*#
MCV-103*# MCH-37.6*# MCHC-36.6* RDW-14.7 Plt Ct-110*#
[**2192-11-6**] 07:15AM BLOOD Plt Ct-110*#
[**2192-11-6**] 07:15AM BLOOD PT-18.9* PTT-36.9* INR(PT)-2.5
[**2192-11-6**] 07:38AM BLOOD Glucose-226* Lactate-2.5* Na-134* K-3.2*
Cl-99*
[**2192-11-6**] 07:15AM BLOOD UreaN-16 Creat-0.6
[**2192-11-6**] 07:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-11-6**] 07:38AM BLOOD Type-ART pO2-550* pCO2-27* pH-7.44
calHCO3-19* Base XS--3
[**2192-11-6**] 07:15AM URINE Color-Pink Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2192-11-6**] 07:15AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose->1000 Ketone->80 Bilirub-NEG Urobiln-1 pH-5.5 Leuks-NEG
[**2192-11-6**] 07:15AM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2192-11-6**] 07:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
------
Head CT:FINDINGS: There is a large area of hyperdensity in the
right hemisphere involving the temporal, frontal, and parietal
lobes, which is consistent with parenchymal hematoma with
dissection into the ventricular system. There is associated
shift of midline structures to the left. The lateral, third and
fourth ventricles are all dilated with clotted blood within
them. There is a right subdural hematoma along the convexity of
the occipital lobe, with a parafalcine component. In addition,
there is a large cystic dilation in the right parietal and
temporal lobes which appears to run along the surface of the
tentorium. It is not clear whether this is in the subdural space
or represents a distorted right temporal [**Doctor Last Name 534**]. There is an area
of calcification adjacent to the left lateral ventricle, likely
representing an area of old hemorrhage. No fractures are
identified. The visualized paranasal sinuses and mastoid air
cells are well pneumatized, apart from some mild mucosal
thickening of the right maxillary sinus. A large area of soft
tissue swelling is seen over the right temporal bone and orbit.
IMPRESSION:
Large right parenchymal hematoma dissecting into the ventricular
system with associated diffuse ventricular dilation.
Moderate-sized right subdural hematoma along the occipital
convexity and the falx, with a possibly cystic component as
well. These findings are associated with leftward subfalcine
herniation.
----
CXR:IMPRESSION:
1. Satisfactory position of endotracheal tube.
2. Likely parenchymal and pleural scarring in the left
hemithorax, although it is difficult to exclude a small left
pleural effusion. Once the patient has been extubated, dedicated
PA and lateral chest radiograph is recommended to allow for
assessment of stability of left apical thickening, which is
asymmetric compared to the right.
Brief Hospital Course:
This was a 72 yo female with h/o metastatic breast CA(currently
undergoing
chemo/XRT), HTN, chronic CA-related pain who was transferred
from
an OSH with ICH/SAH. Her CT scan showed extensive damage and
hydrocephalus. Neurosurgery saw the patient and offered a
venticular drain, with knowledge that it would not likely
provide much benefit given the severity of her bleeding, but the
family declined. She
was neurologically unresponsive, with no evidence of
consciousness
or brainstem function during our entire care of her. She was
not overbreathing the
ventilator. She was on propofol, but even after this was stopped
for a significant time span, she did not change clinically. In
addition, she was no longer on any sedating or paralyzing
medications that may influence our exam. Her chances of
recovery were very slim and chances of meaningful recovery
essentially non-existent. This was discussed with her family.
She was transferred to the ICU and continued on mechanical
ventilation and completed her mannitol dosing. Another series
of family meetings was held and they decided to withdraw
ventilatory support and make the patient CMO. The patient was
then given morphine for comfort and extubated. She did not
breathe on her own and died several minutes after extubation
with her family present in the room.
Medications on Admission:
Zoloft 100 mg qam
Protonix 40
Lisinopril 5 mg qam
Coumadin 1 mg qam
Xeloda 500 mg [**Hospital1 **]
Xanax
Elavil
Tylenol PM
Oxycontin 20 mg q8h
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial hemorrhage with hydrocephalus
Stage IV breast cancer
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"432.1",
"197.0",
"174.8",
"401.9",
"198.5",
"814.00",
"E928.9",
"E849.9",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8535, 8544
|
6990, 8313
|
300, 327
|
8653, 8663
|
4173, 5109
|
8716, 8815
|
3018, 3027
|
8506, 8512
|
8565, 8632
|
8339, 8483
|
8687, 8693
|
3042, 3255
|
257, 262
|
355, 2456
|
3493, 4154
|
5117, 6967
|
3294, 3477
|
3279, 3279
|
2478, 2835
|
2851, 3002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,028
| 195,031
|
17602
|
Discharge summary
|
report
|
Admission Date: [**2191-2-17**] Discharge Date: [**2191-3-1**]
Date of Birth: [**2109-8-2**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Nifedipine / Hydrochlorothiazide
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient 81 yo male with history of ILD now with worening
SOB. Over the past month, the patient has had worsening
shortness of breath/cough with increasing O2 requirement. He was
started on steroids in mid-[**Month (only) **] in an attempt to halt his
IPF. He reports minimal effects. Approxmately 2 weeks ago, he
presented with what sounded like a sinusititis with copious
nasal secretions (no fevers, chills, tooth pain) which improved
with a 5 day course of azithromycin. However shortly after
stopping the Z-pack he began to experience a sensation of phlegm
in the basck of his throat, which when he coughs up is yellow in
color (no hemoptysis). He denied fevers, chills, rhinorrhea. He
states that the sputum is worse at night especially when he lays
down and is relived by expectorating as well as sitting up
right. He denies any pleuritic chest pain. He then began
experienceing worsening fatigue and malaise over the past week.
He was seen in pulmonary clinic this morning and there was
concerning about superimposed pneumonia and he was sent to the
ED.
.
In the ED, initial vitals were T97.0 HR 88 BP142/69 O2 91% 6L. A
CT Chest was performed and showed new superimposed diffuse
ground-glass densities of both lungs. He received 1g IV
ceftriaxone and 500mg IV Azithromycin. At times he desaturated
to the 70's during coughing fits. He was admitted to the ICU for
further management.
Past Medical History:
1. Pulmonary Fibrosis: steady decline over last few years.
2. Hypertension
3. Allergies
4. GERD
5. Melenoma excised [**2169**] excised at the [**Hospital3 14659**]
6. Anemia
Social History:
Lives with wife; has 3 grown children. Occassional ETOH. Distant
smoking history. Retired chemical engineer.
Family History:
Non-contributory
Physical Exam:
Vitals - 97.7 77 132/71 22 100% on 80%HiFlow mask
General - older male, lying in male, able to speak in broken
sentences
HEENT - PERRL
CV - RRR
Lungs - crackles on left [**3-13**] way up; crackles at base on right
Abdomen - soft, NT/ND
Ext - no edema
Pertinent Results:
[**2191-2-17**] CT Chest - 1. New superimposed diffuse ground-glass
densities of both lungs which is most likely concerning for an
atypical infection. The Pneumocystis jirovecii infection is also
a possibility. Superimposed hypersensitivity pneumonitis and
drug reaction are another likely possibilities. Superimposed
acute
interstitial pneumonia such as NSIP also cannot be excluded.
2. Interval worsening of the patient's known interstitial lung
disease with worsening of the bronchiectatic changes of both
lungs and worsening of honeycombing, it was suggested that the
patient's underlying ILD was most likely asbestosis.
[**2191-2-17**] CXR - 1. Stable interstitial lung disease. 2.Subtle
increased opacity in the right cardiophrenic region, could
represent early/developing infiltrate.
.
Sputum culture
**FINAL REPORT [**2191-2-26**]**
GRAM STAIN (Final [**2191-2-24**]):
[**12-3**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2191-2-26**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
Assessment and Plan: 81 yo M with IPF now with worsening SOB and
increaseing O2 requirement.
.
# SOB: patient with severe underlying IPF, now with likely
underlying infection. Initially treated for community acquired
pneumonia and underwent BAL to eval for possible PCP, [**Name10 (NameIs) 6643**] was
negative. He was started on ceftriaxone and azithromycin and
improved gradually. He had a low grade temperature and repeat
sputum culture revealed MRSA, given his tenuous respiratory
status, he was started on vancomycin initially and switched to
linezolid afterwards. Plan is for 14 day course of linezolid.
For the communitya acquired pneumonia, he was switched to
levofloxacin at the time of discharge to finish a 14 day course.
He also received cough suppresants, oxygen and nebs prn. At
day of discharge he was on 95% on RA and needed oxygen with only
exertion.
.
# hyponatremia: Patient has chronic hyponatremia. Etiology
unknown. Urine lytes revealed SIADH, so he was fluid restricted
to 1500cc. There has been a concern for norvasc as contributing
in the past and this was discontinued. His na improved likely
from withholding free water (unclear role of norvasc withdrawl,
as both were done concurrently).
.
# IPF - followed by Dr [**Last Name (STitle) **]; treat underlying infection,
followed by pulmonary in house. He was increased on prednisone
during this infection which was tapered down. Please continue
on 10 mg prednisone until [**2191-3-7**], then switch to 5mg daily
until pt follows up with pulmonary.
.
# Hypertension - continue outpatient meds initially. Norvasc
was discontinued and his BP remained stable.
.
# Narcolepsy: cont provigil
Medications on Admission:
Mucomyst 600 [**Hospital1 **]
Norvasc 5mg daily
Astelin
[**Doctor First Name **]
Fluticasone
Guafenesin
Provigil
Diovan 160 daily
Azithromycin started [**2191-2-15**]
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO daily ().
9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
10. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2
times a day).
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
16. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please continue on 10 mg prednisone until [**2191-3-7**], then
switch to 5mg daily until pt follows up with pulmonary.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Community acquired penumonia
MRSA pneumonia
Pulmonary Fibrosis
Secondary:
Hypertension
GERD
Anemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
underwent series of blood and sputum tests. You were treated
with antibiotics for a pneumonia.
It is important that you finish up the antibiotcs as prescribed.
If you have chest pain, shortness of breath or fever please
contact your PCP or return to the emergency room.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**2-9**] weeks after discharged
form the rehab.
You should also follow up with Dr. [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] as below:
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4506**] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2191-3-23**] 8:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2191-3-23**] 8:10
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2191-3-23**] 8:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2191-3-23**] 8:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2191-3-1**]
|
[
"530.81",
"347.00",
"515",
"482.41",
"V09.0",
"V46.2",
"494.1",
"285.9",
"V10.82",
"V15.82",
"253.6",
"401.9",
"501"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
7866, 7945
|
4480, 6156
|
305, 311
|
8098, 8105
|
2381, 4457
|
8489, 9447
|
2076, 2094
|
6374, 7843
|
7966, 8077
|
6182, 6351
|
8129, 8466
|
2109, 2362
|
262, 267
|
339, 1736
|
1758, 1934
|
1950, 2060
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,283
| 112,334
|
50499
|
Discharge summary
|
report
|
Admission Date: [**2119-5-1**] Discharge Date: [**2119-5-9**]
Date of Birth: [**2059-11-3**] Sex: M
Service: Cardiac Surgery
CHIEF COMPLAINT: Mitral valve disease.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
male with a prior cardiac history including ASD repair in
[**2099**], mitral valve disease, atrial fibrillation/flutter,
status post ablation. He was followed by serial
echocardiograms and a recent echocardiogram showed EF greater
than 55% with moderate to severe mitral regurgitation. He
was schedule for mitral valve replacement.
PAST MEDICAL HISTORY: Mitral valve disease, atrial
fibrillation, status post ablation.
PAST SURGICAL HISTORY: ASD repair in [**2099**].
ALLERGIES: None known.
MEDICATIONS: Aspirin 325 mg q d, Zestril 10 mg q d,
Amiodarone 200 mg q d.
HOSPITAL COURSE: The patient underwent mitral valve
replacement with a #27 mosaic valve on [**2119-5-1**]. He was
transferred to the CSRU post-operatively. He was A-paced on
arrival in the CSRU with intermittent loss of capture, with
hypotension. His underlying rhythm was junctional in the
40's. AV pacing was attempted but ventricular ectopic
activity occurred. There was loss of both A and V capture
with inappropriate sensing despite various measures. He
continued to be bradycardic with hypotension. He was started
on Dopamine, and emergent pacing Swan was placed with
appropriate pacing and sensing. He was also started on
Dopamine drip. He was extubated later on in the same day.
His hemodynamic status stabilized. He was seen by Dr.
[**Last Name (STitle) **] who is his regular electrophysiologist.
Subsequently he continued to be V paced with complete heart
block. He was continued on his Amiodarone. A tentative
decision was made for pacemaker placement because of the
complete heart block. On postoperative day #3 he had
converted to a junctional rhythm and was maintaining his
blood pressure. He was transferred to the regular floor on
postoperative day #3 in a junctional rhythm with pacing
wires. He was hemodynamically stable at this point. On
postoperative day #4 he converted to atrial fibrillation.
His Amiodarone dose was increased per EP and he was started
on a Heparin infusion. Decision was made for cardioversion
on [**2119-5-8**]. The following days he remained hemodynamically
stable while awaiting therapeutic PTT with Heparin and he
continued to be in atrial fibrillation. On [**2119-5-8**],
postoperative day #7, he underwent cardioversion
successfully. He converted to a sinus rhythm with a
prolonged PR interval. He was stable with this rhythm. He
was deemed ready for discharge by both electrophysiology and
cardiac surgery on postoperative day #8. He was discharged
home on postoperative day #8.
DISCHARGE MEDICATIONS: Lasix 20 mg q day times one week, KCL
20 mEq q d times one week, Colace 100 mg [**Hospital1 **], Aspirin,
enteric coated, 325 mg q d, Amiodarone 400 mg q d for one day
followed by 200 mg q d, duration to be decided by EP,
Percocet 1-2 tablets q 4-6 hours prn.
CONDITION ON DISCHARGE: Stable.
FO[**Last Name (STitle) **]P: His primary care physician in two weeks, Dr.
[**Last Name (STitle) **], Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2119-5-9**] 20:28
T: [**2119-5-9**] 21:19
JOB#: [**Job Number 18071**]
|
[
"416.8",
"E878.1",
"997.1",
"458.2",
"427.89",
"427.31",
"424.0",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.24",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
2795, 3056
|
836, 2771
|
689, 818
|
160, 183
|
212, 576
|
599, 665
|
3081, 3502
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,357
| 186,638
|
30376
|
Discharge summary
|
report
|
Admission Date: [**2124-3-17**] Discharge Date: [**2124-3-29**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Transfer from OSH for ERCP for concern for ascending cholangitis
Major Surgical or Invasive Procedure:
ERCP x 2
CARDIAC CATHETERIZATION
History of Present Illness:
85 yoF PMH HTN, PVD, reportedly benign tumor of the colon
removed [**2122**] at [**Hospital1 2025**] presented to [**Hospital3 **] Hospital [**2124-3-16**] with
the acute onset of epigastric pain, [**9-27**], associated with
nausea and vomiting. In the OSH ER, the patient was hypertensive
with systolics in the 200s and HR 110-130. The patient had a
small amount of hematemesis. CT of the abdomen showed
gallbladder and intra- and extra-hepatic biliary duct dilatation
consistent with cholecystitis and concerning for ascending
cholangitis. Cystic lesion at CBD, consistent with cholecocal
cyst. No gallstones visualized on CT or US.
.
Initial liver enzymes significant for AST 105 then 605 prior to
transfer, alkaline phosphatase 110 then 167, total bilirubin 6.7
with direct 4.5. Amylase 153 and lipase 139 prior to transfer.
2/2 blood culture bottles positive for GNR, ID/sensitivities
pending. The patient was started on flagyl and levofloxacin
[**3-16**]; it appears as if the levofloxacin was discontinued and
aztreonam started [**3-17**]. This may haven been changed secondary to
QTc prolongation but it is unclear.
.
The patient's initial WBC 10,000, which increased to 20,000
prior to transfer. Initial platelets were 212 but dropped to 124
prior to transfer. Initial creatinine 0.9, increasing to 1.5
prior to transfer.
.
The patient had a troponin leak prior to transfer, with initial
<0.1, then 0.26, then 0.28. EKG showed no ST or T wave changes
indicative of ischemia. The elevated troponin appears to have
occurred in the setting of ARF. The troponins were not sent with
OSH records and it is unclear if there was CK elevation.
.
On presentation, the patient complains of mild nausea. She
denies fevers, chills, abdominal pain, diarrhea, melena/BRBPR.
She denies further emesis since presentation. She describes the
abdominal pain she experienced on presentation as epigastric and
then radiating to both upper quadrants. She denies chest pain,
SOB, dysuria but complains of some urinary frequency. Review of
systems otherwise negative in detail.
Past Medical History:
1. Hypertension
2. Reportedly benign tumor of the colon removed [**2122**] at [**Hospital1 2025**]
3. Vertigo; unclear history but question of TIA in past with
transient use of coumadin per son, no coumadin for years
.
PSH:
1. Right colectomy [**2122**]
2. Cataract surgery
3. Tonsillectomy
Social History:
Lives in [**Hospital3 **]. Widow with 3 children. Remote smoking
history. Rare alcohol.
Family History:
Brother with gallbladder disease. No known family history of
liver disease, GI bleeding. Father and brother died of colon
cancer. Mother died of stroke, had history of MI at age 80.
Physical Exam:
T 97.1 HR 98 BP 156/72 RR27 O2Sat 94% on NC at 4L
Gen: Patient appears comfortable, but mildly tachypneic
Heent: PERRL, ?JVD to 5 cm
Cardiac: Tachy regular w/ occ ?PACs, normal S1/S2 no murmurs
Lungs: mild bibasilar crackles, no wheeze. Good air movement
Abdomen: soft, mild TTP RUQ, no rebound or gaurding
Ext: 1+ LE edema bilaterally, symmetric 1+ DP; no hematoma or
bruit R groin
Neuro: Awake and alert
Pertinent Results:
[**2124-3-20**] ERCP: 1.The major papilla was located in the second part
of the duodenum with a choledocal cyst in the distal CBD.
2.The proximal PD visualised was normal
3.Cannulation of the CBD was very difficult due to the presence
of a large choledocal cyst.
4.Cannulation was achieved using straight, and angled glide
wires.
5.Even though deep cannulation was achieved,due to looping of
the wire within the choledocal cyst, stenting could not be
achieved.
6.Cholangiogram was suggestive of a slight distal CBD narrowing
which did not appear to be obstructive, however this will need
to be confirmed on a definitive repeat cholangiogram.
7.In order to allow drainage from the choledocal cyst, a small
needle knife fistulotomy was created into the choledocal cyst.
8.Obstructive bile was seen flowing from the cyst, which was
decompressed by the pre-cut.
.
[**2124-3-17**] CXR: Endotracheal tube tip is 2-1/2 cm above the carina.
There is right IJ line with tip in the right atrium. There is a
small left effusion. There is bilateral lower lobe volume loss
with right perihilar infiltrate that is slightly increased
compared to the prior study. There is no pneumothorax.
.
[**2124-3-17**] ECG: Sinus rhythm. Low limb lead voltage. Delayed
precordial R wave progression. No previous tracing available for
comparison.
.
[**2124-3-19**] CXR: 1. Improvement in perihilar opacity on the right
side.
2. Increase in bilateral pleural effusions and in the
retrocardiac density on the left side.
.
[**2124-3-20**] CT HEAD: No intracranial hemorrhage or mass effect.
.
[**2124-3-20**] KUB: No evidence of gross intra-abdominal free air.
.
[**2124-3-21**] CXR: 1. Improvement in perihilar opacity on the right
side.
2. Increase in bilateral pleural effusions and in the
retrocardiac density on the left side.
.
[**2124-3-21**] ECHO: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. A left ventricular mass/thrombus cannot be excluded.
Overall left ventricular systolic function is severely depressed
(ejection fraction 20-30 percent) secondary to akinesis of the
midventricular segment of the anterior septum and anterior free
wall, severe hypokinesis of the inferior septum and lateral
wall, and extensive apical akinesis extending into the
midventricular segment of the inferior and posterior walls. Only
tha basal posterior wall displays apparently normal contractile
function. There is no ventricular septal defect. Right
ventricular chamber size is normal. There is severe hypokinesis
of the apical half of the free wall of the right ventricle.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. An aortic valve vegetation/mass cannot
be excluded. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. No vegetation/mass is seen on the
pulmonic
valve. There is no pericardial effusion.
.
[**2124-3-21**] C.CATH: Left Heart Catheterization: was performed by
percutaneous entry of the right femoral artery, using a 5 French
angled pigtail catheter, advanced to the left ventricle through
a 5 French introducing sheath. Coronary Angiography: was
performed in multiple projections using a 5 French JL4 and a 5
French JR4 catheter, with manual contrast injections.
.
[**2124-3-22**] CXR: Interval partial improvement in pulmonary edema.
Stable small bilateral pleural effusions and left retrocardiac
opacity.
.
[**2124-3-25**] UNILAT LOWER EXT VEINS LEFT: No evidence of left lower
extremity deep vein thrombosis.
.
[**2124-3-25**] CXR: Improvement in the appearance of the pulmonary edema
since the prior examination. Improvement in left lower lobe
atelectasis and/or airspace disease. Persistent bilateral
pleural effusions, left greater than right.
.
[**2124-3-27**] ERCP: 1. Evidence of a wide open duodenal-choledochol
cyst fistula
2. Cannulation of the biliary duct was performed via the
duodenal-choledochol cyst fistula
3. A narrowing was found just above the cystic dilation in the
lower third of the CBD.
4. Cytology samples were obtained using a brush in the lower
third of the common bile duct.
.
[**2124-3-23**] BEDSIDE SWALLOW: SUMMARY / IMPRESSION:
Pt is not demonstrating any s&s aspiration, nor any s&s
oropharyngeal dysphagia at bedside. The pt does appear to have
no
appetite at this time, which is likely affecting her desire to
eat/swallow food/liquid. Also spoke to RN who indicated pt may
benefit from enema as she has not had recent BM and this may be
affecting her poor appetite as well. Pt is drinking her
supplements and is aware of the importance of po intake at this
time. Nutrition is following per medical chart, which is
appropriate.
RECOMMENDATIONS:
1. Continue with current po diet consistency.
2. Nutrition follow up as appropriate.
.
Repeat Echo EF >55%
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mitral
regurgitation is seen. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2124-3-21**],
left and right venticular function are markedly improved
(normalized). No mitral
regurgitation is visualized on the current study. Only focused
views obtained on current study, so severity of valvular disease
not fully assessed. If clinically indicated, a complete study
would better assess for structural valvular disease.
.
[**3-29**] Labs
HCT of 30.0, Chem7 WNL
Brief Hospital Course:
Ms. [**Known lastname 72245**] is an 85 year old woman with PMH HTN, who presented
from [**Hospital3 **] Hospital [**2124-3-16**] with epigastric pain, elevated
LFTs, E. coli bacteremia who is now s/p ERCP which revealed
choledocal cyst. She developed acute respiratory distress and
pulmonary edema and was transferred to the MICU team. Her
hospital course is described below by problem.
.
## Respiratory failure - Secondary to acute pulmonary edema in
the setting of diminished EF/myocardial depression. She was
diuresed with furosemide and responded with abundant UOP. She
was also given albuterol and ipratropium nebulizers as needed.
She had a CXR with possible superimposed pneumonia per
radiology, but the clinical suspicion was low given she was
afebrile and her respiratory status improved on furosemide.
Follow-up CXR showed improving CHF and resolving ? infiltrate vs
atelectasis. Initial Echo showed EF between 20-30; repeat Echo
with normalized EF.
.
## Myocardial depression- EKG changes, troponin leak, and
abnormal [**Month/Day/Year 461**] concerning for recent ischemic event or
having NSTEMI, however cardiac catheterization revealed normal
coronaries. In this setting, LV hypokinesis likely myocardial
depression secondary to sepsis. She will need a follow up ECHO
in several weeks to assess for improvement in EF. She was
continued on BB and an ACEI was started. Diuresed with IV
Lasix. Repeat Echo with improved EF (>55%).
.
## Cholangitis/sepsis - Patient is status post ERCP with
drainage of the choledocal cyst but without stent placement.
Cholangiogram was suggestive of slight distal CBD narrowing
which did not appear to be obstructive. Repeat ERCP showed
evidence of a wide open duodenal-choledochol cyst fistula. LFTs
trended down to normal. Sepsis resolved w/ fluid resuscitation,
abx, ERCP. She will complete a total of 14 days of Aztreonam;
OSH blood cultures growing E. coli sensitive to aztreonam.
.
## Aspiration PNA: Onset post-ERCP. Treated with
aztreonam/flagyl. Subsequent swallow evaluation with no
signs/symptoms of aspiration. On nebs. Follow-up CXR with
resolving atelectasis vs infectious process.
.
## Acute renal failure - On admission Cr 1.7. Likely prerenal in
the setting of septic shock, especially given normalization
after fluid resuscitation and treatment of infection.
.
## HTN: Well controlled on BB + ACEI. Occasional doses have
needed to be held in the setting of aggressive diuresis.
.
## Altered mental status- Per family, patient get disoriented
every time she is in the hospital or in rehab. TSH/folate/B12
normal. CT head with slightly prominent lateral ventricles but
otherwise normal. Consider outpatient neuropsych follow-up to
assess for dementia but, per family, at baseline is very
functional
.
## Thrombocytopenia - Patient initially with drop of platelets.
Felt this was due to low-level DIC secondary to sepsis. HIT ab
negative. Plt nadir of 70 - now normal. Plts 435 on discharge.
.
## Code: Full (documented DNR/DNI prior to hospital stay,
reversed for ERCP; full code for now after discussion with son)
Medications on Admission:
ASA 81, last [**3-16**]
Lisinopril 5 QD
Vitamin C
Vitamin E
Calcium
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): until ambulating
regularly.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for sbp < 100 or hr < 55.
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): hold
for sbp < 100.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
7. Aztreonam 1 g Recon Soln Sig: One (1) gm Injection every
eight (8) hours for 2 days.
8. Furosemide 10 mg/mL Solution Sig: One (1) inj Injection [**Hospital1 **]
(2 times a day): until peripheral edema clears.
Discharge Disposition:
Extended Care
Facility:
Cape Regency Nursing & Rehabilitation - [**Location 41366**]
Discharge Diagnosis:
Primary Diagnoses
E coli Septicemia
Ascending cholangitis
Choledocal cyst s/p I&D
Aspiration pneumonia (following ERCP, swallow eval without s/s
aspiration)
NSTEMI in setting of sepsis, clean coronaries
Systolic heart failure in setting of sepsis
Anemia of Chronic Disease
Discharge Condition:
stable
Discharge Instructions:
Please monitor for temperature > 101, worsening mental status,
drop in blood pressure, drop in O2 sat, or other concerning
symptoms.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**]
Date/Time:[**2124-4-27**] 1:00. Location: [**Hospital Ward Name **], [**Hospital1 18**], [**Hospital Ward Name 23**]
Building [**Location (un) 436**].
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD (cardiology)
Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2124-5-1**] 8:40. Location: [**Hospital Ward Name **], [**Hospital1 18**], [**Hospital Ward Name 23**] [**Location (un) 436**].
3. You have an appointment set up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 51036**],
on [**2124-4-13**] at 3:45. [**Telephone/Fax (1) 72246**]
4. Call Dr. [**First Name (STitle) **] [**Name (STitle) **] office (GI) in one week to find out
the cytology results from the ERCP that was done on [**2124-3-27**].
[**Telephone/Fax (1) 2799**]
|
[
"780.97",
"995.92",
"038.42",
"785.52",
"576.1",
"428.20",
"584.9",
"576.8",
"458.9",
"410.71",
"443.9",
"276.0",
"285.29",
"276.2",
"428.0",
"287.5",
"401.9",
"507.0",
"285.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"51.10",
"96.04",
"38.93",
"37.22",
"51.59",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13430, 13517
|
9405, 12505
|
284, 318
|
13855, 13864
|
3471, 4979
|
14046, 14920
|
2846, 3029
|
12623, 13407
|
13538, 13834
|
12531, 12600
|
13888, 14023
|
3044, 3452
|
180, 246
|
346, 2409
|
4988, 9382
|
2431, 2724
|
2740, 2830
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,901
| 176,417
|
37962
|
Discharge summary
|
report
|
Admission Date: [**2178-7-30**] Discharge Date: [**2178-8-3**]
Date of Birth: [**2130-6-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Right lung atelectasis
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with attempted debulking procedure [**7-31**]
History of Present Illness:
48 yo woman who was intially diagnosed with stage IIIb SCC of
the lung invlolving th carina in [**2177-9-2**]. She was treated
with XRT cisplatin/etoposide and later presented with central
airway obstruction and was referred here where she had a
placement and removal of a silicone Y-stent, placement of 2
Ultraflex metal stents (one in distal trachea, one in R main
stem bronchus), and argon plasma coagulation of tumor. She was
subsequently lost to follow up.
.
Since then she was reasonably well until [**2178-4-2**], when she
had persistent dyspnea and prioductive cough. She was been
treated with avelox for suspected PNA 4-5 times since [**Month (only) 547**].
About two weeks ago, she presented with progressive dyspnea and
could barely ambulate across the room. PET CT on [**2178-7-9**] showed R
lung collapse, intense uptake at distal trachea and proximal R
mainstem bronchus. Bronchoscopy on [**2178-7-22**] revealed complete
malignant right sided airway obstruction with growth of the
tumor through the mesh of the stent. Biopsy was positive for
SCC. She signed out AMA, but then re presented with progressive
dyspnea on [**7-27**]. A plan for brachytherapy was considered, but
patient was transferred to [**Hospital1 18**] to relieve airway obstruction
and for further therapy. On transfer, she was on a medical floor
with no respiratory distress or stridor on 1L NC.
.
She was taken to the OR by IP to evaluate stents and for
possible new stent placment. She was found have complete
obstruction of the right main bronchus and partial obstruction
of the left main bronchus with purulent secretions throughout.
The right mid and lower lobes were localized and were open,
right upper lobe is completely gone. Patient was found to be
hypoxic after the procedure, intubated, and required 2L of LR
and then neosynephrine. She remained largely dependent on
pressors at the time of transfer. Her vent settings were
downtitrated to PEEP 5 and FiO2 of 50%, satting 97%.
Past Medical History:
Stage IIIB NSCLC diagnosed by transbronchial biopsy in [**8-10**].
Currently on chemo/rads.
Post-obstructive pna of the right lung. Treated with cefuroxime
and fluconazole.
Emphysema
Hypertension
Anxiety and panic attacks
TAH w/ tubal ligation
Social History:
Smoking 30 year pack history, recently quit smoking.
ETOH: recently quit, but hx of 3 drinks/day.
denies illicit drug use.
Used to work as a housekeeper at Courtland Manor.
Divorced and lives alone, but has three children.
Family History:
Noncontributory.
Physical Exam:
VS - Temp 98, BP 119/73, HR 90, R 26, O2-sat 98% on CMV 300x20
GENERAL - caucasian female, intubated sedated
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - trachea midline, no lymphadenopathy
LUNGS - wheezing, decreased breath sounds on the right.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-6**] throughout, sensation grossly intact throughout
Pertinent Results:
VS - Temp 98, BP 119/73, HR 90, R 26, O2-sat 98% on CMV 300x20
GENERAL - caucasian female, intubated sedated
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - trachea midline, no lymphadenopathy
LUNGS - wheezing, decreased breath sounds on the right.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-6**] throughout, sensation grossly intact throughout
Brief Hospital Course:
48 yo F with recently diagnosed lung SCC involving the carina,
s/p Y stent in [**8-10**], XRT and chemo, recently re-presetned with
dyspnea found to have total R lung collaps, and complete
malignant obstruction of R main stem, s/p IP intervention,
admitted for hypoxemia and hypotension.
.
She was initially hypotensive and hypoxic immidiately after IP
procedure. She required transient pressor support and was on
the ventilator for approximately 36 hours. It was noted that
she had a pericardial effusion on the CT scan, which cardiology
came to evaluate with echo and determined that there were no
signs of tamponade. She was started on antibiotics (Vanco/[**Last Name (un) **])
empirically for transient bacteremia ([**2-3**] to IP procedure) and
possible post-obstructive pneumonia.
.
Second day, she improved and was able to come off the vent. She
had a repeat imaging that showed mildly improved ventilation of
the right lung (though still largely collapsed [**2-3**] to tumor).
There were appreciable pus and partial blockage of the left main
bronchus from the tumor. Goals of care was discussed with the
patient and she refused any more IP interventions. She was
discharged in stable condition.
.
Access - PIV, porta-cath
.
PPx - DVT ppx with SQ Heparin. Bowel regimen
.
Communication - Patient (OSH contact [**Telephone/Fax (1) 84825**] (east [**Hospital **]
medical in [**Location (un) **]). Referring pulmonologist: Dr. [**Last Name (STitle) 84826**] [**Telephone/Fax (1) 84827**]), daughter [**Numeric Identifier 84828**]
.
Code - FULL CODE confirmed
Medications on Admission:
MVI
Xopenex prn
lorazepam prn
Medications on Transfer:
Albuterol INH q6
MVI daily
symbicort 2 puffs INH [**Hospital1 **]
Tiotropium INH daily
lorazepam 0.5 mg PO q4 prn
vicodin 1 tab 1 6 prn pain
avelox 400mg PO daily started [**2178-7-27**]
enoxaparin
Discharge Medications:
1. Clindamycin Palmitate 75 mg/5 mL Recon Soln Sig: Three
Hundred (300) mg PO Q6H (every 6 hours) for 7 days.
Disp:*8400 mg* Refills:*0*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for dyspnea/wheezing.
Disp:*2 nebulizers* Refills:*0*
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
Disp:*2 inhalers* Refills:*2*
8. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Xopenex 1.25 mg/0.5 mL Solution for Nebulization Sig: One (1)
puff Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
10. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Right lung atelectasis secondary to lung cancer
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 have been admitted to the hospital for right lung collapse.
You were evaluated by our interventional pulmonologists (lung
doctors) and the decision was made to pursue no further
treatment. You are being transferred back to the hospital in
[**State 1727**] per your request.
Followup Instructions:
Transfer to outside hospital
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2178-8-3**]
|
[
"799.02",
"518.0",
"041.89",
"519.19",
"401.9",
"162.2",
"V87.41",
"423.9",
"790.7",
"492.8",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.78",
"96.04",
"32.01",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7298, 7313
|
4149, 5720
|
300, 366
|
7405, 7405
|
3539, 4126
|
7891, 8086
|
2900, 2918
|
6023, 7275
|
7334, 7384
|
5746, 5776
|
7588, 7868
|
2933, 3520
|
238, 262
|
394, 2374
|
7420, 7564
|
5801, 6000
|
2396, 2643
|
2659, 2884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,067
| 199,756
|
34990
|
Discharge summary
|
report
|
Admission Date: [**2165-10-12**] Discharge Date: [**2165-10-17**]
Date of Birth: [**2112-8-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
GI Bleed, Hypotension
Major Surgical or Invasive Procedure:
EGD x 2
History of Present Illness:
This is a 53 year old male with CAD s/p 3 MI's, s/p recent
cardiac arrest/cardiogenic shock 3 weeks ago w/o stenting on ASA
and plavix, ESRD on HD, DM2 who presents with GIB. History is
per daughter. She reports that her father had a grossly bloodly
bowel movement 2 days prior to admission with subsequent clear
bowel movements that day. He reported feeling dizzy and tired
throughout that day and the following day but did not have any
bloody bowel movements, melena or hematamasis one day prior to
admission. Blood pressures taken at home were SBP 90's. Today,
he had another bloody bowel movement in the morning, but went to
hemodialysis. He was half-way through HD when he had several
more bloody bowel movements with clots. His SBP was 70-80s. An
ambulance was called.
.
In the ED: His vitals were SBP 80's, HR 120's, RR 18 100% RA. He
had altered mental status and was moaning. He passed >1liter
maroon stool and then began vomiting. Initally, vomitus was
without gross blood, but NG lavage showed dark maroon blood. He
was then intubated for airway protection; versed and fentanyl
boluses. A cordis was placed. 3 units pRBC's were rapidly
infused. He also received one bag FFP, protonix drip,
octreotide. His vitals improved to HR 117, SBP 155/65.
Past Medical History:
1. CAD
- S/p recent cardiac arrest with cardiogenic shock
- MI [**2162**] with 99% distal LAD stensosis (no stent), 99% lcx
stenosis(s/p stent),60% [**Last Name (un) **] stenosis (stented), 90% Om2
(stented)
- Mi [**2163**] with medically managed occluded 0M2
2. DM 2 - insulin therapy for 12 years
3. ESRD on HD as of [**1-27**] weeks
4. Anemia of chronic disease
5. PVD
6. HTN
7. Hyperlipidemia
Social History:
ASA 325 mg
Plavix 75 mg daily
Atorvastatin 80mg
Nitro SL PRN
Procardia ER 50mg PO daily
Lisinopril 5mg daily
Nephrocaps
Gemfibrazole 600mg [**Hospital1 **]
Omeprazole 30mg daily
Ezetamibe 10mg daily
Family History:
Non-Contributory
Physical Exam:
Vitals: T:97.2 P:114 BP:116/79 R:18 SaO2: 100% on FI02 100%
General: confused, moaning, not following commands
HEENT: NC/AT, PERRL, no scleral icterus noted; NG tube with
bright red blood
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: warm well perfused, no edema, dried blood on thighs
Skin: no rashes or lesions noted.
Neurologic: -mental status: stuporous
Pertinent Results:
Admission Labs:
[**2165-10-12**] 01:00PM WBC-11.0 RBC-1.38* HGB-4.2* HCT-12.3* MCV-89
MCH-30.7 MCHC-34.4 RDW-17.6*
[**2165-10-12**] 01:00PM NEUTS-78.5* LYMPHS-16.3* MONOS-4.0 EOS-0.9
BASOS-0.3
[**2165-10-12**] 01:00PM PLT COUNT-229
[**2165-10-12**] 01:00PM PT-18.0* PTT-150* INR(PT)-1.6*
[**2165-10-12**] 08:37PM LACTATE-3.6*
Laboratory Data on Transfer:
142 108 31
---------------< 141
4.0 26 3.5
.
Ca: 8.3 Mg: 1.7 P: 3.1
.
Source: Line-r groin cortis
86
12.0
11.3 >-------< 155
33.8
.
PT: 15.9 PTT: 27.5 INR: 1.4
.
EKG: LBBB (old), new 2mm ST depressions V3-V6
.
Radiologic Data:
CXR: no acute process
EGD [**10-12**]:
A single superficial bleeding ulcer was found in the second part
of the duodenum. A gold probe was applied for hemostasis
successfully.
Impression: Blood in the antrum and fundus
Ulcer in the second part of the duodenum (thermal therapy)
Otherwise normal EGD to second part of the duodenum
.
EGD [**10-13**]:
The bicapped ulcer in D2 was noted without any stigmata of
active bleeding.
Impression: The bicapped ulcer in D2 was noted without any
stigmata of active bleeding.No blood clot was noted in the
stomach. There was minimal amount of bile in the stomach.
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
53 year old male with CAD s/p 3 MI's, s/p recent cardiac
arrest/cardiogenic shock 3 weeks ago, ESRD on HD, DM2 who
presents with hypovolemic shock, GIB, ST depressions and
hyperkalemia.
.
# Massive upper GI bleed: The patient was initially placed on
a PPI gtt and later transitioned to [**Hospital1 **] dosing. Pt underwent EGD
x 2 (Details above) where he was found to have an oozing
duodenal ulcer which was cauterized. Pt had one subsequent
episode of maroon stools one day after his first EGD, however he
remained hemodynamically stable without decreases in hid HCT.
The patient was initially intubated for airway protection, and
was extubated two days into his ICU course without complication.
The patient was transferred to the floor hemodynamically stable
with a Hct > 30. Pt's Hct continued to rise and had no futher
abdominal complaints. Hct was 35.5 on discharge. Pt was d/c on
2wks of [**Hospital1 **] protonix.
.
# Acute blood loss anemia. Pt presented with a Hct of 12.3. Pt
had two PIVs placed as well as a R Cordis. Pt was aggressively
resuscitated during his course in the MICU receiving a total of
10 units of pRBCs.
# NSTEMI: the patient was s/p 3 MI and cardiac arrest on ASA and
plavix but no stenting since [**2162**]. His initial EKG demonstrated
significant ST depressions in V2-V6 likely demand ischemia.
Troponins peaked at 1.6 during his hospital course. The pt was
placed on an ACEi, B-Blocker and Statin post troponin bump. No
chest pain. TTE (details above) revealed EF 30-40% (down from
last prior known EF of 51%). Pt was continued Lisinopril 10,
Metop 50 TID, Lipitor 80 while inpatient. On discharge his
records from [**Hospital1 2025**] were reviewed and he was put on his home
regimen (see below). Pt was discharged on ASA without plavix.
This change in medications was discussed wiht his primary
cardiologist at [**Hospital1 2025**].
.
# Hospital-acquired vs. Ventilator-associated pneumonia: Pt was
recently at [**Hospital1 2025**] and may have contracted the infection then, and
but was found to have elevated WBC and and increasing secretions
from ETT. Pt was found to have new LLL consolidation, and since
recent admission to [**Hospital1 2025**] from MI pt tx as HAP. Started on
Vano/[**Last Name (un) **]/Levaquin ([**Last Name (un) **] since pcn allergy). On the floor pt was
changed to Vanco/[**Last Name (un) **] and continued that night. On day of
discharg pt was changed to Linezolid and pt was to finish 10d
course of PO linezold.
# Hypertension : pt has needed labetalol in ICU, currently
stable in 160s. Pt was also given hydralizine x1 on the floor.
It was thought that the HTN was due to not being on his home
regimen, since it was unknown at the time. Pt's HTN was
controlled on day of discharge and d/c'd on his home regimen.
# Hyperkalemia: The pt presented with a potassium of 7.1 in ED,
EKG w/o concerning changes for hyperkalemia. The pt was given
Insulin regular 6 units. His repeat K within normal limits (not
apparently hemolyzed). Pt had no further episodes.
# ESRD: Mr. [**Known lastname **] had recently been started on dialysis after
his episode of cardiogenic shock at [**Hospital1 2025**]. While here at [**Hospital1 18**],
he exhibited no signs of acidosis, further episodes of
hyperkalemia, overload or uremia during his stay in the MICU.
Followed closely by renal. The pt made good UOP and subsequently
HD was delayed. Renal saw the patient on the floor and concluded
that the patient may not need dialysis at all anymore. Pt was
not dialyzed while inpt, and will f/u with his nephroligist in 1
wk to see if his renal function continues to improve. At that
time his HD line can be removed.
.
# Diabetes: Pt was on home fixed and sliding scale as outpatient
(which is 10units lantus, and ISS)
Medications on Admission:
ASA 325 mg
Plavix 75 mg daily
Atorvastatin 80mg
Nitro SL PRN
Procardia ER 50mg PO daily
Lisinopril 5mg daily
Nephrocaps
Gemfibrazole 600mg [**Hospital1 **]
Omeprazole 30mg daily
Ezetamibe 10mg daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Gabapentin 100 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. Imdur 120 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 10 units
Subcutaneous once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Duodenal ulcer
- Non-ST elevevated myocardial infarction (heart attack)
- Hosptial-acquired pneumonia
Secondary diagnosis:
- End-stage renal disease
- Diabetes, type 2
- Anemia
- Hypertension
- Hyperlipidemia
- Peripheral vascular disease
Discharge Condition:
good, vitals stable, hematocrit stable and rising
Discharge Instructions:
You had a GI bleed that was due a bleeding ulcer found near your
stomach, specifically the duodenem. You lost significant blood
and need many transfusions, and developed a heart attack when
your blood counts were so low. You were intubated and also
developed a pneumonia while at the hospital. This peptic uclcer
was cauderized and your blood counts stabilized and are
continuing to rise back to normal.
Medication changes:
- your plavix has been discontinued
- your lasix has been discontinued
- you will take Aspirin 325mg once per day
If your bleeding returns, have signficant blood in in your
stool, black stools or vomit coffe-ground material you should
return to the ED. Also return if you have severe chest pain.
Followup Instructions:
Follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80025**] ([**Telephone/Fax (1) 68910**]
Your appointment is on Monday [**2169-10-21**]:00pm
You have a GI appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80026**] on Tuesday [**10-22**] at 2:30pm [**Telephone/Fax (1) **]
Follow up with your Kidney doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 80027**]
has not made yet. Once this appointment has been made with him
they will call you at your home phone number (which is
[**0-0-**]). You should see your kidney doctor in [**7-4**] days.
Follow up with your Cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 78102**]
([**2165**], on [**11-19**] at 1:30pm
Completed by:[**2165-10-19**]
|
[
"250.00",
"585.6",
"285.1",
"412",
"272.4",
"V45.82",
"403.91",
"997.31",
"410.71",
"785.59",
"414.01",
"532.40",
"276.7",
"041.12",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.13",
"44.43",
"96.71",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9079, 9085
|
4078, 7850
|
309, 318
|
9390, 9442
|
2792, 2792
|
10212, 11091
|
2258, 2276
|
8100, 9056
|
9106, 9106
|
7876, 8077
|
9466, 9871
|
2291, 2746
|
9891, 10189
|
248, 271
|
346, 1604
|
9251, 9369
|
2808, 4055
|
9125, 9230
|
2761, 2773
|
1626, 2025
|
2041, 2242
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,411
| 170,942
|
12461
|
Discharge summary
|
report
|
Admission Date: [**2196-12-3**] Discharge Date: [**2196-12-20**]
Date of Birth: [**2138-12-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
fever, neck pain, headache
Major Surgical or Invasive Procedure:
lumbar puncture
Right sided Ommaya reservoir
Left Sided VP Shunt
History of Present Illness:
57 yo F with metastatic non-small cell lung CA and
leptomeningeal disease s/p ommaya placement on [**2196-11-11**] s/p cycle
6 Pemetrexed completed [**11-30**], admitted [**Date range (1) 38706**] for staph
meningitis treated with ~10 days of vancomycin and removal of
ommaya, presenting to clinic [**12-2**] with fever 101/neck pain/HA,
admitted for suspected recurrent meningitis.
.
Since discharge, pt had been doing well although continued to
have hip and leg pain. She was seen in clinic by heme-onc and
rad onc this past week and was started on dexamathasone (took 1
dose) and radiation (1 dose). Last night, she developed fever
to 101 and neck pain prompting her to return to the ED.
In the ED, she was afebrile with a leukocytosis of WBC 13.3
(N87%). CXR and U/A unrevealing. LP was attempted but was
unsuccessful. Neurosurgery consulted and recommend IR guided
LP (the fluctuant mass over omaya site cannot be used for CSF
sampling). She was started on vanc, cefepime, amp. Patient has
been alert and oriented throughout with morphine for pain
control.
.
On arrival to the floor, she is comfortable and in NAD. She has
some pain which she says responded to the morphine. VS: T 96.4,
140/80, HR 98, 95%RA.
Past Medical History:
Met. NSC Lung CA
HL
Depression, Anxiety
migraines
Social History:
Divorced, currently in a relationship. Has 2 daughters and 3
grandchildren. Living w/ one of her daughters. They have been
very supportive.
HABITS: She smoked one pack and one-half a day for 15 years.
She quit ~[**2179**]. 2 drinks/night. no drug use. Occasional
walking but no formal exercise.
Family History:
non-contributory
Physical Exam:
VS: T 96.4, 140/80, HR 98, 95%RA.
GEN: AOx3, NAD
HEENT: PERRL. MMM. neck supple. no oral lesions, mild
tenderness at back of neck
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no rebound/guarding.
Extremities: warm, well perfused, no edema.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
nl gait
PHYSICAL EXAM UPON DISCHARGE:
awake, alert and oriented to self and place only
PERRL, EOMI
face symmetric
tongue midline
B/L UE's moving with full strengths.
generalized weakness b/l LE's [**5-9**]
sensation intact to light touch
Incision- [**Month/Day (1) 2729**] intact, well healing
following commands
Pertinent Results:
ADMISSION LABS:
[**2196-12-3**] 01:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2196-12-3**] 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2196-12-3**] 01:30AM LACTATE-1.5
[**2196-12-3**] 01:10AM GLUCOSE-105* UREA N-12 CREAT-0.6 SODIUM-136
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-25 ANION GAP-18
[**2196-12-3**] 01:10AM WBC-13.3*# RBC-3.46* HGB-11.5* HCT-34.4*
MCV-100* MCH-33.2* MCHC-33.3 RDW-15.8*
[**2196-12-3**] 01:10AM NEUTS-87.0* LYMPHS-7.4* MONOS-5.3 EOS-0.2
BASOS-0.2
[**2196-12-3**] 01:10AM PLT COUNT-327
[**2196-12-3**] 01:10AM PT-13.0 PTT-23.8 INR(PT)-1.1
DISCHARGE LABS:
IMAGING:
MRI Head [**12-3**]:
IMPRESSION: Since the previous MRI examination of [**2196-10-24**],
the number and size of the multiple enhancing metastatic lesions
in the brain involving the supra- and infratentorial brain have
increased. There is slight increase in surrounding edema seen.
There is no obliteration of the basal cisterns, or tonsillar
herniation identified. No hydrocephalus seen. Other findings as
described above. The findings were discussed with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at the time of interpretation of the study on [**2196-12-4**]
at 11:30 a.m.
MRI C,T,L Spine [**12-3**]:
IMPRESSION: No evidence of discitis or osteomyelitis or abscess
in the
cervical region. Small focus of enhancement in the medulla and
enhancement in the cerebellar hemispheres due to brain
metastatic disease, better evaluated on the brain MRI. Other
findings as described above. No extrinsic spinal cord
compression or intrinsic spinal cord signal abnormalities
CT Head [**12-5**]:
IMPRESSION:
1. Interval placement of external ventricular drain via right
frontal
approach in appropriate position and with expected post-surgical
changes.
2. Interval increase of now irregular hyperdensity in the right
cerebellar
hemisphere is highly concerning for bleeding of metastatic
lesion.
CT Head [**12-11**]:
IMPRESSION:
1. No significant change compared to [**2196-12-5**]: Stable
small right
frontal subdural fluid collection, with virtual-complete
resolution of
pneumocephalus and the extraventricular drain in place.
2. Known extensive metastatic disease better-characterized on
recent MR.
[**12-14**] LENI's: IMPRESSION: No DVT of either lower extremity.
[**12-14**] Head CT: IMPRESSION: 1. Interval removal of ventricular
drain, with stable right frontal subdural fluid collection, and
no evidence of hydrocephalus or acute intracranial hemorrhage.
2. Multiple known metastatic lesions are much better-visualized
on MR study of [**2196-12-3**].
[**12-15**] head CT: IMPRESSION: 1. Interval placement of VP shunt and
Ommaya reservoir with post-surgical changes and pneumocephalus
in the frontal region as expected.
2. No evidence of obstructive hydrocephalus or acute
intracranial hemorrhage.
3. Multiple known metastatic lesions are better characterized on
prior study
(MR [**2196-12-3**]).
[**12-16**] head CT: IMPRESSION:
1. Interval retraction of the left ventriculostomy catheter with
the tip now terminating in the parenchyma of the left frontal
lobe.
2. Punctate dense focus along the lateral margin of the right
lateral
ventricle, not definitely seen on previous studies possibly a
tiny focus of subependymal hemorrhage.
3. Expected decrease in the amount of pneumocephalus.
[**12-16**] head CT: IMPRESSION: Overall, minimal change from the
comparison study done on the same date. As before, the
ventriculostomy catheter via the left frontal approach
terminates in the parenchyma of the left frontal lobe and not
within the ventricle.Subtle density right cerebellum represents
metastasis seen on MRI of [**2196-12-3**].
Brief Hospital Course:
57 yo F with metastatic non-small cell lung CA and
leptomeningeal disease s/p ommaya placement on [**2196-11-11**] s/p cycle
6 Pemetrexed completed [**11-30**], admitted [**Date range (1) 38706**] for staph
meningitis treated with ~10 days of vancomycin and removal of
ommaya, presenting to clinic [**12-2**] with fever 101/neck pain/HA,
admitted for suspected recurrent meningitis.
.
#Suspected Meningitis: recent history of coag negative staph
meningitis treatment with IV vancomycin, presenting with F/neck
pain concerning for recurrent meningitis. Sx may also be
related to leptomeningeal disease.
-LP: f/u cytology
-started Dexamethasone 4mg [**Hospital1 **] (cleared by neuro-onc)
particularly given MRI brain with increased size and number of
lesions and enhancement significant for leptomeningeal disease.
-f/u neurosurgery recs- they are aware of bulding frontal area
and new neuro sxs.
-ID following: continue current regimen for now
-pain control with home dose of oxycodone, IV dilaudid for
severe pain was increased this morning
.
#h/o seizure: On previous admission, developed aphasia and
right sided facial droop that self-resolved and was determined
to be acute focal seizure. Was initiated on keppra for seizure
prophylaxis.
-continue keppra
.
#metastatic non-small cell lung cancer: s/p ommaya placement on
[**2196-11-11**] s/p cycle 6 Pemetrexed completed [**11-30**]. MRI on [**2196-11-30**]
shows progression of disease including lesions concerning for
leptomeningeal disease. Cytology from CSF on [**11-28**] also
consistent with leptomeningeal disease. Was to be started on
tarceva [**12-1**], with plan for rad onc to do XRT to L spin for
pain control and IT chemo afterwards.
-hold off on tarceva given recent symptoms
-dexamethasone 4 mg [**Hospital1 **]
-f/u with heme onc and rad onc upon dischage
-continue folic acid 1 mg Tablet
.
# anemia: Guiaic neg overnight
- iron, B12, folate, hemolysis labs: high ferritin and high
haptoglobin, other labs normal
.
# anxiety: continue home meds
.
#HL: will hold statin for now. restart at discharge
The decision was made the morning of [**11-1**] an EVD for
relief of the patient's high ICP and decompression via CSF
draining. She was transferred from the [**Hospital Ward Name 516**] to the [**Hospital Ward Name 12837**] Operating Room for wound exploration and placement of
EVD. SHe had high opening pressures, but no frank pus or
infection was noted. Post operatively her CT dmonstrated good
placement and no hemorrhage. She remained in the SDU for goal
draining of CSF at 10cc/hr. Overnight on [**12-5**] she was being
transferred to another stretcher and her EVD became disconnected
at the distal portion and was immediately clamoped and then
reconnected. Follow-up CT stable. On [**12-6**] she was transferred
back to the [**Hospital Ward Name **] to the [**Hospital Ward Name 332**] ICU so that she could
receive daily radiation treatments. On [**12-7**] she was slightly
confused but doing well. Her EVD, which ahd been at 10cm H2O was
raised to 15cm H2O with the continued goal of draining 10cc/hr
and 80cc/shift. On [**12-8**] her mental status improved and was at
baseline and continued with her daily radaition. On [**12-9**] it was
determined that her radiation treatments were complete per her
radiation oncologist Dr. [**First Name (STitle) 13014**]. As a result of this she was
transferred to the [**Hospital Ward Name **] under the care of neurosurgery.
Her EVD site began leaking CSF on [**12-10**] and her drain was lowered
to 10cm above the tragus. This did result in brief cessation of
fluid from drain site but it again picked up overnight and into
the morning of [**12-11**]. A CT head was obtained and showed stable
ventricular size and no subdural hematoma and her drain was
lowered to 5cm above the tragus.
On the morning of [**12-12**], she had persistent draininage from her
EVD insertion. A purse-string suture was placed to prevent
further drainage. Her vancomycin was increased to 1250 [**Hospital1 **], and
ther CSF cultures showed NGTD.
The decision was made to D/C her EVD on [**12-13**] in preparation for
a VPS placement. It was removed without difficulty. She
remained on the Vancomycin. In the afternoon she began to have
mild CSF drainage from her old incision. Because the tissue was
so friable, it was not amenable to oversewing. It was covered
with sterile 4x4 dressing.
On [**12-14**], a lumbar puncture was performed, and CSF was sent for
a final culture/gram stain. She continued to have drainage from
her old scalp incision. Her neurological exam remained
unchanged, and her repeat Head CT was stable.
On [**12-15**] she went to the OR for placement of a right sided
Ommaya reservoir and a Left sided VP shunt. She tolerated the
procedure well, was extubated in the OR, and was trasnported to
the PACU post-operatively. She remained stable while there and a
post-op CT of the head was routinely obtained which showed
proper placement of the VP shunt catheter and Ommaya reservoir
intracranially. She was trasnported to the floor for further
management.
On [**12-16**] she remained stable, her foley catheter was removed,
she was seen by palliative care, and Infectious disease advised
a continuation of IV antibiotics until at least Sunday. PT and
OT also saw her and recommended that she should go to a rehab
facility, but bacause the focus was more palliative in nature
the plan was to work on sending her hoe.
On [**12-17**] she had a brief episode of complete aphasia. SHe had a
negative head CT. Neurology was consulted and they recommended
placing the patient on Keppra and Ativan for seizure. Shortly
following initiating both of these, her mentation and seech
improved significantly.
On [**12-18**] the patient was improving neurologically, her foley was
discontinued.
On [**12-19**] placement for discharge discussed and options were
discussed and looked into. ID input was requested for discharge
antibiotics and suggested placing on levaquin indefinitely.
On [**12-20**] the patient was again seen by palliative care and
medication adjustments were made as needed. She was evaluated
for hospice. Discussions were had with the patient and her
daughter [**Name (NI) 3235**] and the patient was offically made DNR/DNI. Upon
finalization of care plan, she was discharged home with hospice.
Medications on Admission:
1. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. oxycodone 5-10 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. zolpidem 5-10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. celexa 20 daily
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
11. oxycontin 10 q8
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
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 DAILY (Daily).
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
Disp:*15 Tablet(s)* Refills:*2*
5. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
10. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
11. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
15. oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
16. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*2*
17. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Amedisys Hosptice
Discharge Diagnosis:
Leptomeningeal metastasis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after [**Name (NI) 2729**] and/or staples have
been removed. If your wound closure uses dissolvable [**Name (NI) 2729**],
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? 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 have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
Followup Instructions:
Follow-Up Appointment Instructions
??????Your [**Telephone/Fax (1) 2729**] will be removed 7-10 days from your surgery. You
can call [**Telephone/Fax (1) 1669**] to make an appointment with Dr.[**Name (NI) 9399**]
[**Name (STitle) **] practitioner to have this done. If it is more convienient
your PCP or other practitioners can also remove these for you.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**1-9**] at
1PM. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2196-12-20**]
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,532
| 153,370
|
45290+58801
|
Discharge summary
|
report+addendum
|
Admission Date: [**2130-5-6**] Discharge Date: [**2130-5-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Shortness of breath, tachypnea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a [**Age over 90 **] y/o woman with past medical history of CAD s/p
CABG, s/p [**Age over 90 1291**], presenting from [**Hospital3 **] with fever.
History was obtained from patient.
Per patient, she was in her USOH until a few days ago when she
started to feel fatigued with decreased appetite and lack of
energy. She reports that she may have had an episode of
diarrhea, and she developed shortness of breath and a cough
productive of trace amounts of phlegm. A nurse at her [**Hospital 4382**] facility ([**Street Address(1) 19127**] [**Hospital3 400**]) advised her that
she come to the ED for further evaluation.
In the ED, initial vital signs were: T 101.7, HR 104, BP 159/78,
RR 26, satting 87% RA. O2 sats came up to mid 90s on 6L by nasal
cannula. WBC count was 24.5 with 95% polys, no bands. Lactate
was 2.6, increased to 2.9 at time of admission. UA negative.
Creatinine was 1.3 up from 0.9 in [**2129-12-6**]. CXR consistent
with R sided pneumonia in addition to pulmonary edema. Patient
was given tylenol, ceftriaxone, vancomycin, and levofloxacin.
She got 2L IVFs. No hypotension. She was admitted to the MICU
for persistant tachypnea.
Of note, patient was admitted in [**2129-12-6**] for treatment of
C dificile colitis in the context of antibiotic use for RLE
cellulitis. She completed a 14-day course of metronidazole and
reports that her overall health since then has been fine.
On review of systems, patient denies chest pain or pressure,
lightheadedness or dizziness, headache, stiff neck, or
photophobia. She denies abdominal pain or cramping, rash or new
joint pain. Remainder of ROS is per HPI above.
Past Medical History:
- CAD s/p 3V CABG [**2124**] with saphenous vein grafts to the LAD, OM
and posterior descending coronary arteries.
- s/p Aortic valve replacement with a 21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
bovine prosthesis. Normal function on echo of [**3-13**]
- CHF EF 65%, grade I diastolic dysfunction, mild MR
- Hypercholesterolemia
- h/o PAF
- Depression
- Hypertension
- s/p TAH
- left Total hip replacement
- History of C.diff [**12/2129**]
Social History:
Walks with walker at baseline, lives at [**Hospital3 **], gets
help with ADLS, distant h/o tobacco (quit 50 yrs ago), no
illicit drugs or ETOH. Does not wear a lifeline, has one in
bldg. Reports occasional mechanical falls at home.
- Tobacco: Remote history
- Alcohol: None
- Illicits: None
Family History:
Mother died at 84 from stomach cancer, had hypertension. Father
died at [**Age over 90 **] y/o from "old age".
Physical Exam:
Vitals: BP: 94/53, P: 88, R: 31, O2: 96% 4L
General: elderly woman in no acute distress
Neuro: AAOx3, remote and recent memory intact, good insight
Neck: no jugular venous distention
Lungs: wheezes diffusely with inspiratory squeaky breath sounds,
decreased breath sounds at posterior bases
CV: RRR, normal s1/s2
Abdomen: soft, non-tender, normoactive bowel sounds
GU: foley in place
Ext: right leg slightly more edematous than left (non-pitting);
distal extremities cool with onychomycosis and skin changes
suggestive of peripheral vascular disease
Pertinent Results:
Labs at Admission
[**2130-5-6**] 04:30PM BLOOD WBC-24.5*# RBC-5.48* Hgb-15.5 Hct-46.3
MCV-85 MCH-28.2 MCHC-33.4 RDW-15.0 Plt Ct-212
[**2130-5-6**] 04:30PM BLOOD Neuts-94.9* Lymphs-1.7* Monos-3.0 Eos-0.1
Baso-0.4
[**2130-5-6**] 04:30PM BLOOD PT-11.3 PTT-26.1 INR(PT)-0.9
[**2130-5-6**] 04:30PM BLOOD Glucose-135* UreaN-24* Creat-1.3* Na-138
K-3.7 Cl-97 HCO3-29 AnGap-16
[**2130-5-6**] 04:30PM BLOOD Calcium-9.9 Phos-2.4* Mg-1.8
Lactate
[**2130-5-6**] 04:39PM BLOOD Lactate-2.6*
[**2130-5-6**] 09:16PM BLOOD Lactate-2.9*
[**2130-5-7**] 12:40AM BLOOD Lactate-1.5
Cardiac Enzymes
[**2130-5-6**] 04:30PM BLOOD proBNP-1825*
[**2130-5-6**] 04:30PM BLOOD cTropnT-<0.01
[**2130-5-7**] 05:03AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2130-5-6**] 04:30PM BLOOD CK(CPK)-37
[**2130-5-7**] 05:03AM BLOOD CK(CPK)-56
MICRO:
[**2130-5-6**] 4:30 pm BLOOD CULTURE: STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- <=0.5 S
MEROPENEM------------- S
PENICILLIN G----------<=0.06 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 0.5 S
[**2130-5-6**] URINE URINE CULTURE- NEGATIVE
[**2130-5-6**] URINE Legionella Urinary Antigen - NEGATIVE
INPATIENT
[**2130-5-6**] BLOOD BLOOD CULTURE- NEGATIVE
[**2130-5-6**] URINE URINE CULTURE- NEGATIVE
STUDIES:
.
Admission EKG: Artifact is present. Sinus tachycardia. There is
a late transition which is probably normal. Left ventricular
hypertrophy with associated ST-T wave changes, although ischemia
or myocardial infarction cannot be excluded. Compared to the
previous tracing atrial ectopy is less.
.
CXR ([**5-6**]): IMPRESSION: Heart failure. Confluent opacity in right
infrahilar region may be confluent edema, however concurrent
pneumonia cannot be excluded. Recommend repeat radiography after
appropriate diuresis to assess for underlying infection.
.
TTE [**5-10**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet motion
and transvalvular gradients. No masses or vegetations are seen
on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2128-3-17**],
the estimated pulmonary artery systolic pressure is higher. The
other findings are similar.
Brief Hospital Course:
A [**Age over 90 **] y/o woman with history of [**Age over 90 1291**], CAD s/p CABG, PAF, diastolic
CHF, now presenting with fever, leukocytosis and respiratory
distress, admitted to the MICU for persistent tachypnea.
# Respiratory distress/tachypnea. Suspect pneumonia given
fevers, leukocytosis, focal RLL infiltrate on CXR, and rather
acute onset of symptoms. Other considerations include pulmonary
edema secondary to diastolic dysfunction versus acute coronary
syndrome. Cardiac enzymes were cycled and negative. BNP,
although elevated, was down from prior. Her symptoms were felt
to be most consistent with pneumonia. She was treated with
broad-spectrum antibiotics (ceftriaxone and vancomycin) and her
symptoms improved. On the second hospital day, her tachypnea was
improving and her oxygen requirements decreased. She was felt to
be stable enough for the floor and was transferred out from the
intensive care unit. Her antibiotics were changed to
levofloxacin. Her respiratory status remained stable, with only
mild expiratory wheezes. She was transferred to a rehab center
with instructions to complete a fourteen day course of
levofloxacin, for her pneumonia as well as her bacteremia (see
below). Her discharge meds also included ipratropium and
albuterol nebulizers.
# Bacteremia: One blood culture from admission labs came back
positive for STREPTOCOCCUS PNEUMONIAE, sensitive to
levofloxacin. A pulmonary source was presumed. TTE showed no
vegetations, but they could reportedly not be ruled out, due to
suboptimal study. Surveillance blood cultures were negative. She
will be treated with levofloxacin for a total of fourteen days.
# Hypotension. Previous discharge summaries note systolic BPs in
the range of 110-130, as high as 160. In the MICU< her systolic
BP was in the mid to high-90s. She was hydrated with IVF
overnight and during the first day in the ICU. Her hypotension
improved to baseline.
# Diastolic CHF: Patient was euvolemic on exam, although CXR
suggested pulmonary edema. BNP, as above, was elevated but less
than prior values. She was hydrated with IVF and her home blood
pressure/heart failure meds restarted when she became
hemodynamically stable. An echocardiogram was performed during
this admission, showing findings similar to her prior echo,
except for possibly increased pulmonary artery systolic
pressure.
# CAD s/p CABG. EKG shows new increased voltage consistent with
LVH. Cardiac enzymes were cycled x2 [**32**]-hours apart and were
negative. Her home statin and aspirin were continued during this
admission.
# Depression, anxiety, insomnia. No active concerns. We
continued her home venlafaxine and trazodone.
# Acute kidney injury. Resolved with intravenous fluids.
# Code: DNR/DNI, confirmed with patient and daughter (HCP)
during this admission.
# Dispo: The patient was transferred to [**Hospital3 **]
Center. A message was left with the PCP's office on the day of
transfer, to notify the PCP that the patient was hospitalized
and will be discharged to rehab.
Medications on Admission:
- Acetaminophen 500 mg Q6H as needed for pain.
- Aspirin 81 mg once a day.
- Calcium Carbonate 500 mg [**Hospital1 **]
- Amiodarone 100 mg DAILY
- Cholecalciferol 800 unit DAILY
- Simvastatin 20 mg once a day.
- Venlafaxine 75 mg Sust. Release DAILY
- Trazodone 50 mg HS as needed for insomnia.
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 8 days: Last dose on [**2130-5-18**].
2. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebulizer treatment Inhalation Q6H
(every 6 hours) as needed for SOB, wheeze.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulizer
treatment Inhalation Q6H (every 6 hours) as needed for SOB or
wheeze.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Pneumonia
SECONDARY DIAGNOSES
Chronic diastolic heart failure
Depression and anxiety
Paroxysmal atrial fibrillation
Coronary artery disease
S/p aortic valve replacement
Hypercholesterolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 96763**],
You were admitted to the hospital for treatment of pneumonia.
You were also found to have an infection in your blood. You were
given antibiotics intravenously and orally, and your symptoms
improved. Please complete a ten-day course of antibiotics to end
on [**2130-5-19**]. You are now medically stable and you are going to be
transferred to a rehabilitation cetner to build your strength.
We made the following changes to your medicines:
- Started LEVOFLOXACIN 250 mg tabs, THREE TABS by mouth, once
every other day. Last dose will be on [**2130-5-18**]
- Started ALBUTEROL SULFATE nebulizer, one nebulizer treatment
every six hours as needed for shortness of breath or wheeze
- Started IPRATROPIUM BROMIDE nebulizer, one nebulizer treatment
every six hours as needed for shortness of breath or wheeze
Please call your doctor or return to the emergency room if you
experience any fevers, worsening shortness of breath or chest
pain, or other new concerning symptoms.
Followup Instructions:
Discharge to [**Hospital3 **] Center
Name: [**Known lastname 15372**],[**Known firstname 4497**] Unit No: [**Numeric Identifier 15373**]
Admission Date: [**2130-5-6**] Discharge Date: [**2130-5-10**]
Date of Birth: [**2032-12-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 161**]
Addendum:
Transient hypotension in setting of bacteremia could conceivably
have represented sepsis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**]
Completed by:[**2130-6-1**]
|
[
"272.0",
"458.9",
"780.52",
"300.4",
"V42.2",
"733.00",
"584.9",
"V45.81",
"414.00",
"428.0",
"481",
"V43.64",
"799.02",
"038.2",
"401.9",
"428.32",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13038, 13278
|
6486, 9508
|
292, 299
|
11318, 11318
|
3463, 6463
|
12496, 13015
|
2766, 2878
|
9853, 10957
|
11086, 11297
|
9534, 9830
|
11469, 12473
|
2893, 3444
|
221, 254
|
327, 1966
|
11333, 11445
|
1988, 2442
|
2458, 2750
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,941
| 174,970
|
3695
|
Discharge summary
|
report
|
Admission Date: [**2190-9-22**] Discharge Date: [**2190-9-27**]
Date of Birth: [**2136-12-24**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Iodine; Iodine Containing / Tape / Ibuprofen /
Levofloxacin
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53yo F with diabetes type 1 c/b neuropathy w/chronic foley in
place, morbid obesity, wheelchair-bound, hypertension, coronary
artery disease s/p CABG, diastolic CHF, recent admission for
flash pulmonary edema, and sarcoidosis complicated by chronic
tracheostomy on 2.5 L/[**First Name3 (LF) **] trach collar at home who p/w shortness
of breath. The pt reports her sxs began abruptly this morning at
home. She noted shortness of breath with associated HA and
nausea (vomited several times) but no chest pain, palpitations,
fevers, chills, cough or wheezing. The pt presented to the ED
where initial vitals were HR 100, 181/105, 97% on 10L. She was
given morphine, Zofran, NTG and a single dose of Lasix.
Consideration to a CTA of the chest was made however the pt
declined because she did not feel she could lie flat and did not
want to be placed on a vent. She was then admitted to the MICU
for further care.
Past Medical History:
1. DM type 1 since age 16 diagnosis (c/b neuropathy,
gastroparesis, nephropathy, retinopathy)
2. Sarcodosis ([**2175**])
3. Tracheostomy - [**3-13**] upper airway obstruction, sarcoid.
4. Arthritis - wheel chair bound
5. Neurogenic bladder
6. Sleep apnea
7. Asthma
8. Hypertension
9. Cardiomyopathy - diastolic dysfunction
10. Pulmonary hypertension
11. Hyperlipidemia
12. CAD s/p CABG [**2179**](SVG to OM1 and OM2, and LIMA to LAD)
last c. cath [**2187-2-28**]: widely patent vein grafts to the OM1 and
OM2, widely patent LIMA to LAD(distal 40% anastomosis lesion).
13. VRE, MRSA - unknown sources
14. s/p cholecystectomy
[**97**]. s/p appendectomy
16. Chronic low back pain-disc disease
17. Morbid obesity
18. Persistent left breast cellulitis
Social History:
Lives alone, has monogamous partner lives 15 [**Name2 (NI) **] away, denies
ethanol, tobacco use.
Family History:
No hx of CAD, diabetes in cousin and uncle
Father had MI in his 60s
Physical Exam:
Vitals: T: 99 BP:86/76 P:72 R:12 SaO2: 965 2L NC 02
Gen: Chronically ill appearing adult female, no acute distress.
HEENT: PERRL, EOMI. Dry MM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD. No tenderness with
palpation.
Chest: Distant breath sounds but no crackles or wheezes.
Cor: Normal S1, S2. RRR. No murmurs appreciated.
Abdomen: Soft, non-tender and non-distended. +BS, no HSM.
Extremity: Warm, without edema. 2+ DP pulses bilat.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
Pertinent Results:
[**2190-9-22**] 02:15PM BLOOD WBC-10.8 RBC-4.28 Hgb-12.3 Hct-37.3
MCV-87 MCH-28.8 MCHC-33.0 RDW-13.7 Plt Ct-210
[**2190-9-27**] 05:55AM BLOOD WBC-8.1 RBC-3.41* Hgb-10.1* Hct-29.2*
MCV-86 MCH-29.6 MCHC-34.6 RDW-13.7 Plt Ct-175
[**2190-9-22**] 02:15PM BLOOD PT-12.1 PTT-22.6 INR(PT)-1.0
[**2190-9-22**] 02:15PM BLOOD Glucose-246* UreaN-43* Creat-1.3* Na-133
K-4.3 Cl-94* HCO3-29 AnGap-14
[**2190-9-27**] 03:43PM BLOOD Glucose-118* UreaN-29* Creat-0.9 Na-135
K-3.9 Cl-92* HCO3-36* AnGap-11
[**2190-9-22**] 02:15PM BLOOD ALT-63* AST-66* CK(CPK)-218* AlkPhos-183*
TotBili-0.7
[**2190-9-22**] 02:15PM BLOOD cTropnT-<0.01
[**2190-9-23**] 11:31AM BLOOD CK-MB-10 cTropnT-0.08*
[**2190-9-22**] 02:15PM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.5 Mg-1.8
[**2190-9-27**] 03:43PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.3
Brief Hospital Course:
53 yo female with MMP admitted with increasing SOB and oxygen
requirement.
#Shortness of breath/Hypoxia: DDx includes dCHF in setting of
elevated BP, cardiac ischemia, PE or asthma/sarcoid flair. On
admission was satting adequately on 10L, however pt is at clear
risk for respiratory decompensation. In ED and on arrival to
MICU, importance of CTA was discussed with pt, however she
refused because she stated she could not tolerate the nausea
with IV contrast administration. She was admitted to the ICU for
further care. A heparin drip was started given suspicion of
pulmonary embolus vs cardiac ischemia. Patient was ruled out for
myocardial infarction and lower extremity DVT's were ruled out
with bilateral ultrasound. Heparin was discontinued. No evidence
of fluid overload on clinical examination and shortness of
breath resolved without diuresis. Patient was discharged on home
dose of oxygen at 2.5L delivered by trach mask during the day
and 10L at night for comfort due to sleep apnea. The etiology of
these symptoms remains unclera, however they had completely
resolved with minimal intervention.
#HTN: Pt hypertensive at admission with systolic blood pressures
in the 180's yet is on a minimal antihypertensive regimen at
home. Attempt to gain better BP control with IV meds (hydral)
while uptitrating home regimen. Held [**Last Name (un) **] in setting of possible
CTA. Blood pressures remained low after hydralazine with
systolic pressures in the 90-110 range. All home meds were
reinitiated with BP's in the 110 systolic range.
#ARF: Pt with mildly elevated Cr from baseline (1.0->1.3) on
admission. Suspect pre-renal etiology given pt??????s nausea and poor
PO intake. Consider gentle hydration if no improvement, although
some reluctance to do this in setting of acute lung process.
Patient was given gentle fluid resuscitation and renal function
improved.
#Sarcoid: Pt may have sarcoid flair, although acute onset argues
against this. For now, continue home inhaled steroids and
bronchodilators.
#UTI:Patient has indwelling Foley for urinary retention with
frequent urinary tract infections with multi drug resistant
organisms in the past. She was initially started on zosyn and
the Foley was changed. Urine culture revealed similar resistance
profile to prior infections and she was started on macrobid once
renal function improved.
Medications on Admission:
Aspirin 325 mg daily
Benztropine 1 mg TID
Citalopram 30 mg daily
Docusate Sodium 100 mg [**Hospital1 **]
Fluticasone 110 mcg/Actuation two puffs [**Hospital1 **]
Insulin Glargine 62 units at bedtime.
Furosemide 40 mg [**Hospital1 **]
Lidocain to mucus membranes [**Hospital1 **]
Lorazepam 2 mg QHS PRN
Losartan 25 mg daily
MVI
Metoclopramide 10 mg QIDACHS (20mg, 10mg, 20mg, 10mg)
Metoprolol Tartrate 50 mg [**Hospital1 **]
Gabapentin 300 mg TID
Omeprazole 20 mg [**Hospital1 **]
Salmeterol 50 mcg/Dose Disk with Device [**Hospital1 **]
Simvastatin 20 mg daily
Hydrocodone-Acetaminophen 5-500 mg 1-2 tabs TID PRN
Slow-Mag 64 mg three tabs [**Hospital1 **]
Psyllium one packet TID
Humalog 100 unit/mL Solution Subcutaneous
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Benztropine 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty Two (62)
units Subcutaneous at bedtime.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO WITH
LUNCH AND AT BEDTIME ().
12. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO WITH
BREAKFAST AND DINNER ().
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
16. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
17. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
19. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day).
20. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
PRN (as needed).
21. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 13 days.
Disp:*25 Capsule(s)* Refills:*0*
22. Mag 64 64 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO three times a day.
23. Humalog 100 unit/mL Solution Sig: Sliding scale
Subcutaneous with meals.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
Primary:
Hypoxia, etiology undetermined
Acute Renal Failure
Urinary Tract Infection
Secondary:
Diastolic Heart Failure
Obstructive Sleep Apnea
Sarcoidosis
Hypertension
Discharge Condition:
Good. Hemodynamically stable and afebrile. Satting 96% on 2.5
Liters
Discharge Instructions:
You were admitted to the hospital with shortness of breath. It
was thought that this was likely due to your high blood pressure
at that time, however it is not entirely clear. You improved
however during hospitalizations and were much improved at the
time of discharge.
You were treated for a urinary tract infection and should
continue antibiotics.
The following changes were made to your medications:
1)Added macrobid 100mg twice daily for 13 days after discharge
You should return to the emergency department if you should
develop shortness of breath, fevers >101 F, chills, abdominal
pain, nausea, vomiting, chest pain, or any other symptoms that
are concerning to you
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2190-10-4**] 2:50
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2190-10-20**] 2:20
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2190-11-8**] 2:45
Completed by:[**2190-9-28**]
|
[
"583.81",
"327.23",
"414.00",
"250.41",
"357.2",
"425.4",
"135",
"493.90",
"401.9",
"278.01",
"250.61",
"536.3",
"V45.81",
"272.4",
"V44.0",
"428.0",
"596.54",
"428.30",
"584.9",
"416.8",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8811, 8866
|
3712, 6075
|
354, 361
|
9079, 9150
|
2892, 3689
|
9874, 10388
|
2204, 2274
|
6848, 8788
|
8887, 9058
|
6101, 6825
|
9174, 9851
|
2289, 2873
|
295, 316
|
389, 1302
|
1324, 2072
|
2088, 2188
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,540
| 162,150
|
10702
|
Discharge summary
|
report
|
Admission Date: [**2185-12-10**] Discharge Date: [**2185-12-13**]
Date of Birth: [**2127-6-16**] Sex: M
Service: C-MEDICINE
CHIEF COMPLAINT: Status post myocardial infarction.
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
male with cardiac risk factors including age, sex, pipe
smoking, hypertension. The patient has no previous cardiac
history and is transferred from [**Hospital **] Hospital status post
cardiac catheterization.
The patient woke up on the day of admission, and went outside
to work in his yard. He had abrupt onset of ten out of ten
substernal chest pain associated with mild dizziness, but no
dyspnea, diaphoresis or nausea. The patient called a
neighbor who is a nurse, who gave him 325 mg of Aspirin. The
patient called EMS and got sublingual Nitroglycerin times
three which dropped his pressure. The patient was taken to
[**Hospital **] Hospital. Electrocardiogram demonstrated 2.0 to 3.[**Street Address(2) 27948**] elevation in leads II, III and aVF with lead
III being greater than lead II. The patient also had 1.0 to
2.[**Street Address(2) 35042**] depression in leads V1 through
V2, and Q waves present in the inferior leads. Right sided
electrocardiogram demonstrated 1.[**Street Address(2) 2811**] elevation
and Q wave in lead V4.
The patient was immediately taken to the Catheterization
Laboratory at [**Hospital **] Hospital where his filling pressures
were as follows: right atrial 20, right ventricle 45/20,
pulmonary artery 45/25, pulmonary capillary wedge pressure
20, cardiac output 3.5. The patient had a normal left main,
80% mid left anterior descending lesion, normal circumflex
and 100% proximally occluded right coronary artery. The
patient received percutaneous transluminal coronary
angioplasty and two stents to the right coronary artery. His
initial CK was 61 but MB and troponin were pending at the
time of procedure. There was no CCU bed available at [**Hospital **]
Hospital, so he was transferred to [**Hospital1 190**] for evaluation and postinfarction monitoring.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Pipe smoker.
3. Gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 50 mg p.o. once daily.
2. Zantac 150 mg p.o. twice a day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient smokes a pipe, five to six times
a day, for over thirty years. Occasional alcohol. No
intravenous drug use.
FAMILY HISTORY: Positive for coronary artery disease.
PHYSICAL EXAMINATION: Vital signs revealed temperature 98,
pulse 76, blood pressure 110/64, respiratory rate 16, oxygen
saturation 98% on three liters nasal cannula. In general,
the patient is awake, alert, in no apparent distress. Head,
eyes, ears, nose and throat examination - The pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements are intact. Mucous membranes are
moist. Neck - jugular venous pressure at 10 centimeters
Heart - regular rate and rhythm, no murmurs, gallops or rubs.
The lungs revealed bilateral basilar crackles. The abdomen
is soft, nontender, nondistended, normoactive bowel sounds,
no hepatosplenomegaly, masses or bruits. Extremities -
pulses 2+ bilaterally, warm, no cyanosis, clubbing or edema.
LABORATORY DATA: From the outside hospital revealed white
blood cell count 8.1, hematocrit 45.0, platelet count
276,000. Sodium 141, potassium 3.4, chloride 105,
bicarbonate 27, blood urea nitrogen 15, creatinine 1.1,
glucose 134. Prothrombin time 12.5, partial thromboplastin
time 27.0, INR 1.0. Albumin 3.4, ALT 38, AST 18, CK 61.
Electrocardiogram prior to catheterization showed sinus
bradycardia at 46 beats per minute, normal axis and
intervals, 2.0 to 3.[**Street Address(2) 2811**] elevation in II, III and
aVF, 1.0 to 2.[**Street Address(2) 2811**] depression V1 to V2, 1.[**Street Address(2) 27948**] elevation in right sided V4. Electrocardiogram
after the procedure showed normal sinus rhythm at 64 beats
per minute, ventricular ectopy, superior axis, 1.[**Street Address(2) 35043**] elevation and T wave inversion in lead III, Q waves in II,
III and aVF, and Q waves in right sided leads V3 through V6.
HOSPITAL COURSE: In short, this is a 58 year old male with
cardiac risk factors of age, sex, pipe smoking, hypertension,
family history, who presents with an acute inferior Q wave
myocardial infarction, status post right coronary artery
stenting. The patient was initially hemodynamically stable
and brought to the floor. He was chest pain free at this
time. The patient was given low dose Lopressor and Captopril
and subsequently dropped his systolic blood pressure to the
high 70s to low 80s. At this point, it had ready been
decided to transfer the patient temporarily up to the CCU,
given the fact that there was right ventricular involvement
based on his right sided electrocardiograms and the patient
is very prone to sudden hypotension.
The patient was bolused for the hypotension and had an
uneventful short CCU course. The patient was brought back to
the general floor the following day. The patient's CPK
peaked at 1179 with a MB of 161 and an index of 13.7. The
CPK came down to 427. The patient remained pain free and
symptom free during his hospitalization. He remained
hemodynamically stable.
On [**2185-12-13**], the patient received an echocardiogram to
evaluate status of his heart post myocardial infarction.
Echocardiogram showed a moderately depressed systolic
function with an ejection fraction of 35 to 40%, mild
dilatation of the right ventricle, mild global hypokinesis
and mildly thickened aortic and mitral valves. The patient
was medically optimized on Lopressor, Plavix, sublingual
Nitroglycerin and Lipitor. Captopril was held secondary to
hypotension. It was decided not to currently address the 80%
left anterior descending lesion, as it was doubtfully a
participant in the patient's acute myocardial infarction.
However, it was decided that the patient will need a repeat
catheterization and probable stenting for that lesion within
one month's time.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged to home with
cardiac rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. twice a day.
2. Plavix 75 mg p.o. once daily.
3. Aspirin 325 mg p.o. once daily.
4. Sublingual Nitroglycerin 0.3 mg p.r.n.
5. Lipitor 10 mg p.o. once daily.
6. Zantac 150 mg p.o. twice a day.
FOLLOW-UP: The patient has an appointment with Dr. [**Last Name (STitle) **] on
[**2185-12-30**], at 10:00 a.m. on the seventh floor of the [**Hospital Ward Name 23**]
Building for consultation regarding repeat catheterization
for the 80% left anterior descending lesion. The patient is
also to follow-up with his regular primary care physician,
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 4127**], to be made by the patient.
DISCHARGE DIAGNOSES:
1. Status post Q wave inferior myocardial infarction with
right ventricular involvement.
2. Status post right coronary artery stenting.
3. Hypertension.
[**Name6 (MD) 475**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9632**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2185-12-17**] 12:47
T: [**2185-12-18**] 13:38
JOB#: [**Job Number 35044**]
|
[
"401.9",
"V45.82",
"530.81",
"410.41",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2465, 2504
|
6938, 7342
|
6232, 6917
|
2186, 2308
|
4210, 6091
|
2527, 4193
|
159, 195
|
224, 2065
|
2087, 2160
|
2325, 2448
|
6116, 6206
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,167
| 194,400
|
26839
|
Discharge summary
|
report
|
Admission Date: [**2187-2-21**] Discharge Date: [**2187-3-20**]
Date of Birth: [**2171-2-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p high speed rollover MVC
Major Surgical or Invasive Procedure:
On [**2187-2-21**]:
1) External fixation of left femural shaft fracture
2) Left SFA interposition graft with RSV right
3) 4 cmpt left lower leg fasciotomy
4) Left thigh fasciotomy
5) Repair of femoral vein branch
On [**2187-3-1**]:
1) Removal of external fixator
2) IM nail left femur
On [**2187-3-9**]:
partial closure of wound
On [**2187-3-14**]:
Debridement/washout with split thickness skin graft of left
lower extremity.
History of Present Illness:
16 y/o male who was the unrestrained driver in a high speed
rollover MVC at approximately 12:30PM on the day of admission.
He was reportedly driving a stolen car and being pursued by the
police. No LOC. His only apparent injury on the scene was a left
thigh deformity. He was evaluated at a referring hospital and
then transferred to [**Hospital1 18**] for continued trauma care. His only
complaint upon arrival was left leg pain.
Past Medical History:
None
Family History:
Noncontributory
Physical Exam:
Upon admission in the ED:
HR 145 BP 108/62 RR 12 100% NRB
GCS 15
Abrasion behind left ear with hematoma, PERRL, EOMI
OP clear, dentition intact
No c-spine tenderness
CTA bilat, no crepitus
Tachy
FAST neg, distended bladder, NT
Pelvis stable
No scrotal hematoma
5/5 strength RLE, no stepoffs, LLE deformed, ext rotated, cool,
mottled. No pulses by palp or Doppler
CNII-XII intact, symmetric UE movements
Pertinent Results:
[**2187-2-21**] 05:00PM FIBRINOGE-<35*
[**2187-2-21**] 05:00PM PLT SMR-VERY LOW PLT COUNT-59*
[**2187-2-21**] 05:00PM WBC-5.0 RBC-1.08* HGB-3.2* HCT-9.8* MCV-90
MCH-29.4 MCHC-32.6 RDW-13.0
[**2187-2-21**] 05:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-2-21**] 06:05PM PT-14.4* PTT-24.3 INR(PT)-1.3*
[**2187-2-21**] 06:05PM PLT COUNT-149*
[**2187-2-21**] 06:05PM CK(CPK)-3218* AMYLASE-27
[**2187-2-21**] 06:05PM GLUCOSE-117* UREA N-9 CREAT-0.6 SODIUM-137
POTASSIUM-3.7 CHLORIDE-109* TOTAL CO2-18* ANION GAP-14
CHEST (PORTABLE AP) [**2187-3-2**] 4:07 AM
CHEST (PORTABLE AP)
Reason: pna
[**Hospital 93**] MEDICAL CONDITION:
16 year old man s/p MVC POD 9 & 1, sp femur ORIF & SFA graft
REASON FOR THIS EXAMINATION:
pna
INDICATION: Postoperative day nine status post femur ORIF.
Question pneumonia.
Comparison is made to [**2187-2-26**]. The left subclavian
central venous catheter is in unchanged position with the tip in
the proximal SVC. The heart is normal in size. The mediastinal
and hilar contours are unremarkable. The lungs are clear without
consolidations. No pleural effusions are seen. Subcutaneous air
is seen in the left periclavicular area which is seen on the
prior film. This is of uncertain etiology. No pneumothorax is
seen.
IMPRESSION: No evidence for pneumonia.
Sinus tachycardia. P-R interval 140 milliseconds. Normal
tracing. No previous
tracing available for comparison.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
133 98 88 278/356.42 67 71 16
CTA CHEST W&W/O C &RECONS [**2187-2-28**] 9:53 PM
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: r/o PE
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
16 year old man s/p MVC, persistant tachycardia 7 days post-op
from femoral ex-fix and vascular bypass graft.
REASON FOR THIS EXAMINATION:
r/o PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 16-year-old man with recent MVC, now with persistent
tachycardia.
TECHNIQUE: MDCT was used to obtain contiguous axial images from
the thoracic inlet to the lung bases after administration of IV
contrast. Multiplanar reformats were also obtained.
Comparison with CT chest of [**2187-2-21**].
CT CHEST WITH IV CONTRAST: There is a small pericardial
effusion, which has increased slightly in size since the last
examination. New subcutaneous emphysema is seen along the left
lateral chest wall, extending from the supraclavicular fossa,
below the scapula, and in the left axilla. No pneumothorax or
pleural effusion is seen. A PICC is seen from the left,
terminating at the cavoatrial junction. No fractures are
identified. The abdomen is incompletely imaged, however, images
are significant for a tiny region of perfusion abnormality in
the right lobe of the liver, 6 mm, too small to fully
characterize. The imaged portion of the spleen, stomach, and
left adrenal as well as pancreas are normal.
CT ANGIOGRAPHY CHEST: No aortic dissection; the aorta is normal
in caliber. There is no evidence of pulmonary embolism. As
previously identified, there is a small pericardial effusion.
Bone windows show no suspicious sclerotic or lytic lesions.
Multiplanar reformats confirm the findings above.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Left-sided supraclavicular, axillary, and subscapular
subcutaneous emphysema, of uncertain etiology.
3. Tiny pericardial effusion which has increased slightly in
size.
Preliminary findings were discussed with Dr. [**Last Name (STitle) 26321**] in person at
approximately 12 midnight, [**2187-3-1**].
FEMUR (AP & LAT) LEFT [**2187-3-15**] 5:13 PM
FEMUR (AP & LAT) LEFT
Reason: follow up for comparison after surgery
[**Hospital 93**] MEDICAL CONDITION:
16 year old man with fx femur and repair. Pt is to keep left leg
elevated above heart at all times. Lying or sitting are both OK.
Thank you.
REASON FOR THIS EXAMINATION:
follow up for comparison after surgery
INDICATION: 16-year-old man with femur fracture status post
repair.
LEFT FEMUR, TWO VIEWS: Comparison is made to the intraoperative
films taken on [**2187-3-1**]. Metallic screws transfix an
intramedullary rod within the left femur, which traverses a
mildly displaced distal diaphysis femur fracture. There is no
callus formation across the fracture site. There is no evidence
of hardware loosening. Multiple skin staples are seen within the
proximal, mid and distal subcutaneous tissues. A drainage tube
is seen within the skin medially. The visualized knee
demonstrates normal alignment.
IMPRESSION: Left femur intramedullary rod traversing a mildly
displaced distal diaphyseal femur fracture. No evidence for
hardware loosening.
Brief Hospital Course:
After evaluation in the trauma bay, the pt was emergently taken
to CT scan. A CTA demonstrated no flow of contrast below his
left SFA at the level of the distal femur. The orthopaedic and
vascular teams were both available for immediate operative
planning. He was taken emergently to the OR for temporary
external fixation of his left femur fracture, thigh and leg
fasciotomies, and bypass grafting around his vascular injury.
This restored distal pulses to the left leg, however there was
no muscle twitching noted in the operating room upon [**Last Name (un) 4161**]
stimulation. The wounds were packed and the pt was transferred
back to the ICU post-operatively, where he remained intubated
until HD 6. He was aggressively resuscitated and his urine was
alkalinized. His CK levels were followed, which progressively
decreased from a peak of 100,200 on HD 2. His urine output
cleared and was adequate. His creatinine was also followed,
which never bumped higher than 0.8. He received nutrition via a
NG tube until extubation. He was transferred to the floor on HD
7.
On the floor the pt was persistently tachycardic. As he was at
severe risk for developing a DVT/PE, and chest CTA was checked.
This was negative for PE. The pt was on DVT prophylaxis
throughout his course.
On HD 9 the pt was taken back to the OR by the orthopaedic
service for ORIF with IM rodding of his left femur fracture. He
experienced pain control issues and was started on long acting
narcotics which have controlled his pain adequately thus far.
On [**3-14**] patient was taken to the operating room by Plastic
surgery for debridement and washout with split thicknesss skin
graft. A VAC dressing was initially placed; this has been
discontinued. Xeroform dressing changes are being performed
daily. He will need to return to [**Hospital 3595**] Clinic on [**3-27**] for
removal of sutures.
Patient failed voiding trial postoperatively and subsequently
his foley catheter was replaced. Normal saline 400 cc's was
instilled into his Foley and patient only experienced slight
bladder fullness with 360 cc's; foley left in place and remains.
Another bladder trial should be done once in rehab and patient
more ambulatory. Should he continue to experience difficulties
he may returen to [**Hospital 159**] Clinic here at [**Hospital1 **], [**Telephone/Fax (1) 164**].
Medications on Admission:
None.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
4. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO twice a day as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 0.3ml syringe
Subcutaneous Q12H (every 12 hours) for 15 days.
Disp:*15 syringe* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehabilitation
Discharge Diagnosis:
s/p Rollover Motor Vehicle Crash
Left Femur Fracutre
Discharge Condition:
Stable
Discharge Instructions:
Follow up with Orthopedics, Plastic Surgery, Vascular Surgery
and Trauma after discharge.
You may weight bear as tolerated on your left leg.
Use the Xeroform (petroleum) dressing as instructed by the
nurses.
Followup Instructions:
Call [**Telephone/Fax (1) 1228**] for an appointment in 2 weeks with
Orthopedics.
Call [**Telephone/Fax (1) 5343**] for an appointment with Plastic Surgery in 2
weeks.
Call [**Telephone/Fax (1) 1237**] for an appointment with Vascular Surgery in 2
weeks.
Call [**Telephone/Fax (1) 6439**] for an appointment in Trauma Clinic in 2
weeks.
Completed by:[**2187-3-20**]
|
[
"423.9",
"E849.5",
"821.01",
"904.7",
"920",
"891.2",
"904.2",
"728.89",
"E812.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.32",
"83.14",
"38.93",
"86.22",
"83.82",
"86.69",
"96.6",
"83.32",
"79.35",
"78.15",
"78.45",
"93.59",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
9680, 9741
|
6509, 8855
|
342, 770
|
9838, 9847
|
1735, 2383
|
10105, 10476
|
1274, 1291
|
8911, 9657
|
5539, 5680
|
9762, 9817
|
8881, 8888
|
9871, 10082
|
1306, 1716
|
275, 304
|
5709, 6486
|
798, 1230
|
1252, 1258
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,576
| 146,010
|
48269
|
Discharge summary
|
report
|
Admission Date: [**2126-11-19**] Discharge Date: [**2126-11-27**]
Date of Birth: [**2055-3-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
New brain lesion
Major Surgical or Invasive Procedure:
[**2126-11-20**]: Right craniotomy for tumor resection with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]
History of Present Illness:
Mr. [**Known firstname 449**] [**Known lastname 43109**] is a 71 yo RH man with a history of NSCLC
s/p resection and chemotherapy, presenting with 6 days of
confusion. According to his wife he was in his normal state of
health until ~1 week ago, when he began to act more 'distant.'
She reports that he became slow to respond, and would take
significant prompting to do things. He was normally independent
in his ADLs, but she was having to help him get dressed, wash
up,
and generally take care of him. His wife notes that he had run
out of his home medications, so made an appointment for him to
be
seen in clinic today for further evaluation. While there he had
a CT of his head, which showed a new 4x4 cm cystic lesion in the
R parietal lobe. He was given 10mg of Decadron, and
arrangements
were made to transfer him to [**Hospital1 18**] for possible surgical
evaluation.
Past Medical History:
NSCLC, s/p resection [**10-27**] and chemotherapy
HTN
HLD
DM
Social History:
Lives in [**Location 669**] with his wife. Retired assembly line worker at
GM. No EtOH, used to smoke, quit 20 years ago. No illicits.
Family History:
Mother died in her 80s of heart disease, father died at age 78,
unknown cause.
Physical Exam:
PHYSICAL EXAM on ADMISSION:
O: T: 98.6 BP: 147/80 HR:58 R:18 O2Sats: 100% on
RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2->1mm bilaterally EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
-Mental Status: Alert, oriented x 3. Some difficulty relaying
history. Inattentive, unable to name days of the week
backwards.
Language is fluent but with occasional paraphasic errors
('water'
instead of 'wallet'). Pt. was able to name all objects on the
NIH stroke card, but took significant prompting, and would often
appear to be trying to pluck the objects off the page.
Paraphrased all sentences when attempting to read. Speech was
not dysarthric. Able to follow simple, but not multi-step
commands. Pt. was able to register 3 objects and recall [**2-19**] at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia. Showed left sided neglect - unable
to correctly bisect lines, only identified the woman at the sink
in the cookie jar picture.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2mm to 1
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-23**] throughout, although requires
significant prompting on left. Unable to cooperate with testing
for pronator drift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally. Extinguishes to double simultaneous
stimulation.
Reflexes: B T Br Pa Ac
Right 2 2 2 3 2
Left 2 2 2 3 2
Toes downgoing bilaterally
Coordination: Difficulty following commands for FNF, HTS,
however
no obvious dysmetria.
On Discharge:
xxxxxxxxxxxxxxxxxxxxxxxx
Pertinent Results:
CT Head [**2126-11-19**]:
IMPRESSION: Large cystic lesion centered within the right
parietal lobe with surrounding edema and minimal shift of
normally midline structures towards the left. Although
morphologically more consistent with a primary brain neoplasm, a
metastasis is primarily considered given further history
obtained regarding a known primary lung malignancy. Minimal
uncal herniation is also identified.
MRI Brain [**2126-11-19**]:
IMPRESSION: Large right temporal lobe mass with solid and cystic
components and moderate mass effect.
Head CT [**2126-11-20**] (Post-op):
Expected post-operative changes, immediately status post right
temporoparietal craniotomy and resection of intra-axial mass.
Small foci of overlying subarachnoid hemorrhage and parenchymal
hemorrhage at the resection margins. Decrease in leftward shift
of the midline structures, now measuring only 5 mm.
Torso CT [**2126-11-20**]:
1. Enlargement of the left suprahilar nodule in comparison to
[**6-/2126**],
likely due to progression of malignancy.
2. Incompletely characterized hyperattenuating hepatic lesions,
which can be further evaluated with MRI if clinically indicated.
They are not
typical of metastatic disease and appear unchanged in size,
although Hepatic cysts and additional hypoattenuating hepatic
lesions that are too small to characterize.
3. Unchanged duodenal lipoma and equivocal benign-appearing left
adrenal
nodule in comparison to 10/[**2124**].
4. Bilateral renal cysts. Additional small renal lesions are
too small to
characterize.
5. Air in the non-dependent portion of the urinary bladder,
which may be due to instrumentation.
MRI Brain [**2126-11-22**] (Post-op):
IMPRESSION:
Postoperative changes with blood products at the surgical
cavity. Residual rim enhancement is seen at the anterior and
medial margin of the surgical cavity. Mass effect on the right
lateral ventricle is slightly less or unchanged.
Brief Hospital Course:
Mr. [**Known lastname 43109**] is a 71 yo male who was admitted to Neurosurgery
Dr. [**First Name (STitle) **] on [**2126-11-19**] for right parietal cystic lesion. On
[**2126-11-20**] he underwent a right craniotomy for tumor resection
which he tolerated well. He was monitored closely overnight in
SICU and remained at neurologic baseline with left neglect,
motors full and following simple commands, but he remains with a
dense left neglect. His diet and activity were advanced. He had
post op MRI which showed stable post-op changes with some
improvement to midline shift and mass effect. He was
transferred to the floor from the ICU on [**11-22**]. A speech and
swallow eval was done on [**11-21**] and [**11-22**] and soft/pureeds and thin
liquids with supervision were recommended. On [**11-23**]
Neuro-Oncology consulted and recommended radiation treatment. On
[**11-26**] radiation planning was completed and ten treatments were
recommended. His left neglect improved significantly during his
hospital course and was cleared for transfer to rehab on
[**2126-11-27**].
Medications on Admission:
Medications prior to admission (prescribed, not taking):
-Zestril 5mg
-Hydrodiuril 12.5mg
-Zocor 40mg
-ASA (last taken 1 week ago)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO 6 HRS ().
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Right parietal brain mass
Right parietal brain mass
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
General Instructions/Information
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????Your sutures are dissolvable, you must keep that area dry for
10 days. Please do not place any ointments or creams on your
incision.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????You have been put on Keppra (Levetiracetam) for seizure
precaution. It is important to take this medicine as prescribed.
DO NOT discontinue without the approval of Dr. [**First Name (STitle) **]
??????You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????Make sure to continue to use your incentive spirometer while at
home.
Please call Dr.[**Name (NI) 9399**] office with any questions or concerns at
[**Telephone/Fax (1) 3231**]
Followup Instructions:
You will need to follow up with Dr. [**First Name (STitle) **] in the Brain [**Hospital 341**]
Clinic in 4 weeks. This appointment may be sooner once pathology
is finalized. You will not need an MRI at that time. You will
also follow-up in 3 months with a MRI brain with and without
contrast. Please call [**Telephone/Fax (1) 1844**] to make this appointment.
Completed by:[**2126-11-27**]
|
[
"198.3",
"V15.82",
"272.0",
"V87.41",
"250.00",
"348.4",
"272.4",
"V45.76",
"401.9",
"V10.11",
"348.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
8005, 8090
|
5832, 6914
|
338, 470
|
8187, 8187
|
3883, 5809
|
9979, 10371
|
1639, 1720
|
7096, 7982
|
8111, 8166
|
6940, 7073
|
8366, 9956
|
1735, 1749
|
3837, 3864
|
282, 300
|
498, 1382
|
2823, 3823
|
1763, 2017
|
8201, 8342
|
1404, 1467
|
1483, 1623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,372
| 177,087
|
54503
|
Discharge summary
|
report
|
Admission Date: [**2177-3-26**] Discharge Date: [**2177-4-11**]
Date of Birth: [**2116-5-14**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10416**]
Chief Complaint:
chronic R frontal scalp wound
Major Surgical or Invasive Procedure:
[**3-26**]:
1. Debridement and removal of calvarial bone flap.
2. Placement of titanium mesh cranioplasty.
3. Debridement of scalp open wound.
4. Soft tissue reconstruction with right radial forearm
free flap with subsequently split thickness skin graft.
History of Present Illness:
The patient is a 60y.o. man who suffered a myocardial infarction
in [**2170**] that
required him to undergo angioplasty and stent placement and
ongoing Coumadin therapy. He subsequently developed an acute
subdural hematoma on the right side that required emergent
evacuation and craniectomy that was performed at the [**Hospital1 3372**]. Following adequate clinic stabilization, his
cranial bone flap was replaced; however, he subsequently
developed a chronic draining wound in his right frontal scalp
that has persisted for the subsequent seven years. He has been
followed intermittently by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the Plastic
Surgery Clinic and was last seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in his
clinic on
[**2177-1-20**]. During the course of that evaluation, the
patient was recommended for a CT scan that showed necrosis of
the central portion of the patient's right frontal/temporal bone
flap that appears to be associated with full thickness bone loss
at the central portion of the flap. He presented on [**3-26**] for
cranioplasty and free flap scalp reconstruction.
Past Medical History:
- CAD s/p MI with PCI ([**12/2170**])
- R frontal ICH ([**1-/2171**]) in setting of anticoagulation for MI
- AML s/p chemo in [**2156**], in remission
- h/o seizures
- Anal fissure [**2170**]
- OSA
- HTN
- Hyperlipidemia
- H/o 'MRSA infection' in [**12/2170**]
- Depression
Social History:
no EtOH or Smoking. The patient is married, lives at home with
his wife and works as an office manager.
Family History:
Mother - died at 83 of cirrhosis [**1-18**] surgical complications of
[**Name (NI) 10259**]
Father - died at 57 secondary to CAD
Physical Exam:
Pre-op:
AVSS
Gen: well appearing, NAD
HEENT: obvious depression in the superior frontal region of his
scalp with an associated, approximately 1 cm diameter draining
sinus tract that is productive of fibrinous material. There is
no surrounding erythema, but there is significant chronic
inflammatory tissue surrounding this tract site.
Lungs: CTA
Heart: RRR
Abd: soft, N-T, N-D
Pertinent Results:
CT HEAD W/O CONTRAST [**2177-3-27**] 4:48 PM
FINDINGS: Comparison is made to head CT from [**2177-1-22**] and head MR
from [**2177-2-12**].
The previously seen craniotomy bone flap has been removed and
there is a new mesh in the craniotomy defect. There is overlying
soft tissue air as well as a new scalp flap. Surgical clips are
seen within the flap.
There is a tiny amount of air deep to the mesh. There is
heterogeneous high- density material immediately under the mesh,
which may represent post-surgical fluid, but if there is concern
for infection, this could be further evaluated with MR.
Again seen is encephalomalacia of the adjacent right frontal
lobe. There are no intracranial hemorrhages.
Again seen is a dilated CSF space in the left middle cranial
fossa, consistent with an arachnoid cyst.
The ventricles and extra-axial CSF spaces are unchanged in size.
The visualized orbits appear normal. The visualized paranasal
sinuses are clear.
IMPRESSION: No intracranial hemorrhages.
TTE (Complete) Done [**2177-3-31**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate to severe focal left ventricular hypokinesis with
akinesis of the anteroseptum and anterior walls and hypokinesis
of the inferoseptum and anterolateral walls (LVEF ?30 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. The mitral valve
leaflets are not well seen. Trivial mitral regurgitation is
seen.
[**2177-3-26**] 11:29AM HGB-13.0* calcHCT-39
[**2177-3-26**] 08:50PM WBC-9.7# RBC-3.49* HGB-11.6* HCT-33.3* MCV-95
MCH-33.1* MCHC-34.7 RDW-13.0
[**2177-3-26**] 08:50PM CK-MB-17* MB INDX-1.0 cTropnT-<0.01
Brief Hospital Course:
The patient was admitted on [**3-26**] for cranioplasty and free radial
scalp flap for chronic, non-healing scalp wound. The infected
cranial graft was removed and a titanium mesh placed. Next a
free flap was taken from the R radial forearm and transposed to
the scalp. A split thickness skin graft from the thigh was used
for the radial wound. A lumbar drain was placed intra-op by
neurosurgery to minimize pressure on the repair. The patient was
transferred to the ICU ventilated following surgery for post op
management. He was extubated on POD#1. Flap doppler checks were
performed frequently post-operatively and showed good pulses.
He was transferred to the floor on [**3-31**].
NEURO:
On POD#1 the patient had 2 witnessed generalized tonic-clinic
seizures. He was treated acutely with ativan and neurology was
called. The patient reported missing an unspecified number of
tegretol doses prior to admission. The patient was loaded with
dilantin and put on a course of dilantin and tegretol. Tegretol
levels were drawn to follow the level which remained
subtherapeutic for most of the hospital course and required 2
additional loading doses. Ativan was used to bridge between the
dilantin and tegretol, and the dilantin was tapered off, being
discontinued on [**4-9**]. Tegretol level was increased [**4-11**] for
discharge with follow up with patient's primary neurologist on
[**4-18**].
Lumbar drain: post op 20cc/hour were drained with clamping of
the drain in the interim. This was tapered to 10cc/h after 48h
and the drain was d/c'd on [**3-31**] without complication.
Cardiology: the patient was tachycardic post-op and required
beta blockade and diltiazem to reduce his rate. He did remain
normotensive post-op.
ID:The patient was initially covered with vancomycin and zosyn.
OR tissue cultures grew MRSA. Blood cultures and CSF cultures
had no growth.Zosyn was d/c'd on [**3-28**] following reports from the
OR cultures. Rifampin was started on [**4-2**] for additional
coverage per ID consult's recommendation.
Wound: The radial donor site was initially treated with a VAC
dressing. This was taken down on [**4-1**] and the wound was dressed
with xerform and kerlix and changed daily. The graft took well
an continued to heal without complication. The STSG donor site
was dressed with xeroform and allowed to dry.
Nutrition: the patient started a clear liquid diet on POD#1 and
a regular heart healthy diet on POD#2.
Medications on Admission:
Atenolol 12.5mg QD
Carbamazepine 400mg [**Hospital1 **]
Lipitor 40mg qHS
ASA 81mg QD
MVI, fish oil
Discharge Medications:
1. Outpatient Lab Work
Weekly CBC with Diff, electrolytes, LFTs, ESR and CRP.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 4 weeks.
Disp:*56 Recon Soln(s)* Refills:*0*
4. Rifampin 150 mg Capsule Sig: Three (3) Capsule PO twice a day
for 4 weeks.
Disp:*168 Capsule(s)* Refills:*0*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Lipitor 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous twice a day as needed: flush IV BID and PRN.
Disp:*60 ML(s)* Refills:*2*
10. Normal Saline Flush 0.9 % Syringe Sig: Five (5) cc Injection
twice a day for 4 weeks: [**Hospital1 **] with IV meds and PRN .
Disp:*75 flushes* Refills:*2*
11. Carbamazepine 200 mg Tablet Sig: Five (5) Tablet PO twice a
day.
Disp:*300 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Chronic scalp wound.
Discharge Condition:
Good. Tolerating a regular diet. Pain well controlled on oral
medication.
Discharge Instructions:
Take medications as directed.
Resume a regular diet.
Change the dressing on your arm daily with xerform, kerlix and
ACE bandage.
The dressing on your thigh will fall off on its own.
Call your physician for fever >101.5, discoloration of the scalp
flap, pain, redness, swelling or drainage at the wound sites, or
any other symptoms that may concern you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in the office in 1 week. Call for
appointment:([**Telephone/Fax (1) 10419**]
You have an appointment with Dr. [**Last Name (STitle) 32878**], your neurologist on
[**2177-4-18**] at 12:30PM to follow up your anti-epileptic medication
regimen. You should have a tegretol level drawn at this time.
You will need weekly lab draws while you are on rifampin (until
[**5-8**]) which include CBC with differential, BUN/Creatinine, LFTs,
ESR, CRP. Please fax the results of these test to the Infectious
disease nurse [**First Name (Titles) **] [**Last Name (Titles) 18**] at [**Telephone/Fax (1) 432**]. Call [**Telephone/Fax (1) 14774**] with
questions regarding the antibiotics or labs.
|
[
"780.6",
"205.01",
"730.18",
"272.4",
"428.0",
"041.11",
"345.90",
"401.9",
"412",
"285.22",
"V09.0",
"V45.82",
"428.22",
"V12.54",
"998.89",
"998.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.69",
"02.04",
"01.25",
"93.59",
"83.43",
"02.06"
] |
icd9pcs
|
[
[
[]
]
] |
8399, 8457
|
4604, 7042
|
345, 605
|
8522, 8598
|
2779, 4581
|
8999, 9729
|
2236, 2366
|
7191, 8376
|
8478, 8501
|
7068, 7168
|
8622, 8976
|
2381, 2760
|
276, 307
|
633, 1802
|
1824, 2099
|
2115, 2220
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,530
| 130,942
|
51633
|
Discharge summary
|
report
|
Admission Date: [**2154-4-2**] Discharge Date: [**2154-4-8**]
Date of Birth: [**2097-3-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
shortness of breath and chest pain
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
57y M s/p gastric bypass on [**3-26**] ([**Hospital 882**] hospital), no
complications discharged [**2154-3-30**], was on SC heparin as well as
venodynes. On [**4-1**] had some left calf pain with ambulation, no
edema. On [**4-1**] some mild pleuritic CP Wife reported
listlessness, fatigue. Early in am of admission ([**4-2**]) after
walking down stair, fell - found by wife,
diaphoretic/unresponsive. EMS called. HR at 140, 02% 90 on
non-rebreather, RR 40-50. CTA at [**Hospital 882**] hospital showed large
saddle pulm embolism. Patient received 10,000 heparin bolus.
Patient then transferred to [**Hospital1 18**] to receive ICU care.
Past Medical History:
1) S/p gastric bypass surgery at [**Hospital 882**] hospital on [**3-26**]
2) Obstructive sleep apnea on CPAP
3) Morbid obesity
4) S/p thyroidectomy
5) Borderline Diabetes Mellitus
Social History:
works as general manager at community television, no tobacco,
rare etoh, lives w/wife.
Family History:
Aunt with "[**Name2 (NI) **] clots"
Physical Exam:
Gen: Obese man, NAD, having difficulty moving [**3-13**] size in large
Kinair bed
MMM, No JVD observed though difficult given excess neck
subcutaneous tissue
RRR, nl s1s2, no mrg
Lungs with dry rales b/l, no wheezes/no rhonchi
Abd obese, soft, nabs
Ext groin c/d/i w/o bruit, 2+ dp
trace edema
Pertinent Results:
IVC Filter Placement - IMPRESSION:
1. IVC venogram demonstrating a single and patent IVC and patent
bilateral common iliac veins. Reflux of contrast is seen into
the iliac veins consistent with elevated right atrial pressures.
2. Successful placement of a Bard recovery IVC filter within the
inferior vena cava inferior to the level of the renal veins. The
filter could be removed at any time using a jugular approach if
necessary.
.
CT CHEST:
FINDINGS: There is no axillary, hilar or mediastinal lymph
adenopathy. Coronary artery calcifications are seen along the
LAD. There are no definite pleural effusions or evidence of
pneumothorax.
On the right, there is probably linear atelectasis at the
superior segment of the the lower lobe. There is opacification
of the right posterior CP angle, probably representing
combination of consolidation and small pleural effusion. There
is discoid atelectasis vs infarction of the peripheral upper
anterior and anterior CP angle of the right middle lobe (unable
to distinguish without IV contrast). There is also ground glass
opacity of the dependent right middle lobe, probably
representing incomplete consolidation.
On the left, there is linear atelectasis at the lateral segment
of the lower lobe, as well as linear atelectasis at the lateral
lingula. Mild consolidation vs atelectais is also seen at the
left posterior CP angle.
There appears to be multiple surgical staples within the abdomen
adjacent to the stomach, and anastomotic suture lines also are
apparent along the stomach, probably relating to prior gastric
bypass surgery. IVC filter is present.
Coronally and sagittally reformatted images were also reviewed,
critical for delineating the lobar distribution of disease,
described above.
IMPRESSION:
Scattered regions of atelectasis, consolidation, and possibly
effusion as described above. Without IV contrast, we cannot
assess whether the thicker wedge-shaped opacities represent
discoid atelectasis or consolidation (pneumonia/infarction).
.
ECHO:There is moderate symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic
(EF>75%). No masses or thrombi are seen in the left ventricle.
The right
ventricular cavity is dilated. Right ventricular systolic
function appears depressed. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. There is no mass/thrombus in the right ventricle. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. There is no
aortic valve
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is at least moderate
pulmonary hypertension.There is a trivial/physiologic
pericardial effusion.
IMPRESSION: These findings are consistent with significant RV
strain.
.
LENI: Deep vein thrombosis extending from the proximal-to-mid
left superficial femoral vein and involving the left popliteal
vein as well
Brief Hospital Course:
1)Pulmonary embolism: Pt was hemodynamically stable throughout
course. Pt was admitted directly to the MICU and treated with
heparin and coumadin. Although pulmonary embolism was very
large, he was not a candidate for thrombolytics given his recent
gastric bypass surgery. An echocardiogram was performed which
showed moderate symmetric LVH, LVEF > 75%, no thrombus in the
LV, dilated RV, depressed RV function, and abnormal RV systolic
motion c/w RV pressure overload. LENI's showed DVT at left
popliteal to superficial femoral vein. An IVC filter was placed
wtih plan on removing it in several months, at time to be
determined by pulmonary team. Pt was continued on heparin for
48 hours after INR reached goal of [**3-14**], which was [**2154-4-9**]. It
was discussed with pt that his INR would require high frequency
checks as his diet will be changing per his post gastric bypass
surgery protocol. It was also noted that a large component of
his diet wich was a carbohydrate drink contained Vitamin K.
His INR will be monitored closely as his diet is changed. He
was noted to desat on room air while ambulating, so he was
discharged on home o2, 2L continuous.
2)Acute renal failure: The patient was also noted to have a
creatinine of 1.6 upon admission to the MICU, however this
decreased to 0.9 after hydration.
3)S/p gastric bypass surgery: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] was consulted and was
involved in decisions regarding appropriate and safe
anticoagulation s/p surgery. Pt was continued on diet as
outlined by his surgeon, with his wife bringing the nutrition
from home. Nutrition was consulted for general recomendations
and also to educate pt regarding means of taking in more water
to stay hydrated.
Medications on Admission:
Levoxyl 0.75, Zantac [**Hospital1 **], percocet (not taking), MVI, Vitamin
B12 SL q-Saturday
Discharge Medications:
1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*qs Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Cyanocobalamin Sublingual
4. Home O2
O2 at 2liters/minute continuous
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-10**] Sprays Nasal
DAILY (Daily) as needed.
6. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
Disp:*150 ML(s)* Refills:*2*
7. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day).
Disp:*600 mL* Refills:*2*
9. Warfarin Sodium 2.5 mg Tablet Sig: ASDIR Tablet PO at
bedtime: Take 2 tabs Monday, Wednesday, Friday, Saturday. Take
3 tabs Sunday, Tuesday, Thursday.
Disp:*68 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pulmonary embolism
deep vein thrombosis
hypertension
Discharge Condition:
stable
Discharge Instructions:
You must follow up with [**Hospital1 **] to be followed by their
[**Hospital 2786**] clinic. You will need to get your [**Hospital **] drawn
there multiple times a week and the nurses there will let you
know what dose of coumadin to take.
Please return to the emergency department immediately if you
become acutely short of breath or develop a new worsened chest
pain.
Your coumadin dose will need adjustment whenever you change your
post-gastric-bypass diet.
Followup Instructions:
1) Please go to [**Hospital1 **] for an INR check on Wednesday
at 3pm. You will see Dr. [**Last Name (STitle) **] at 5pm on Wednesday where you
coumadin dose might be adjusted.
|
[
"E878.8",
"401.9",
"453.41",
"244.9",
"415.11",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
7576, 7582
|
4727, 6484
|
305, 327
|
7679, 7687
|
1688, 4704
|
8198, 8379
|
1321, 1358
|
6627, 7553
|
7603, 7658
|
6510, 6604
|
7711, 8175
|
1373, 1669
|
231, 267
|
355, 996
|
1018, 1201
|
1217, 1305
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,197
| 130,412
|
44942
|
Discharge summary
|
report
|
Admission Date: [**2155-8-30**] Discharge Date: [**2155-10-3**]
Date of Birth: [**2077-5-4**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Atenolol
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Chest pressure with 5.8cm descending thoracic aortic aneurysm
Major Surgical or Invasive Procedure:
[**2155-8-30**]
1. Emergent stent graft repair of descending thoracic
aortic aneurysm with 4 [**Doctor Last Name 4726**] TAG endoprostheses. The
endoprostheses are the following:
a. Catalog #[**Serial Number 96113**], batch code [**Numeric Identifier 96114**].
b. Reference #[**Serial Number 96115**], batch code [**Numeric Identifier 96116**].
c. Reference #[**Serial Number 96115**], lot #[**Serial Number 96117**].
d. Catalog #[**Serial Number 96118**], batch code [**Numeric Identifier 96119**].
2. Left common iliac artery stenting with two 5 cm x 10 mm
Viabahn stents.
3. Repair of left common femoral artery iatrogenic injury
with a 6-mm Dacron tube graft with patch angioplasty of
the superficial femoral artery.
4. Thoracic and abdominal aortography
[**2155-9-23**]
5. PEG placement
History of Present Illness:
Mrs. [**Known lastname **] is a 78 year-old female recently admitted with chest
pressure and hypertensive urgency, found to have 5.9 cm TAAA
(has been present since at least [**2150**] but now larger), who
presents with the same symptoms. She had a CTA done on [**2155-8-28**]
showing an aortic aneurysm all the way from the aortic arch to
the iliac bifurcation.
Her chest pressure started this morning when she bent forward
and has continued unabated for hours. She describes the location
as substernal with radiation to her back and intense in nature.
The pressure is worse than on last admission and the back
radiation is new. She has no abdominal pain, nausea, vomiting,
diarrhea, or shortness of breath. Her SBP is 170 in the right
arm as on initial examination of the patient; she was also
hypertensive when picked up by EMS. In the interim, her pressure
has intermittently dropped after nitroglycerin administration.
She has known left subclavian stenosis and SBP in the left arm
is typically around 100 consequently.
She has a PMH of STEMI s/p stenting of RCA in 2/[**2153**]. During the
last admission, cardiac enzymes were cycled and were normal
throughout.
Past Medical History:
-NSTEMI [**2153-8-25**] - medically managed
-Left subclavian steal -> therefore has discrepancy in BP in R
versus L arm. BP should be measured in R arm.
-Hypertension
-Tobacco habit, half pack per day times 40 years.
-Hyperlipidemia, primarily LDL elevation.
-Right carotid bruit.
-Peripheral [**Month/Day/Year 1106**] disease status post stenting to right iliac
artery.
-Thyroid cancer, papillary carcinoma, removed with total
thyroidectomy in [**2148-9-23**]. Of note, had two
hyperfunctioning nodules and one cold nodule. on synthroid
-Left rotator cuff tendonitis.
-Status post left hand crush injury in distant past
Social History:
-Tobacco history: Currently smokes [**11-24**] ppd for 54 years
-Alcohol: None
-Illicit drugs: None
Patient lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], functional with ADLs and IADLs.
Drives, with no help needed for ambulation.
Family History:
CVA in brother at 55 years of age, CHF in mother at [**Age over 90 **] years of
age. No history of collagen/fibrillin disorders, no history of
aneurysms.
Physical Exam:
On presentation,
VS: Temp 98.0 HR 49 BP 169/88 18 100%RA
CV: regular rate, rhythm. No appreciable murmurs, rubs or
gallops
Pulm: clear to auscultation bilaterally
Abd: soft, +BS, nondistended,nontender
Extrem: no lower extremity edema bilaterally. Moves all
extremities purposefully.
Pulses:
fem [**Doctor Last Name **] PT dp
R p p p p
L p p p p
Upon discharge:
VS: Tcurrent 98.2 HR 66 BP 157/45 RR 15 O2sat 94% 2L NC
CV: regular rate, rhythm. No murmurs, rubs, gallops
Pulm: clear to auscultation bilaterally
Abd:soft, + BS, non distended, nontender.
Extrem: left groin mildly indurated, stable. No fluctuance, no
erythema, no drainage. Palpable femoral pulses, dopplerable
popliteal pulses, palpable dorsalis pedis pulses, dopplerable PT
pulses bilaterally. Paraplegic from T6, unable to move lower
extremities, mute plantar reflexes. Full ROM, 5/5 strength of
left upper extremity. Passive ROM of right upper extremity.
Please refer to neurologic exam in discharge summary for further
details.
Neuro: alert, oriented to person, place. Approximate sense of
time. Appropriate responses, less withdrawn, more interactive.
CN II-XII grossly intact.
Pertinent Results:
[**2155-8-30**]: CXR: No acute intrathoracic process with unchanged
6.2-cm thoracic aortic aneurysm. Subsequent CTA demonstrates
intramural aortic hematoma which is not visible by plain
radiography.
[**2155-8-30**]: CT Chest/Abd/Pelvis with/without contrast:
1.Type B intramural hematoma of the thoracic aorta extending
from the aorta just distal to the left subclavian origin to the
mid descending thoracic aorta. No significant interval change in
the size of the fusiform descending thoracic aortic aneurysm,
maximally measuring 5.5 cm with internal intramural thrombus
within the aneurysm.
2. Stable appearance of the fusiform infrarenal abdominal aortic
aneurysm
maximally measuring 3.5 cm.
3. Stable chronic occlusion of the left subclavian artery origin
with distal reconstitution.
[**2155-9-1**]: MR Lumbar spine WOC:
Elevated signal, linear in pattern within the mid-thoracic
spinal cord, at approximately the T6-7 level. Cord is not
swollen, however recent aortic surgery raises the suspicion for
developing infarction.
There does not appear to be any spinal cord compression. Within
the lumbar region, there is generalized moderate desiccation of
the discs, with mild bulging disc noted at L4-5. Moderate left
and milder right foraminal stenosis.
[**2155-9-3**]: Lower extremity non-inasive studies: no DVT
bilaterally.
[**2155-9-6**]: CT Head WOC: IM No evidence for acute intracranial
hemorrhage, large mass, mass effect, edema, or hydrocephalus.
Prominent extra-axial CSF spaces, sulci, and ventricles suggest
age-related involutional changes. White matter hypodensities are
likely secondary to small vessel ischemic disease.
[**2155-9-6**]: MRA Head/Neck with/without contrast: limited by
motion. Diminished flow signal in the left ICA is seen in the
cavernous region and in the petrous region, but the flow signal
in the MCA is poorly visualized due to motion. Flow signal is
seen in the sylvian branches of both middle cerebral arteries.
The right CCA, visualized right subclavian artery, and the right
ICA demonstrate no evidence of high-grade stenosis or occlusion.
Right vertebral artery is tortuous but demonstrates normal flow
without stenosis.
[**2155-9-6**]: CTA Head/Neck: 1. Head CT shows no hemorrhage. 2.CT
angiography of the neck demonstrates slight narrowing of the
origin of the left CCA but no evidence of diminished flow seen
distal to the origin. Approximately 50% stenosis in the left
internal carotid bifurcation region is identified with
calcification. 3. The left subclavian artery is occluded near
the origin and is reconstituted through collateral flow from the
left vertebral artery
[**2155-9-15**]: CT Chest/abdomen/pelvis with contrast: Satisfactory
appearance of the thoracic aortic stent graft. Small left
pleural effusion noted with compressive atelectasis in the left
lower lobe. Post-surgical changes seen in the left inguinal
region with a seroma overlying the right common femoral artery
access point.
[**2155-9-24**]: Bilateral Lower Extremity non-invasives: No evidence of
deep venous thrombosis in either extremity.
[**2155-9-26**]: PEG tube study: Appropriate positioning of PEG with
placement confirmed by contrast. No evidence of contrast
extravasation.
[**2155-9-26**]: CT Torso with contrast: stable appearance of thoracic
aortic stent graft. Small pleural effusions, left greater than
right. Stable cardiomegaly with pericardial effusion. Status
post gastrostomy placement with expected trace free air. Severe
atherosclerotic disease with multivessel narrowing at the origin
and high-grade stenosis of the left renal artery origin.
Enlarged left inguinal fluid collection with no rim enhancing
lesion.
[**2155-9-27**]: ECG: Sinus rhythm @ 69 bpm. Left ventricular
hypertrophy with secondary repolarization abnormalities.
Compared to the previous tracing findings are similar.
Brief Hospital Course:
The patient was admitted to the [**Month/Day/Year 1106**] surgery service on
[**2155-8-30**] for urgent repair of a descending thoracic aortic
aneurysm with intramural thrombus and pending rupture associated
with chest pressure and hypertensive urgency; she was properly
consented for and was informed of the risks and benefits of the
procedure, including death, stroke, paralysis, and significant
bleeding from iliac injury. She subsequently underwent an
endovascular thoracic aortic repair with stent placements in her
left common iliac artery and left external iliac artery and
repair of a left common femoral artery iatrogenic injury with a
6-mm Dacron tube graft with patch angioplasty of the superficial
femoral artery. The reader is referred to the operative notes in
OMR for further details of the procedure.
By system,
Neurologic: a lumbar drain was placed pre-operatively due to the
large portion of aorta that needed to be covered as well as for
protective measure for paralysis prevention. At the immediate
time, the patient's PT/INR had not returned at the time, but
after discussion with the cardiothoracic surgery and anesthesia
teams, the small risk of epidural hematoma was less than the
risk of not having a lumbar drain. It was decided at the time to
proceed with lumbar drain. In the immediate post-operative
period, the patient received IV fentanyl and propofol for
sedation and relief of pain while in the cardiovascular ICU. She
was weaned from CPAP within the next 24 hours with appropriate
concomitant weaning of propofol and fentanyl. It was at this
point on POD#2 around 08:20AM on [**2155-9-1**] when the
patient was found to have a change in her motor function, with
inability to move her lower extremities with preserved passive
motion. The patient was noted to have volitional movements of
all four extremities until 10PM the prior evening, with no
nursing/neurologic assessments documented until 8-8:20AM when
the [**Year (4 digits) 1106**] team was notified of the change in status.
The initial impression at the time was that she had paralysis at
the thoracic level secondary to spinal cord ischemia; the
neurology service was consulted immediately and an MRI of the
spine was performed, which showed mid-thoracic spinal cord
ischemia at the T6-T7 level. Initial neurology recommendations
were implemented, namely to achieve MAP >90, maintain the lumbar
drain at 10-12mmHg, without the need for steroid therapy. Prior
to this change in neurologic exam, her CSF pressures had been
low with minimal non-bloody drainage, with her initial MAP goal
for > 80; her CSF pressures and output remained unremarkable
until the lumbar drain was removed on POD #4. Her CKs were
trended, which initially were 237 but peaked to the 25,000s on
POD#2, which were thought to be related to low perfusion during
her prolonged operative time. Her creatinine at the time was
within normal limits at 0.7-0.9, and there was no evidence of
acidosis at that time. Her neurologic exam as detailed by the
[**Year (4 digits) 1106**] neurology service confirmed absent active movement and
sensation of the lower extremities with absent quadriceps,
patellar, and achilles tendon reflexes bilaterally. Her pulse
exam was noted for preserved dopplerable PT signals and palpable
femoral and DP pulses bilaterally.
During the remainder of her stay in the CVICU through [**2155-9-5**],
or POD#6, the patient was alert and oriented to person, place
and time, was able to follow simple commands and responded
appropriately to verbal, tactile and noxious stimuli. She was
able to move both her upper extremities but not her lower
extremities.
On POD #7 while in the CVICU, she was persistently hypertensive
despite her current regimen of oral anti-hypertensives,
including clonidine, hydralazine, metoprolol and lisinopril; she
remained consistently in the 150s-160s and was kept in the CVICU
for blood pressure control; nicardipine drip was started at this
time, which was weaned off soon thereafter. When stable, the
patient was transferred to the VICU, and overnight on POD#7 was
noted to have right upper extremity weakness. An MRA of the head
and neck and CTA head were performed which demonstrated a likely
embolic stroke in the left frontal lobe as well as in the
subcortical region around the periatrial area. There was also
note of a 50% stenosis in the left internal carotid
bifurcation region, identified with calcification. Given her
presentation and radiologic findings, the source was concluded
to be likely of embolic source, and heparin drip was immediately
started and blood pressure managed with both IV and oral
anti-hypertensives. She remained in sinus rhythm with no
sustained arrythmias. She was unable to squeeze her right hand
and actively move her right arm after this event on POD#7, with
no deterioration in her status for the next several days. She
remained on heparin drip with therapeutic goal acheived, which
was discontinued on POD#12 and received a plavix load for
long-term anti-coagulation. In this interval, the patient was
intermittently cooperative, with inconsistent ability to obey
commands, although it was difficult to ascertain whether this
was secondary to depression and apathy or from a change in
neurologic status. A repeat CT of the head on POD#12
demonstrated a likely evolving CVA in the previously left
frontal [**Doctor Last Name 534**] area; the patient was continued on anti-coagulation
(aspirin and plavix for at least 3 months) as recommended by the
[**Doctor Last Name 1106**] neurology service with no aggressive changes at that
time. Psychiatry was also consulted at this time; please refer
to separate section below.
Her neurologic status otherwise between POD#12 and that prior to
discharge improved slightly with the ability to obey commands,
respond to both verbal, tactile and painful stimuli. Her
attention improved although she remained largely withdrawn,
likely secondary to depression. She remained unable to move her
lower extremities as before, with noted preservation of her left
upper extremity movements and strength. Of note, when agitated
or angry, she would actively flex her arm with concern for
spasms/jerky movements; [**Doctor Last Name 1106**] neurology was re-consulted on
POD#16, with little suspicion for encephalitis or seizure
activity. It was thought that the patient would become agitated
secondary to frustration, and would flex her arm accordingly.
This remained her baseline the few days prior to discharge with
no changes in her neurologic status.
She remained on frequent neurologic status checks and assessment
of pain level. Her pain in the initial post-operative period
while in the ICU was transitioned to morphine IV, and
acetaminophen IV, with appropriate addition of oral pain
medications after passing a speech and swallow evaluation; this
regimen included tramadol, and lidocaine patch with good effect
and adequate pain control. The chronic pain service was
consulted in the early post-operative period with
recommendations to add gabapentin for neuropathic pain, which
was added to her regimen with good effect. She noted mostly back
pain and abdominal pain consistent with her spinal cord infarct;
the chronic pain service was re-consulted for this reason, and
it was concluded that she may have been experiencing neuropathic
pain secondary to her cord infarct. Prior to discharge, her
pain, which was mainly in her back, was well controlled with
oral pain medications, including oxycodone, gabapentin and
tylenol as well as lidocaine patch.
On discharge, the patient grimaced to pain in both upper
extremities, but not in the lower extremities bilaterally. Tone:
her right upper extremity and bilateral lower extremities
remained flaccid. Strength in the left upper extremity was at
least 4-/5. Reflexes in the right upper extremity were 3+, and
2+ in the left upper extremities. Reflexes were absent in the
quadriceps, achilles bilaterally; plantar response was mute
bilaterally.
Cardiovascular:
Upon presentation in the ED, the patient was noted to be
hypertensive in the 190s, which was moderately controlled with
oral and IV anti-hypertensives. Intra-operatively the patient
was noted to have SBP ~160 with T wave inversions: CK and
troponins were cycled, with troponins <0.01 or <0.02, and CK-MB
peaking at 143 on POD#1, then returning to baseline. Her aspirin
and beta-blocker were continued for cardioprotection as well
given her history of CAD and RV STEMI(02/[**2153**]). She was
monitored continuously on telemetry and remained within sinus
rhythm with good rate control, largely in the 60-80s in the
CVICU with no further evidence of myocardial ischemia.
As noted earlier, the patient was found to be hypertensive
post-operatively wth systolic blood pressures ranging between
140-190; MAP goals were kept at 100mmHg with a regimen of
nicardipine drip, hydralazine and metoprolol. In the immediate
post-operative period, her blood pressures were placed under
strict parameters with SBP to remain 110-150. While in the
CVICU, her pressures were managed with both IV metoprolol,
hydralazine and nicardipine drip, the latter of which was
titrated appropriately and weaned off by the end of POD #2.
After transfer to the floor, her blood pressure was initially
managed with metoprolol 100XL daily among prn [**Year (4 digits) 4319**] of
hydralazine; however, she was noted to be borderline bradycardic
in the 50-60s, with beta-blockade changed to 50mg po TID. Her
blood pressures were maintained with clonidine patch,
hydralazine po and IV (prn), lisinopril and HCTZ. She was
monitored on telemetry, and remained in sinus rhythm with rate
consistently in the 60-70s; blood pressure was stable in the
140-150 range systolic on the stated regimen prior to discharge.
Her blood pressure goal remained within 110-150, and she did not
require much of her hydralazine IV prn [**Year (4 digits) 4319**] prior to discharge
as she remained within this range. For specific discharge
medication [**Year (4 digits) 4319**], please refer to medication section of the
discharge summary.
Pulmonary: the patient underwent her procedure on the evening of
[**2155-8-30**] and was extubated after being transitioned to CPAP on
POD#2, which she tolerated well. She achieved excellent O2sats
on face-mask the day of extubation. Prior to this, a CXR for
drop in hematocrit had been performed on [**2155-8-31**], which showed
a small left pleural effusion and atelectasis, which remained
largely unchanged in subsequent CXRs. On POD#13, in the context
of placing a dobhoff tube for nutritional supplementation, the
patient expectorated green-yellow sputum, which was found to
grow Klebsiella pneumoniae; a CXR demonstrated a possible LLL
consolidation or effusion. The patient was then started on a two
week course of IV vancomycin and cefipime with no leukocytosis
on daily CBC or spike in temperature until [**2155-9-26**],
with a temperature spike to 102F; CXR was performed, which was
unremarkable for, and blood cultures, sputum sample, and U/A
were sent. Her antibiotic coverage was broadened to
vancomycin/ciprofloxacin/metronidazole. This was discontinued
after a few days secondary to fever spike to 102F with
subsequent negative blood and urine cultures and unchanged CT
findings; ID was consulted at this time, with the suspicion that
his fevers, with their cyclical nature, were likely drug-fever
related. Please see the ID section for further details.
GI: after successful extubation on POD#2, the patient underwent
a speech and swallow evaluation with advancement of diet to
nectar thick liquids and pureed solids. Her intake was initially
limited by pain, but improved somewhat over the course of her
stay in the CVICU. After transfer to the floor, the patient
continued to be intermittently despondent, and withdrawn. Out of
concern for her nutritional status, calorie counts were started
on POD #11, and a tube feed was placed on POD#13, with feeds
started, and nutrition recommendations in place: her tube feeds
were set for a goal 40cc/hr daily with 960kCal/59 grams of
protein, which would provide 75% of the patient's estimated
needs. This was in conjunction with the patient's estimated oral
intake, which ranged from 300-600 calories per day. The patient
was encouraged to take her supplemental shakes with every meal.
However, the dobhoff soon became clogged despite multiple
attempts. After much discussion with the patient, family and
interventional radiology, PEG placement was attempted on POD#18
by IR without success as the patient refused consent at the time
for any form of [**Last Name (un) **]-gastric placement. In the interim, a PICC
line was placed on POD#21 for TPN supplementation, which was
coordinated by Nutrition with appropriate supplements and
calories tailored for the patient's needs; the TPN was kept
continuously during the next few days until after repeated
discussions about the declining nutritional status of the
patient, the clear decline in skin integrity of the patient's
pressure ulcers, it was then decided by the family and patient
and [**Last Name (un) 1106**] team to proceed with a PEG tube placement on POD#
25 by the Thoracic Surgery service. The placement was
successfully performed under general anesthesia with no issues.
The PEG tube was kept to gravity overnight, then was used for
medications the next day, which the patient tolerated. Tube
feeds were started on POD#26, which again the patient tolerated
with no complaints of nausea, emesis or reflux. The patient was
kept on a bowel regimen consisting of miralax, senna, colace and
milk of magnesia, which was titrated appropriately for regular
bowel movements. Prior to discharge, the patient's tube feeds
were at 50cc/hr with a goal of 90cc/hr, TPN had been
discontinued, and the patient was encouraged to take in oral
intake. Calorie counts were continued as well, which upon
discharge averaged about 200-300 calories per day. Nutrition
followed closely with appropriate changes to her tube feeds
given her caloric intake.
Genitourinary: Given the level of the patient's spinal cord
infarct, long-term foley management was discussed, with regular
changing of the foley catheter. Her renal function remained
robust, with creatinine largely below 1.0, peaking only twice at
1.5. Upon discharge, her creatinine was between 0.3-0.7.
Perioperatively, the patient received adequate fluid
resuscitation with good blood pressures and brisk urine output.
She continued to have good urine output throughout her admission
and prior to discharge. She also underwent routine U/A checks
for UTI, the most recent on [**2155-9-29**], which was negative. She
will require long-term foley management with routine replacement
every 4-6 weeks and routine U/A checks.
Heme: the patient initially presented with a hematocrit of 40.2
in the emergency department, received adequate resuscitation
with LR intra-operatively and received no blood products
intra-operatively. Her post-operative hematocrit in the CVICU
was 41. Frequent hematocrit checks were employed, which were
changed to [**Hospital1 **] hematocrit checks; her hematocrit did drift to
30.8 on POD #2, but remained stable at this point. Her
hematocrit remained within the high 20s to mid 30s during her
admission, with no requirement for blood transfusion. Her
platelets were originally at 180, found to be 90 on POD#2; a HIT
panel was sent around this time, which was ultimately negative.
Subcutaneous heparin was intially held until the assay returned
negative, and was continued throughout her stay for DVT
prophylaxis.
For her post-operative embolic stroke, and per [**Hospital1 1106**]
neurology recommendations, the patient was continued on plavix
and aspirin for at least a 3 month course.
ID: the patient was given standard IV vancomycin and cefazolin
peri-operatively, with no initial signs of infection. She
remained largely afebrile with no overt leukocytosis on daily
labwork. As mentioned earlier in the Pulmonary section, on POD #
13, the patient produced green-yellow sputum, which grew
Klebsiella that was sensitive to cefipime; the culture also grew
gram positive rods/gram positive cocci which did not speciate,
but was covered with a 14 day course of IV vancomycin and
cefipime. She tolerated this well with no signs of infection,
and her course was completed prior to discharge. As noted, CXR
demonstrated a LLL ? consolidation/pleural effusion with later
on CT chest/abd/pelvis was likely to be post-surgical changes,
which was stable, and not consistent with abscess or infection,
but more likely blood or serous fluid. As noted earlier, the
patient spiked a fever to 102F on [**2155-9-26**], with subsequent urine
and blood cultures; Her IV antibiotics were subsequently
discontinued, and Bactrim was started for a possible bacterial
UTI on repeat U/A. She remained on a three day course of bactrim
([**Date range (1) 55797**]) with no fever spikes, her Tmax reaching 100.9, and
upon discharge, was afebrile at 98F. Her foley was changed
weekly. While on the floor, the patient maintained excellent
O2sats on room air with no additional oxygen requirement.
Endo: the patient underwent routine fingersticks while on TPN
and tube feeds, and placed on RISS for goal <150. Her
fingersticks were generally within normal range throughout her
admission with very little requirement for insulin (110-140s).
Her FSBG values were within the 120-150s prior to discharge.
Psych: a psychiatry consult was placed on [**9-7**], in light of the
patient's intermittent cooperation with exam and poor oral
intake. At this time, pharmacologic therapy was deferred until
the patient was able to engage in discussion. Conclusions and
recommendations included that the patient was likely
experiencing an adjustment disorder with disturbance of emotion,
with the decreased capacity at the time to refuse medically
necessary treatment. Psychiatry was again re-consulted later
during her admission as her oral intake plateaued despite
encouragement from family and staff, with the recommendations at
the time to use haldol prn for any agitation, and to add remeron
which would help both her appetite and sleep. The patient
appeared less active while on this regimen, thus her remeron was
changed to celexa within the next few days. Ritalin was
suggested as an appetite stimulant, which was also added soon
thereafter with some improvement in both mood and appetite.
Nutrition: the patient was kept NPO status until a speech and
swallow evaluation on POD#2, which she passed. Recommendations
were implemented for nectar thick liquids/pureed solids, which
the patient tolerated. This was under 1:1 supervision, while
sitting upright to avoid aspiration. As described in the GI
section, the patient was later fed by tube feeds for a few days
before placement of a PICC for TPN while the family and team
discussed PEG placement, which she received the week of
discharge. She was fed via tube feeds, which were eventually
cycled at night, and encouraged to eat with appropriate
supplemental shakes. She tolerated both well prior to discharge.
Skin care: the patient was noted to have a sacral wound within
the first few post-operative days. A formal wound consult was
obtained on POD#4 which noted a 3.5cm x 2cm area on the left
sacrum with recommendations for wound care and frequent
repositioning as well as supportive nutrition and hydration.
These were implemented aggressively with frequent wound checks.
When transferred to the floor, the patient
was again evaluated by wound care, with noted increase over the
next few weeks of her sacral decubitus pressure ulcer, which
according to wound care was unstageable in that the wound could
not be staged since the depth could not be appreciated (covered
by eschar). It was thought that the progression of her ulcer was
mainly from poor nutritional status, which had been addressed
several times via several interventions; first by oral intake,
then dobhoff feeds, TPN via PICC, then ultimately a PEG
placement, which was agreed on by all parties. Her nutritional
labs demonstrated a poor state with albumin of 2.6-2.8 although
her iron studies were within relative normal range. Wound care
recommendations included off-loading pressure of the sacrum with
special pillows (RoHo cushion for 1/2 hour, twice daily), and
avoiding direct pressure on the area; frequent repositioning
(q1h) was also implemented, as well as mattress change to a
[**Doctor First Name **]-air step 1 bed. Her wound was dressed and cleansed daily,
and upon discharge was noted to be 10cm x 9.5cm with open area
measuring 8cm x 9.5cm. The base has mixed tissue 70 % black
eschar, 20% red yellow tissue, primarily on the right side, on
the right superior edge. There was some serous drainage from the
wound, and it did not appear infected.
Prophylaxis: the patient was started on protonix for GI ulcer
prophylaxis. She also received subcutaneous heparin throughout
her stay for DVT prophylaxis.
Medications on Admission:
lisinopril 20mg qd, pindolol 10mg [**Hospital1 **], simvastatin 40mg [**Last Name (LF) **], [**First Name3 (LF) **]
325mg qd,levothyroxine 25mcg qd, hydralazine 100mg tid
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
6. HydrALAzine 10 mg IV Q6H:PRN sbp>160
7. Pantoprazole 40 mg IV Q24H
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
15. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
16. gabapentin 250 mg/5 mL Solution Sig: One (1) PO TID (3
times a day).
17. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
18. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
20. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every [**2-26**]
hours as needed for fever/pain.
21. therapeutic multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for yeast.
23. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for pain .
Disp:*90 90* Refills:*0*
24. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
25. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
26. glucagon (human recombinant) 1 mg Recon Soln Sig: [**11-24**] Recon
Solns Injection Q15MIN () as needed for hypoglycemia protocol.
27. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-24**]
Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea.
28. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain.
29. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
30. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
31. 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.
32. 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.
33. loperamide 1 mg/5 mL Liquid Sig: One (1) PO BID (2 times a
day): discontinue if pt has constipation.
34. Insulin Sliding Scale
Insulin SC (per Insulin Flowsheet) Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
Instructons for NPO Patients: Evening Prior to
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 100% usual dose. Morning of
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 50% of usual dose; If on premix insulin
(e.g. 70/30, 75/25): take total number of AM units ordered,
divide by 3, and give that many units as NPH; If on sliding
scale of short acting insulin: administer according to HS
schedule. Hold all oral antidiabetic medications, and consider
sliding scale coverage; If appropriate, give IVF with dextrose
to prevent hypoglycemia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital for continuing medical care- [**Hospital1 **]
Discharge Diagnosis:
Hypertensive urgency with 5.9 cm thoracic aortic aneurysm with
pending rupture
hypertensive urgency with 5.9 cm thoracic aortic aneurysm with
pending rupture
Discharge Condition:
Mental status: alert, awake, oriented to person, place.
Appropriate responses, but withdrawn.
Ambulatory status: paraplegic @ T6. Able to actively move upper
extremity. Wheelchair bound.
Discharge Instructions:
You were admitted to the hospital with chest pressure and known
thoracic aortic aneurysm which on imaging was found to be close
to rupturing. Your blood pressure was found to be very high, and
was controlled with medications, both oral and through IV. A
scan of your chest and abdomen showed a pending rupture of your
aneurysm, thus you were consented for and explained the risks
and benefits of a thoracic endovascular aneurysm repair.
Unfortunately your course was complicated by a spinal cord
infarct at the thoracic level, which although small, is a known
complication of the procedure. Additional imaging and consult
from the Neurology service confirmed this with recommendations
to keep you on aspirin and plavix for at least three months. You
also developed a left sided stroke with resulting right upper
extremity paralysis, again confirmed with imaging and review by
the Neurology service; it was concluded this was likely a plaque
that had embolized from your arteries. Your left arm has
preserved function and strength, and you have been taught to use
this arm to reposition yourself while in bed and to stabilize
yourself. You will continue your aspirin and plavix for the next
2 months for stroke prevention, and you should remain on heparin
shots for the prevention of deep vein clots.
You worked with physical therapy regularly to get out of bed to
chair at least twice a day during your initial weeks out of the
intensive care unit. When your sacral decubitus ulcer, or
pressure ulcer along your 'tailbone' which was noted
peri-operatively, was found to get increase in size despite
wound care, dressing changes and cushions, you worked with PT
regularly to sit up in bed for 15-20 minutes and avoid prolonged
pressure on your sacrum. This was in accordance with wound care
recommendations which were implemented aggressively with wound
cleansing, protective barriers, and cushions as well as a more
pressure sensitive mattress bed. Despite these efforts, however,
your pressure ulcer continued to increase in size, largely due
to your nutritional status, which was addressed on the second
day after your surgery.
Regarding nutrition specifically, you maintained very poor
intake on thin liquids and ground solid foods. Because of this,
a feeding tube was placed, which was a temporary measure for
tube feeds. This was replaced by nutrition by IV or 'TPN' (total
parenteral nutrition) during the last week of your
hospitalization, then to a PEG ('G or 'gastric' tube) by your
consent and your family's consent. You are currently receiving
at least adequate nutrition for your body's needs, but there is
much more progress to be made for your nutritional health as it
relates to your overall well being, as well as energy and skin
integrity.
Your tube feeds will continue at your rehabilitation facility
and specific instructions on timing and rate of feeds will be
provided to your team.
Regarding your subsequent stroke you should stay on your aspirin
and plavix daily. You should continue doing exercises with your
right arm on a daily basis.
Bladder function: you will require a permanent foley to collect
your urine from your bladder. This should be changed every [**2-26**]
weeks in a sterile manner. You should follow-up with Dr. [**Last Name (STitle) **], a
urologist at [**Hospital3 **] regarding management of your foley.
Please refer to the follow-up section for details.
Bowel function: you had regular bowel movements upon discharge.
You should continue taking your laxative and stool softener
unless you have loose bowel movements or diarrhea. As mentioned
earlier, your tube feeds should continue and be cycled at night;
you are encouraged to eat soft solids and can drink thin
liquids.
Physical activity: you should continue using your left arm to
position yourself in bed and to reach for items. You should sit
up at the edge of bed with supervision for about 15 minutes a
day on a soft cushion. You should be getting out of bed to chair
once a day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 4120**] your foley placement on
[**2155-11-3**] at 2:30PM. You may call his office at
[**Telephone/Fax (1) 164**].
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2155-10-31**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2155-10-31**] 11:45
Completed by:[**2155-10-3**]
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"V10.87",
"496",
"V45.82",
"707.25",
"434.11",
"344.1",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.46",
"39.50",
"00.41",
"43.11",
"39.90",
"39.73",
"99.15",
"96.6",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
33982, 34079
|
8576, 29565
|
343, 1187
|
34286, 34286
|
4704, 8553
|
38514, 38995
|
3329, 3486
|
29787, 33959
|
34100, 34265
|
29591, 29764
|
34499, 38491
|
3501, 3882
|
242, 305
|
3898, 4685
|
1215, 2386
|
34301, 34475
|
2408, 3031
|
3047, 3313
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,325
| 137,772
|
22029
|
Discharge summary
|
report
|
Admission Date: [**2108-11-3**] Discharge Date: [**2108-11-19**]
Date of Birth: [**2041-8-12**] Sex: M
Service: MEDICINE
Allergies:
Naprosyn
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
abd pain and hematuria
Major Surgical or Invasive Procedure:
intubation
ERCP
History of Present Illness:
67 yo man with CLL found to have atypical lymphocytes at outside
hospital. Failed ERCP and MRCP for LFT's. Transfered here with
high LFT's low grade fever.
Past Medical History:
CLL
High Chol
HTN
Social History:
no tob
+ EtOH 7 beers per week
no IVDU
Family History:
CAD
MM
Physical Exam:
98.8 98 154/85 95%on 2L NC
sleepy
PERRL, icteric sclera
supple neck
CTAB
RRR occ ectopy, no murmur
abd obese distended
Ext- no c/c/e
Skin - vesicles diffusely over body consit with VZV
Pertinent Results:
[**2108-11-3**] 10:45PM GLUCOSE-105 UREA N-14 CREAT-0.6 SODIUM-122*
POTASSIUM-3.5 CHLORIDE-86* TOTAL CO2-28 ANION GAP-12
[**2108-11-3**] 10:45PM LIPASE-186*
[**2108-11-3**] 10:45PM ALT(SGPT)-666* AST(SGOT)-408* ALK PHOS-242*
AMYLASE-110* TOT BILI-7.3* DIR BILI-3.6* INDIR BIL-3.7
[**2108-11-3**] 10:45PM CALCIUM-7.7* PHOSPHATE-2.3* MAGNESIUM-1.9
[**2108-11-3**] 10:45PM HAPTOGLOB-46
[**2108-11-3**] 10:45PM TSH-2.1
[**2108-11-3**] 10:45PM NEUTS-10* BANDS-0 LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-85* METAS-0 MYELOS-0
[**2108-11-3**] 10:45PM WBC-49.8* RBC-4.92 HGB-15.7 HCT-41.8 MCV-85
MCH-31.9 MCHC-37.5* RDW-13.7
[**2108-11-3**] 10:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2108-11-3**] 10:45PM PLT SMR-VERY LOW PLT COUNT-60*
[**2108-11-3**] 10:45PM PT-12.9 PTT-28.9 INR(PT)-1.0
[**2108-11-3**] 10:45PM FIBRINOGE-301
Brief Hospital Course:
Resp Failure - required intubation wor worsening mental status
and failure to protect airway. Found to have inpaired
oxygenation. Asp pna vs ards. Mult sputums unremarcable for
organisms including AFB, fungi, and nocardia.
Fever - despite tx for zoster and resolution of his LFT;s pt
continued to spike fevers for his entire admission. All studies
including cx and CT did not reveal a secondary source.
SVT/Hemodynamic instability - possible infeciton of heart with
zoster. PT with many rhythms during stay including a-fib,
bigeminy, wide complex tach. Exacerbated by fevers.
Intermittent hypo and hyper tension. Amiodarone used with some
effect.
[**Name (NI) **] pt given 2 week course of acyclovir with resolution of
vesicles.
ARF - pt developed ATN likely due to hypotension.
Low Plt- ITP vs CLL = did not respond to single donor plts.
On [**11-18**] pt HR dropped below 100 and BP started to decrease <60
on max dose neosynephrine. Family decided not to add more
pressors. Priest called, pressors stopped and pt was extubated.
His HR trended down and he died. Time of death 11:35pm
[**2108-11-18**]. Family present, declined autopsy.
Medications on Admission:
leukeran
ci[rp
famotidine
folic acid
HCTZ
lopressor
oxycodone
prednisone
tylenol
dilaudid
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
CLL
zoster
repiratory failure
hemodynamic instability
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
|
[
"401.9",
"427.0",
"518.5",
"995.92",
"112.5",
"486",
"276.1",
"577.0",
"584.5",
"570",
"204.10",
"284.8",
"054.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"38.93",
"99.62",
"86.11",
"96.6",
"99.04",
"99.25",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
3096, 3105
|
1770, 2927
|
291, 308
|
3202, 3212
|
839, 1747
|
3265, 3272
|
609, 617
|
3067, 3073
|
3126, 3181
|
2953, 3044
|
3236, 3242
|
632, 820
|
229, 253
|
336, 495
|
517, 537
|
553, 593
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,425
| 109,321
|
45914
|
Discharge summary
|
report
|
Admission Date: [**2119-7-24**] Discharge Date: [**2119-8-1**]
Date of Birth: [**2056-10-16**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Shellfish / OxyContin / Codeine
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 20893**] is a 62 y/o female with a history of breast cancer,
lung cancer and tracheal cancer (currently being treated with
chemo and radiation), and hypertension who presented with a 5
day history of nausea, vomiting a poor PO intake. She notes that
after her radiation therapy on Thursday she developed
progressive nausea with vomiting daily. She notes that this is
not her first cylce of radiation and that she typically gets
nauseated after her radiation. Due to persistent nausea and
vomiting she presented to the ED.
.
In the ED inital vitals were, 98.6 82 132/105 16 99% RA. She was
noted to have heart rate in the 180's and after a few doses of
IV diltiazem she was started on a dilt drip. She was
hemodynamically stable during this. She was transferred to the
ICU with a HR in the 130's.
.
Upon arrival to ICU, she noted that she was doing well however
was having significant throat pain. She denied any
lightheadedness or chest pain. She was asking for her pain
medications but was asking for food.
Past Medical History:
- Hypertension
- Asthma
- Breast Cancer [**1-/2103**]
- Depression
- Hyperlipidemia
- Rheumatoid arthritis
- Osteoarthritis
- bilateral carpal tunnel syndrome w/ hand weakness
- spondylolisthesis of L4-5, radiculopathy w/stenosis
- Right total shoulder arthroplasty [**10/2114**]
- Right total knee arthroplasty
- Left shoulder replacement
- Lung cancer s/p lobectomy
- Fibromyalgia
Social History:
Lives by herself, but has a lot of support from her children and
grandchildren. Her husband was in a coma/vegetative state since
a car accident in [**2099**], died one month age 8/[**2118**]. She smokes 4
years +, but denies alcohol or illicit drug use.
Family History:
No brothers and sisters.
Father died of pneumonia.
Mother with breast cancer; died of MI (first MI at age 24)
Daughter with metastatic breast cancer
Physical Exam:
ON ADMISSION:
Vitals:VITALS: Tm 97.7, 159/69, 91, 18, 98-100%RA
PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, scant hair
regrowth
Neck: supple, no JVD, no LAD, radiation burns scattered on chest
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate/rhythm, normal S1 + S2
Abdomen: soft, non-tender, mildly distended, bowel sounds (+),
no rebound or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
ON DISCHARGE:
VITALS: 97.7-98.2, 144-148/81, 90, 18, 96-100%RA
I/O: 980 + [**Telephone/Fax (1) 97782**] (diarrhea X 1)
PHYSICAL EXAM:
General: Alert, oriented X 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, scant hair
regrowth
Neck: supple, no JVD, no LAD, radiation burns on chest
Lungs: wheezes bilaterally, decreased BS posteriorly in bases
CV: Regular rate/rhythm, normal S1 + S2
Abdomen: soft, non-tender, distended, bowel sounds (+), no
rebound or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS ON ADMISSION:
[**2119-7-24**] 12:15PM BLOOD WBC-1.8* RBC-2.62* Hgb-9.4* Hct-26.9*
MCV-103* MCH-35.9* MCHC-34.9 RDW-14.1 Plt Ct-159
[**2119-7-24**] 12:15PM BLOOD Neuts-86.5* Lymphs-9.8* Monos-3.1 Eos-0.2
Baso-0.4
[**2119-7-24**] 12:15PM BLOOD Glucose-108* UreaN-24* Creat-1.0 Na-136
K-4.3 Cl-101 HCO3-18* AnGap-21*
[**2119-7-24**] 12:15PM BLOOD ALT-188* AST-116* AlkPhos-46 TotBili-0.5
[**2119-7-24**] 12:15PM BLOOD Lipase-59
[**2119-7-24**] 12:15PM BLOOD cTropnT-<0.01
[**2119-7-24**] 12:15PM BLOOD Albumin-3.6 Calcium-7.6* Phos-2.9 Mg-1.3*
[**2119-7-24**] 12:15PM BLOOD TSH-0.19*
[**2119-7-25**] 04:02AM BLOOD Free T4-1.3
[**2119-7-24**] 12:26PM BLOOD Lactate-1.9 K-4.0
.
LABS ON DISCHARGE:
[**2119-8-1**] 05:52AM BLOOD WBC-3.2*# RBC-2.57* Hgb-8.8* Hct-25.4*
MCV-99* MCH-34.3* MCHC-34.6 RDW-16.2* Plt Ct-120*
[**2119-8-1**] 05:52AM BLOOD Neuts-70 Bands-3 Lymphs-13* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-3* NRBC-8*
[**2119-8-1**] 05:52AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-1+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 16591**]1+
[**2119-7-31**] 06:03AM BLOOD Gran Ct-1290*
[**2119-7-31**] 06:03AM BLOOD Glucose-139* UreaN-25* Creat-0.9 Na-135
K-4.2 Cl-97 HCO3-32 AnGap-10
[**2119-7-31**] 06:03AM BLOOD Calcium-8.9 Phos-2.8# Mg-2.0
.
STUDIES & IMAGING OF INTEREST:
.
CTA [**2119-7-24**]: 1. No PE or acute aortic syndrome.
2. Diffuse full-length circumferential esophageal wall
thickening, likely
indicating esophagitis; however, of unknown etiology.
3. Tracheal abnormality previously noted is no longer present.
The lumen is
patent with no endoluminal lesions noted.
4. Dystrophic calcification in the right breast and fibrotic
changes in the
anterior right lung are stable and presumed related to prior
radiation.
5. Coronary artery disease and cardiomegaly.
6. Ovoid fluid collections around the urethra at the base of the
bladder.
These are stable since at least [**2117-3-19**] and may represent small
urethral
diverticulae. Correlate clinically.
7. Subacute vs. chronic ununited lateral right seventh rib
fracture.
.
ECHO [**2119-7-25**]: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild global left ventricular
hypokinesis (LVEF = 45 %). No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. with
normal free wall contractility. There is abnormal septal
motion/position. The diameters of aorta at the sinus, ascending
and arch levels are normal. There is no aortic valve stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CTA [**2119-7-29**]: 1. No pulmonary embolism or acute aortic
pathology. 2. Patchy opacities involving both lungs could
reflect edema given the relative rapid onset, but fulminant
pulmonary infection or toxicity from new medication should also
be considered.
Brief Hospital Course:
Ms. [**Known lastname 20893**] is a 62 y/o female with a history of breast cancer,
tracheal cancer and lung cancer (currenlty being treated with
chemo and radiation), and hypertension who presented with a 5
day history of nausea, vomiting a poor PO intake.
.
# Atrial Fibrillation: This appears to be new onset afib for
patient however she is asymptomatic with rapid heart rates. Her
CHADS score is 1 with hypertension. Precipitating factors
include volume depletion, infection and increased pain.
Echocardiography shopwd reduced EF of 45% with mild global
hypokensis consistent with cardiomyocte injury secondary to
hypotension. She was repleted with fluids. Her rate was
initially controlled on diltiazem; following spontaneous
cardioversion to sinus rhythem, she was transitioned first to PO
metoprolol, and then also her home medications lisinopril and
amlodipine. Due to low CHADS would not start coumadin for
anticoagulation, patient also noted to have an aspirin allergy.
.
# Nausea/Vomiting: The most likely etiology includes
chemotherapy and radiation. She notes that her symptoms came on
after her recent dose of radiation. Her nausea was controlled
with PRN ondansetron adn she was given fluids for rehydration;
and her appetite returned and nausea was well controlled.
.
# Metabolic Acidosis: She presented with anion gap metabolic
acidosis. The most likely source of her acidosis includes
ketoacidosis from starvation. Her lactic acid was noted to be
normal therefore less likely. Following fluid resuscitation, her
acidosis resolved.
.
# Tracheal Cancer/ throat pain: She is being treated as an
outpatient with chemo and radiation. She appears to be
tolerating her regimen well. XRT was held on [**2119-7-25**], but she
received XRT on [**2119-7-26**]. In addition she noted significant
throat/ epigastric pain, and had recently been noted to have
oral thrush. She was started on PO fluconazole as well and
nystatin and maalox/diphenhydrane/lidocaine mouthwash to treat a
candidal esophagitis. PEG tube placement was considered to aid
nutrition given the ongoing concern for throat paina nd poor PO
intake.
# Hypertension: Her blood pressure appears to be well controlled
on her current regimen. Due to possible volume depletion, would
introduce medications one at a time.
- continue Metoprolol for rate control
- will introduce lisinopril and amlodipine as BP improves
.
# Chronic Pain: She has chronic pain which is controlled on
narcotics. She was treated intially with IV morphine, and then
transitioned to PO MS Contin and oxycodone once she was able to
resume PO intake.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 solution inhaled every six (6) hours as needed
for asthma
ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler -
2
puffs q 4 hours as needed for asthma
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
BUDESONIDE - (Not Taking as Prescribed) - 0.5 mg/2 mL
Suspension
for Nebulization - 1 ampule twice a day
BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg
Tablet - 1 Tablet(s) by mouth once, may repeat in 1 hour as
needed for headache PLEASE DO NOT TAKE WITH OTHER
TYLENOL-CONTAINING PRODUCTS - No Substitution
CLOTRIMAZOLE - 1 % Cream - apply to affected area twice a day
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other
Provider)
- 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth
once a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays each nostril
[**Hospital1 **] x 5 days then once a day
FLUTICASONE-SALMETEROL [ADVAIR HFA] - 230 mcg-21 mcg/Actuation
Aerosol - 2 puffs [**Hospital1 **] with spacer
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day as
needed for swelling
INHALATIONAL SPACING DEVICE [AEROCHAMBER MAX WITH FLOW-VU] -
Spacer - as directed with inhalers twice a day
LEFLUNOMIDE - 20 mg Tablet - 20 mg Tablet(s) by mouth 1 qd
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - [**11-20**]
patches to affected area on for 12 hours, off for 12 hours
LIDOCAINE-HYDROCORTISONE AC [ANAMANTLE HC] - 0.5 %-3 % Cream -
Apply to perianal skin rectally twice daily.
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - apply to portacath 30
min prior to chemo appointment
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
MAALOX:BENADRYL:2%LIDOCAINE MIXTURE - (Prescribed by Other
Provider) - - Take One Tablespoon 15 Minutes before meals and
at bedtime as needed for as needed-[**Month (only) 116**] take an additional dose
each meal
METOPROLOL TARTRATE - 50 mg Tablet - 2 Tablet(s) by mouth three
times a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
MORPHINE - 15 mg Tablet Extended Release - 1 Tablet(s) by mouth
in the morning, 1 tab in the afternoon, and 2 in the evening
NYSTATIN - 100,000 unit/gram Powder - apply to affected area
after bathing once a day
NYSTATIN - 100,000 unit/gram Cream - apply to affected area
twice
a day
NYSTATIN - (Prescribed by Other Provider) - Dosage uncertain
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth three times
a day as needed for nausea
OXYCODONE-ACETAMINOPHEN [ROXICET] - 5 mg-325 mg Tablet - [**11-20**]
Tablet(s) by mouth every 4-6 hours. Not to exceed more than 11
pills in a 24 hour period.
POTASSIUM CHLORIDE - 10 mEq Capsule, Extended Release - 1
Capsule(s) by mouth twice a day as needed for when you take
Lasix
POTASSIUM CHLORIDE [KLOR-CON] - 25 mEq Packet - 1 Packet(s) by
mouth once a day while on lasix
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 10 mg Tablet - 2 Tablet(s) by mouth daily
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
up
to four times per day as needed for nausea
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet
- 2 Tablet(s) by mouth twice a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 inhaled QAM
VARENICLINE [CHANTIX STARTING MONTH PAK] - (Prescribed by Other
Provider) - 0.5 mg (11)-1 mg (3x14) Tablets, Dose Pack - 1
Tablets(s) by mouth Take as directed 0.5 mg ORALLY once daily
for
days 1 through 3, then 0.5 mg twice daily for days 4 through 7,
then 1 mg twice daily. (Not Taking as Prescribed)
.
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - 600 mg-400
unit Tablet - 1 Tablet(s) by mouth twice a day
CETIRIZINE - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - 400 unit Capsule - 2
Capsule(s) by mouth once a day pls dispense gel cap
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
four times a day
FOOD SUPPLEMENT, LACTOSE-FREE [BOOST] - Liquid - 1 can(s) by
mouth three times a day diagnosis: persistent anorexia and
weight
loss, recent lung surgery for lung cancer
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
NICOTINE - (Not Taking as Prescribed) - 7 mg/24 hour Patch 24
hr
- apply one patch daily
NICOTINE (POLACRILEX) - (Prescribed by Other Provider) - 2 mg
Lozenge - Take 1 lozenge up to 10 times daily as needed for
urges
to smoke (Not Taking as Prescribed)
NONI [**Doctor Last Name **] LIQUID - (OTC) - - 1 cup once a day
SENNOSIDES [SENNA] - 8.6 mg Capsule - 1 Capsule(s) by mouth four
times a day
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for asthma.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for swelling.
7. leflunomide 20 mg Tablet Sig: One (1) Tablet PO daily ().
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical ASDIR (AS DIRECTED) as needed for radiation therapy.
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 2.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*75 Tablet Extended Release 24 hr(s)* Refills:*1*
12. morphine 15 mg Tablet Extended Release Sig: [**11-20**] Tablet
Extended Releases PO twice a day: Take 1 tablet in the morning
and 2 tablets at night.
Disp:*112 Tablet Extended Release(s)* Refills:*0*
13. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO every 4-6 hours as needed for pain.
Disp:*560 ML(s)* Refills:*1*
14. prednisone 10 mg Tablet Sig: 1.5 Tablets PO once a day.
15. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
16. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice
a day.
17. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation QAM (once a day (in the morning)).
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
19. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for XRT burns.
20. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
21. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
22. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
23. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
24. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO QID (4
times a day).
25. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 syringes* Refills:*2*
26. heparin lock flush (porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
Disp:*30 syringes* Refills:*0*
27. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: [**11-20**] tbsp Mucous membrane every eight (8) hours as
needed for throat pain.
Disp:*450 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Tracheal Cancer
Atrial Fibrillation
Malnutrition
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 because you were feeling unwell and were found
to have a rapid heart rate. You were initially admitted to ICU
where you were given medication to help slow your heart rate.
You were then transferred to the oncology floor.
.
When you were on the floor, your port appeared malpositioned
which required removal and replacement of your port.
.
You were also started on TPN to help with your nutritional
status and will continue on this until you are instructed to do
so.
.
Lastly you completed your last treatments of radiation while you
were are in the hospital. You will need to follow up with them
as an outpatient.
.
The following changes were made to your medications:
-- STARTED Metoprolol SUCCINATE (Toprol) 100mg, take 2 and half
tablets a day
-- STOPPED Metorolol TARTRATE (Lopressor)
-- STARTED Roxicet 5/325mg, take 5-10mL every 4 to 6 hours as
needed for pain. Do not exceed 40mL per day.
--
Followup Instructions:
Please be sure to keep the following appointments:
Department: RHEUMATOLOGY
When: WEDNESDAY [**2119-8-2**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2119-8-3**] at 9:00 AM
With: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2119-8-8**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2119-8-5**]
|
[
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"E879.2",
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"942.04",
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"V10.11",
"530.81",
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"787.20",
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icd9cm
|
[
[
[]
]
] |
[
"99.15",
"92.29",
"86.07",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
16925, 16983
|
6625, 9228
|
320, 326
|
17076, 17076
|
3374, 3379
|
18200, 19259
|
2081, 2231
|
13884, 16902
|
17004, 17055
|
9254, 13861
|
17259, 18177
|
2917, 3355
|
2797, 2902
|
264, 282
|
4071, 6602
|
354, 1386
|
3393, 4052
|
17091, 17235
|
1408, 1792
|
1808, 2065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,318
| 139,859
|
29492
|
Discharge summary
|
report
|
Admission Date: [**2132-1-8**] Discharge Date: [**2132-1-11**]
Date of Birth: [**2073-6-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
coronary catheterization with drug eluting stent placement in
LAD
History of Present Illness:
The patient is a 58 year old male physician with history of
hypertension, mild chronic kidney disease (baseline Cr 1.5) no
known CAD who presents with sudden onset heavy substernal chest
pain that started at ~1am on the day of admission. He presented
to the [**Hospital1 18**] ED at 3:40am with 3/10 chest pain. The pain did not
radiate. His initial EKG showed ST elevations in V1-V4 with
inferior ST depressions. He received aspirin, plavix 600,
heparin and integrillin bolus and was taken emergently to the
cath [**Hospital1 **].
ROS: denies DOE, PND, orthopnea, SOB, edema, palpitations,
syncope, or presyncope. denies bloody or tarry stools
Past Medical History:
Hypertension
mild Chronic kidney disease (Cr baseline 1.5)
Social History:
patient is a urologist. he lives with his wife who is an
anesthesiologist. he denies cigarrette use. no etoh no illicit
drugs
Family History:
mother had an MI in her 60s
Physical Exam:
VS: Temp: BP: / HR: RR: O2sat
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
[**2132-1-8**] 03:50AM BLOOD WBC-8.0 RBC-4.15* Hgb-12.7* Hct-35.3*
MCV-85 MCH-30.7 MCHC-36.0* RDW-14.0 Plt Ct-179
[**2132-1-9**] 05:10AM BLOOD WBC-12.5* RBC-3.98* Hgb-12.0* Hct-33.5*
MCV-84 MCH-30.2 MCHC-35.9* RDW-14.2 Plt Ct-175
[**2132-1-11**] 06:20AM BLOOD WBC-9.3 RBC-3.90* Hgb-11.8* Hct-33.2*
MCV-85 MCH-30.3 MCHC-35.6* RDW-14.0 Plt Ct-152
[**2132-1-8**] 03:50AM BLOOD Neuts-46.9* Lymphs-45.2* Monos-5.6
Eos-1.7 Baso-0.6
[**2132-1-10**] 03:40PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Spheroc-1+
Ovalocy-1+ Schisto-OCCASIONAL
[**2132-1-8**] 03:50AM BLOOD PT-13.1 PTT-24.0 INR(PT)-1.1
[**2132-1-10**] 07:30AM BLOOD PT-14.7* PTT-83.5* INR(PT)-1.3*
[**2132-1-11**] 06:20AM BLOOD PT-14.0* PTT-25.5 INR(PT)-1.2*
[**2132-1-8**] 03:50AM BLOOD Glucose-170* UreaN-33* Creat-1.5* Na-139
K-4.0 Cl-109* HCO3-28 AnGap-6*
[**2132-1-8**] 08:48PM BLOOD Creat-1.3* K-3.8
[**2132-1-11**] 06:20AM BLOOD Glucose-110* UreaN-17 Creat-1.2 Na-139
K-4.0 Cl-101 HCO3-27 AnGap-15
[**2132-1-8**] 03:50AM BLOOD CK(CPK)-145
[**2132-1-8**] 06:52AM BLOOD CK(CPK)-3749*
[**2132-1-8**] 01:43PM BLOOD CK(CPK)-5188*
[**2132-1-8**] 08:48PM BLOOD CK(CPK)-4579*
[**2132-1-9**] 05:10AM BLOOD CK(CPK)-3587*
[**2132-1-8**] 03:50AM BLOOD CK-MB-5 cTropnT-<0.01
[**2132-1-8**] 06:52AM BLOOD CK-MB-330* MB Indx-8.8*
[**2132-1-8**] 01:43PM BLOOD CK-MB-GREATER TH cTropnT-17.34*
[**2132-1-8**] 08:48PM BLOOD CK-MB-291* MB Indx-6.4* cTropnT-14.78*
[**2132-1-9**] 05:10AM BLOOD CK-MB-137* MB Indx-3.8 cTropnT-12.38*
[**2132-1-8**] 03:50AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.1
[**2132-1-10**] 07:30AM BLOOD Calcium-8.6 Phos-1.7* Mg-2.0 Iron-19*
[**2132-1-10**] 07:30AM BLOOD calTIBC-218* Ferritn-436* TRF-168*
RENAL U/S:
The right kidney measures 10 cm, has a 6.4-cm cyst extending off
the upper pole. This has clear walls and no solid elements. The
renal parenchyma is well preserved throughout. There is no
hydronephrosis.
The left kidney shows moderate hydronephrosis. The renal
parenchyma is reasonably preserved suggesting some renal
function is still present. No stones are seen.
Arterial Doppler was performed on both kidneys. It was estimated
at between 0.66 and 0.59 on the left and 0.66 and 0.67 on the
right.
By history, the appearances of the kidneys are unchanged since
the prior ultrasound.
IMPRESSION: Hydronephrosis left kidney with good preservation of
renal parenchyma, normal right kidney with upper pole cyst.
PORTABLE AP CHEST: Heart size is borderline. The aorta is
tortuous. Lungs are clear. The pulmonary vasculature is not
engorged. There is no evidence of pneumothorax or pleural
effusion.
IMPRESSION: No evidence of acute cardiopulmonary process.
PTCA COMMENTS: Initial angiography revealed a 100%
proximally
occluded LAD that appeared acute with very faint collaterals to
the
septal perforators from the RCA. We planned to emergently PTCA
and
stent the LAD. Heparin and integrilin were used for IV
anticoagulation.
A 6F XBLAD3.5 guiding catheter provided good support. The
proximal LAD
occlusion was crossed easily with a Choice PT XS wire and
immediate
partial reperfusion was restored. The lesion was predilated
with a
2.0x20 mm Voyager balloon at 8 ATM with TIMI 2 flow restored. A
3.5x23
mm Cypher stent was deployed across the lesion at 16 ATM and
then
postdilated with a 4.0x13 mm Powersail balloon at 20 ATM. IC
Nitroglycerin and adenosine were given and normal flow in the
LAD was
restored. A small 1mm diagonal branch was jailed and partially
occluded
by the stent and could not be rescued. Final angiography
revealed 0%
residual stenosis, no dissection, and TIMI 3 flow.
CARDIAC CATHETERIZATION:
1). Successful emergency PTCA and stenting was performed of the
proximal
LAD occlusion with a 3.5x23 mm Cypher stent which was
postdilated to 4.0
mm. Final angiography revealed 0% residual stenosis, no
dissection, and
TIMI 3 flow. (see PTCA comments)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Acute anterior myocardial infarction, managed by acute ptca.
PTCA of proximal LAD vessel.
3. Successful PTCA and stenting of the proximal LAD with a drug
eluting
stent.
ECHOCARDIOGRAM/TTE:
Left Atrium - Long Axis Dimension: 4.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.2 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 40% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 0.83
Mitral Valve - E Wave Deceleration Time: 185 msec
INTERPRETATION:
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderately
depressed LVEF.
AORTA: Mildly dilated aortic root. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR. LV inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Overall left ventricular systolic
function is
moderately depressed. Mid and distal anterior and apical
akinesis and distal
septal hypokinesis are present.
3. The aortic root is mildly dilated.
4. The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
EKG: [**1-8**]
1. Sinus rhythm
2. Borderline first degree A-V delay
3. Anterior myocardial infarction with ST-T wave configuration
consistent with acute process
4. No previous tracing available for comparison
EKG: [**1-10**]
1. Sinus rhythm
2. Borderline first degree A-V delay
3. Probable left atrial abnormality
4. Anterior myocardial infarction with ST-T wave configuration
acute/recent/in evolution process
5. Since previous tracing of [**2132-1-9**], no significant change
Brief Hospital Course:
58-year old white male was immediately taken to cardiac
catheterization with intervention in the LAD, as noted above,
transferred to CCU for post-procedure stabilization, and
transferred to cardiology floor. Discharged in stable
condition.
1. CV:
Upon admission to [**Hospital1 18**], EKG showed acute st-elevations in the
anterior leads, initial troponins were negative. Due to high
suspicion of STEMI, patient was initiated on a heparin and
integrillin drips and the patient was emergently taken to the
cath [**Hospital1 **], where a 100% occlusion was found in the LAD and
successfully stented, please see note above. An echocardiogram
showed depressed systolic function with mid and distal anterior
and apical akinesis and distal septal hypokinesis. In the CCU,
patient remained in stable condition, with SBPs maintained
between 120 and 140 and HR in 70s/80s. On hospital day #2,
patient was transferred to the floor where he recovered well
with stable hemodynamics.
From a medication standpoint, patient was treated with 80mg of a
statin, aspirin 325mg, metoprol 25mg quid, plavix (post-cath)
150qd, and captopril, initally at 6.25 tid with uptitration to
12.5 tid. On day of discharge, patient's medication regimen
continued with the high dose statin, aspirin, toprolXL 100qd,
lisinopril 5mg qd.
2. HEME: Given risk for thrombus formation secondary to wall
akinesis, anticoagulation was continued with an INR goal of 1.6
to 2.0. On hospital day 2, pt was begun on a coumadin bridge.
Due to a small drop in hematocrit to 30, pt's anticoagulation
with held with a subsequent rise to 33 with stabilization by the
time of discharge. Patient's coumadin was re-initiated at 4mg
qhs, with a discharge INR of 1.3 Patient was given one dose of
80units SC lovenox prior to his discharge and given a
prescription for 80 units SC lovenox [**Hospital1 **] until early next week
after follow INR checks, which will be addressed by patient's
PCP. [**Name10 (NameIs) **] was also prescribed coumadin at 4mg qhs to be
taken daily with the lovenox.
On the day of discharge, patient had guiac (+), non-melanotic or
grossly bloody stool. Patient was also advised to have a
follow-up hematocrit check at the same time of his INR check on
[**1-14**].
3. PULM: patient's respiratory status was not an active issue
during his stay, as he did not require oxygen supplemenation and
did not acquire any shortness of breath upon exertion. Patient
was noted to intermittently have O2 sats in the mid 90s on room
air however.
4. RENAL: pt's admit Creatinine was 1.5 without evidence per
report or in the medical records available as to the source of
this elevation. A renal ultrasound was performed, see results
above, which showed no acute abnormality. Patient's urine
output remained adequate throughout his stay. On day #2,
patient's creatinine dropped to 1.2 and remained at this level
until discharge.
5. ID: On day #2, patient had a mild temperature elevation with
a mild leukocytosis, prompting a pan-culture. Empirically he
was initated on vancomycin and levofloxacin, with
discontinuation of levofloxacin after a CXR failed to show any
signs of pneumonia or infiltrate. A u/a was negative for
infection. Patient did not have any overt signs of a stool
infection and no signs of cdiff infection. His leukocytosis
stabilized and his temperature did not spike but he did have
periods of low grade temps. The pIV lines were removed
secondary to tenderness and possible cause of infection. Due to
low clinical suspicion of an active clinical infection, the
vancomycin was discontinued on day of discharge.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12 () for 5 days: First dose to be administered,
[**1-12**].
Disp:*10 syringe* Refills:*0*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily):
First dose to be administered [**1-12**], received dose on [**1-11**].
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
First dose to be administered on [**1-12**], first dose given on [**1-11**].
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
First dose in PM of [**1-11**].
Disp:*7 Tablet(s)* Refills:*2*
9. Outpatient [**Name (NI) **] Work
PT/INR and CBC check needed [**1-13**] or [**1-14**]. Please fax to Dr. [**Name (NI) 70774**] office - their office is expecting the results of this
test. Please also call pt at home to inform him of these
results so they can be addressed. Thank you.
Discharge Disposition:
Home
Discharge Diagnosis:
1. STEMI
2. Chronic kidney disease
3. Anemia
Discharge Condition:
stable. chest pain free. afebrile. stable vital signs.
tolerating oral medications and nutrition. ambulating well.
Discharge Instructions:
Patient is advised to continue all medications as prescribed.
Patient is advised to return to the ED if he acquires chest
pain, shortness of breath, nausea, vomiting, or pain that is out
of the ordinary for him.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2132-2-15**] 1:20
2. You will be speaking with Dr. [**Last Name (STitle) 66738**] on [**Last Name (STitle) 766**] concerning
your PT/INR and your CBC check. Please set up an appropriate
appointment at that time with him to address these issue. I
have spoken with Dr. [**Last Name (STitle) 66738**] about this plan, he agrees.
***Pt has been started on coumadin treatments for his depressed
ejection fraction on his echocardiogram secondary to his
myocardial infarction. Goal INR is 1.6-2.0. On day of
discharge, pt's INR was 1.3. Plan is to administer lovenox
80units sc prior to discharge and to write a prescription for
lovenox 80units SC bid, concurrently administered with warfarin
4mg qhs saturday, sunday, and [**Last Name (STitle) **]. Patient is given a PT/INR
prescription to be checked on [**Last Name (STitle) 766**], which has been explained
to him, and to which he and his wife agreed. The INR/PT results
are to be faxed to Dr.[**Name (NI) 70775**] office, the pt's PCP, [**Name10 (NameIs) 10139**] the
results return. Dr. [**Last Name (STitle) **] will then adjust the regimen of
anticoagulation as he deems clinically indicated ([**Telephone/Fax (1) 49449**]).
*** Also, pt's hematocrit initially had a small drop to 30, but
returned to 33 and was stable on two checks prior to discharge.
He was guiac positive on the day of discharge, but did not have
any overly bloodly stools or melanotic stools. He should also
have his hematocrit checked and followed-up by his PCP. [**Name10 (NameIs) **] PCP
should further [**Name9 (PRE) 8019**] possible sources of GI bleed - if his
hematocrit continues to fall by recheck on [**Name (NI) 766**], pt may need
to be readmitted for work-up of a GI bleed. Also, if pt
continues to bleed, risk vs. benefit of anticoagulation will
have to be evaluated with PCP.
|
[
"585.9",
"414.01",
"403.90",
"410.11",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"36.07",
"00.45",
"37.23",
"99.20",
"00.66",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
13542, 13548
|
8325, 11939
|
324, 392
|
13640, 13758
|
1958, 5855
|
14018, 15976
|
1313, 1342
|
11962, 13519
|
13569, 13619
|
5872, 8302
|
13782, 13995
|
1357, 1939
|
274, 286
|
420, 1070
|
1092, 1152
|
1168, 1297
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,321
| 158,991
|
7427+7428
|
Discharge summary
|
report+report
|
Admission Date: [**2126-12-4**] Discharge Date:
Date of Birth: [**2051-11-20**] Sex: M
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 75-year-old
male admitted to the Medical Intensive Care Unit on [**2126-12-24**] with the chief complaint of respiratory failure.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 27250**] is a 75-year-old
male with a prolonged hospitalization since [**2126-12-3**], when he was admitted with a subdural hematoma to the
Neurosurgery Service. He eventually required evacuation and
Coumadin reversal. Hospital course was complicated by
pneumothorax secondary to right subclavian line placement and
also continuous copious secretions requiring him to be
re-intubated and admitted to the Neurology SICU on [**2126-12-12**]. Chest tube was placed. The patient was extubated
on [**2126-12-16**]. The patient was sent to the floor with
oxygen provided by shovelmask and NG tube. The patient was
received tube feeds, awake and alert, doing quite well, but
failed speech and swallow assessment. On [**12-23**], he
was sent down to Interventional Radiology for percutaneous
enterogastric tube placement, left lying flat and became
hypoxic with respiratory decompression, thick tan secretions.
Chest x-ray was obtained, which was consistent with right
lower lobe collapse secondary to a right mainstem bronchus
mucous plug. The patient was then emergently reintubated on
[**2126-12-23**] at 5 p.m. The patient was stable on intermittent
mandatory ventilation overnight and switched on [**12-24**]
to minimal CPAP. Bronchoscopy on [**2126-12-23**], after
endotracheal tube placement, produced thick tan secretions on
the right. Hospital course was also complicated by rapid
atrial fibrillation. The Cardiology Service was consulted.
Echocardiogram was obtained and the patient was recommended
to be treated with Atenolol and Digoxin for rate control with
followup after admission discharge for stress testing and
possible discontinuation cardioversion on Amiodarone.
PAST MEDICAL HISTORY: Coronary artery disease status post
CABG times three with percutaneous transluminal coronary
angioplasty in [**2118**] Echocardiography [**2126-12-9**],
demonstrating EF of 20% with global hypokinesis and mild
valve disease. Carotid endarterectomy bilaterally in [**2118**].
Abdominal aortic aneurysm repair in [**2118**]. Chronic atrial
fibrillation on Coumadin anticoagulation. Transient ischemic
attack in [**2118**]. Seizure disorder. Prior subdural hematoma
in [**2119**]. Gastroesophageal reflux disease and peptic ulcer
disease. Chronic obstructive pulmonary disease.
MEDICATIONS ON TRANSFER TO THE MEDICAL ICU:
1. Zantac 50 mg t.i.d..
2. Zocor 50 mg per day.
3. Dilantin 200 mg t.i.d.
4. Atenolol 50 mg b.i.d.
5. Digoxin 125 mcg per day; tube feeds at 75 cc an hour.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives independently at home,
fully functional, prior to admission subdural hematoma,
x-smoker, quit 15 years ago.
REVIEW OF SYSTEMS: The patient was found to have a weak
cough, copious secretions in the past on prior
hospitalizations according to his son. There is no history
of wheezing, chest pain, edema, nausea, vomiting, low-grade
temperature at night. There was no headache, vision changes,
focal weakness.
On admission, physical examination revealed the following:
Temperature maximum 101.4, temperature current 100, blood
pressure 124/61, pulse 102, respiratory rate 9, tidal volume
700, oxygen saturation 100%. GENERAL: The patient opens his
eyes, responds, attempts to speak, follows complicated
commands. He was anicteric. PERRLA, EOMI, cranial nerves
symmetrical. There was no jugulovenous distention. CHEST:
Chest had decreased breath sounds anteriorly bilaterally.
HEART: Irregular. ABDOMEN: Soft, mild tenderness around
the PEG site, which was clean, dry, and intact. EXTREMITIES:
Pneumoboots in place, no edema, and warm. He had two
peripheral IVs on admission.
Chest x-ray: [**12-24**] at 8 a.m. revealed complete re-expansion
of the right lung, patchy opacity with air bronchograms in
the right lower lobe. [**12-23**] 5 p.m. revealed partial
re-expansion of right lung with endotracheal tube. [**12-23**] at 2
p.m. collapse of right lung with opacification of right
mainstem bronchus.
Admission CBC revealed the white blood cells 16.7, hematocrit
32.8, down from 36.7 on the day before, platelet count 388,
INR 1.2, PTT 28.5. Urinalysis was significant only for
moderate blood. Potassium was 4.3, creatinine 0.5, BUN 25.
Digoxin level was 0.7. Dilantin level was 15.2.
Admission blood gas revealed the pH of 7.42, PCO2 42, PO2
101, FIO2 .5, pressor support of 10, respiratory rate 9,
tidal volume of 700. Blood cultures were pending. Sputum
from [**12-23**], showed 3+ gram-positive cocci. Sputum
from [**12-9**] showed 2+ gram-negative rods consistent with
Serratia.
GENERAL: This is a 75-year-old male with a possible history
of COPD and repeated respiratory failure secondary to copious
sections and plugging exacerbated while laying flat, most
likely consistent with aspiration pneumonia, although
possible orthopnea secondary to congestive heart failure.
The patient had had minimal antibiotic therapy prior to
transfer to the Medical Intensive Care Unit despite
persistent purulent sections and new leukocytosis and fever,
apparently while awaiting culture and bronchoscopy results.
On admission to the ICU Medicine Service, the patient was
doing quite well as long as he was getting aggressive
suctioning requiring pressor support. It was decided that
the patient was likely extubatable, but past experience
suggested high risk of reintubation if the secretions do not
diminish.
ISSUES:
#1. SECRETIONS: Likely pneumonia. + or - aspiration with
gram-positive cocci in the sputum, but no further culture
data. The patient was initiated on Vancomycin, Ceftriaxone,
and Flagyl. PICC line consultation was obtained for
antibiotic therapy. Suctioning was continued every two hours
with chest PT. Endotracheal tube was maintained until the
night of [**2126-12-25**] when the patient extubated
himself. He exhibited a weak cough and maintained copious
secretions requiring suctions. On the 17th, his white count
on antibiotic therapy decreased to 7.6. The antibiotic
coverage was narrowed to p.o. Levofloxacin and Flagyl for
aspiration pneumonia for a 14-day course to end on [**2127-1-7**]. The patient remained stable until [**12-27**]
when the family was consulted and it was decided that given
the history of failure due to copious sections, the patient
would likely require reintubation at some point in the nature
future and that it was more desirable to have a percutaneous
tracheostomy placed in a controlled setting rather than have
to emergently reintubate the patient for respiratory arrest.
This was performed on [**12-27**] and the patient tolerated
the procedure well. The patient had some stridor post
procedure and chest x-ray indicated that his tracheostomy
tube placement was positional because of a tortuous trachea
that depended on the patient's position.
On [**12-29**], cultures returned from [**2126-12-23**]
demonstrating that the patient had methicillin resistant
Staphylococcus aureus in his sputum. Because of this
Vancomycin was added for a 14-day course and a peripherally
inserted central-venous catheter was inserted, on
[**12-31**] to facilitate access for IV antibiotics.
ISSUE #2: ASPIRATION: The patient had percutaneous
enterogastric tube place prior to transfer to the Medical
Intensive Care Unit. The patient was given nutrition via
tube feeds, based on nutrition consultation. Tube feeds, as
ordered by nutrition, were Promod with fibers with a goal of
75 cc per hour with residuals checked q.4h. and held for
residuals greater than 100 cc.
ISSUE #3: SUBDURAL HEMATOMA: This was stable on admission
to the Medical ICU from the Surgical ICU. The patient
remained alert and oriented during the rest of his hospital
course. The patient was continued without anticoagulation
due to risk of rebleeding from the subdural hematoma.
ISSUE #4: ATRIAL FIBRILLATION: The patient remained rate
controlled on Atenolol 75 mg b.i.d. and Digoxin .125 mg per
day. It is recommended that at some point he obtain a
cardiac stress test when his respiratory issues have
stabilized for risk for ischemic damage. The patient may
also consider having discontinued cardioversion for atrial
fibrillation electively as an outpatient. The patient was
discharged on [**2127-1-1**] to [**Hospital1 **]
[**Hospital **] Hospital in good condition tolerating a trach
mask and off the ventilator, but requiring suctioning every
two to four hours for his secretions. He is to continue
Flagyl and Levofloxacin through his G tube until [**2127-1-7**] and he is to continue Vancomycin IV until [**2127-1-13**].
DISCHARGE STATUS: Full code.
DIAGNOSIS:
1. Subdural hematoma.
2. Aspiration pneumonia.
DR. [**First Name (STitle) **]
Dictated By:[**Name8 (MD) 4430**]
MEDQUIST36
D: [**2126-12-31**] 14:47
T: [**2126-12-31**] 15:00
JOB#: [**Job Number **]
cc:[**Hospital1 27251**] Admission Date: [**2126-12-4**] Discharge Date: [**2127-1-3**]
Date of Birth: Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: This is a 75 year old white male
transferred from [**Hospital3 **] with a history of a recent
fall late on the evening of the [**2-2**], at which
time he landed on the back of his head with a report of a
loss of consciousness for an unknown period of time. The
patient reported that he awoke and noted he was still at home
and others took him to the Emergency Room. At the [**Hospital3 9683**], a CT scan was positive for a small subacute right
sided frontal parietal subdural hematoma with layered blood
posteriorly, which was felt to be new since the prior CT scan
done after a fall on [**2126-11-4**]. The patient was
therefore transferred to the [**Hospital1 188**] for further Neurosurgical assessment and a plan.
PAST MEDICAL HISTORY:
1. Recent history of falls.
2. History of unstable angina in the past.
3. History of chronic atrial fibrillation.
4. History of a transient ischemic attack in [**2118**].
5. History of peptic ulcer disease.
6. Gastroesophageal reflux disease.
7. History of chronic obstructive pulmonary disease.
8. History of seizure disorder status post an motor vehicle
accident in [**2119**].
PAST SURGICAL HISTORY:
1. History of three-vessel coronary artery disease status
post stent in [**2118**].
2. Bilateral carotid endarterectomies in [**2118**].
3. Abdominal aortic aneurysm repair in [**2118**].
4. Transurethral resection of the prostate in [**2117**].
5. Status post subdural hematoma secondary to motor vehicle
accident in [**2119**]. This reportedly was never evacuated and
after which he developed a seizure disorder.
ALLERGIES: He has no known drug allergies.
MEDICATIONS AT THE TIME OF ADMISSION:
1. Aspirin 1 p.o. q. day.
2. Dilantin 100 mg p.o. three times a day.
3. Imdur 30 mg p.o. q. day.
4. Atenolol 25 mg p.o. twice a day.
5. Zocor 20 mg p.o. q. day.
6. Coumadin, which was discontinued after the fall,[**2128**]8 hours
prior to admission.
7. Nitroglycerin p.r.n.
8. Sotalol 80 mg p.o. twice a day.
SOCIAL HISTORY: He reports he quit tobacco smoking 20 years
prior to admission. He denies the use of alcohol.
PHYSICAL EXAMINATION: On physical examination, he was an
elderly appearing white male seen while supine in bed, awake,
alert, confused, but knows his name and knew the day's date
but did not know the place or follow any simple commands very
well. He had a positive left upper extremity drift and the
pupils were equal, round and reactive to light and
accommodation. His extraocular movements are intact.
Peripheral field examination was inconsistent. He moved all
extremities. Strength was five over five in all groups.
There was a mild left pronator drift. The sensory
examination was intact but limited secondary to poor patient
compliance. On deep tendon reflexes the patient was tense in
all extremities and reflexes were unable to be obtained at
the time of examination due to increased tone. Plantar
responses were downgoing weakly bilaterally. The neck was
supple without nodes or adenopathy. The lungs were clear.
The heart showed an irregularly irregular rate and rhythm
consistent with atrial fibrillation. Abdominal examination
was soft and nontender, nondistended, and bowel sounds were
present in all four quadrants. Extremities were without
cyanosis, clubbing or edema. He was transferred to the
hospital with Venodyne on, so the Venodyne were present at
the time of examination.
LABORATORY: Review of the [**Hospital3 **] CT scan dated the
[**11-2**] revealed a subacute subdural hematoma of the
right frontal parietal area measuring approximately 2.1 cm
thick and approximately 6.0 cm long, along the right frontal
parietal area with a slight midline shift and preservation of
the [**Doctor Last Name 352**]-white junction and moderate widening and prominent
sulci on the left, which was consistent with long-standing
brain atrophy.
Coagulation studies at [**Hospital3 **] at 07:55 a.m. on the
[**2126-12-4**], were reported as a PT of 21, PTT 31.6
and an INR of 2.86.
HOSPITAL COURSE: Due to the clinical findings, the patient
was admitted to the hospital Neurosurgical Intensive Care
Unit and arrangements were made for INR to be corrected with
fresh frozen plasma urgently, with a goal to get the INR
below 1.3. A repeat CT scan was scheduled for the morning
and the patient was admitted to the hospital Neurosurgical
Intensive Care Unit.
Upon review with Dr. [**Last Name (STitle) 6910**], on the following day the
patient was felt to have a subdural hematoma with indication
for evacuation of the clot and due to the findings, the
patient was taken to the Operating Room where the patient
underwent a bur-hole drainage of the subdural hematoma with
placement of a subdural drain. The patient tolerated the
procedure well and was returned to the Neurosurgical
Intensive Care Unit in stable condition.
The patient's neurologic status improved moderately. He
still showed evidence of occasional confusion. Physical
examination was otherwise unchanged and the subdural drains
were removed on the second postoperative day after adequate
drainage and repeat CT scans confirmed a reasonably good
drainage.
The patient was subsequently transferred to the Floor,
however, due to an episode of respiratory distress while out
on the Medical-Surgical Floor, the patient was urgently
re-intubated and readmitted to the Neurosurgical Intensive
Care Unit. He was suctioned aggressively and found to have
multiple mucous plugs and tolerated this well. A chest x-ray
was obtained which showed a small pneumothorax. A chest tube
was placed by the Cardiothoracic Service and he was followed
in the Neurosurgical Intensive Care Unit for several more
days. The chest tube was subsequently removed.
The patient was returned again to the Medical-Surgical Floor
and did well for several days. He was subsequently
transferred to [**Hospital1 **] [**Hospital **] Hospital on
[**2127-1-3**], with follow-up to see Dr. [**Last Name (STitle) 6910**] in the
Clinic in several weeks' time.
CONDITION AT DISCHARGE: Stable and improved.
DISPOSITION: Discharge to the [**Hospital1 700**]
for aggressive Physical Therapy and Occupational [**Hospital **]
rehabilitation services as an inpatient.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2127-5-19**] 18:16
T: [**2127-5-22**] 12:59
JOB#: [**Job Number 16761**]
|
[
"507.0",
"496",
"852.20",
"518.81",
"780.39",
"512.1",
"E888.9",
"482.41",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"02.93",
"31.1",
"96.6",
"01.31",
"96.72",
"43.11",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
13424, 15426
|
10567, 11391
|
11527, 13406
|
15442, 15856
|
3080, 9381
|
9410, 10133
|
10155, 10544
|
11408, 11504
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,853
| 142,202
|
1394
|
Discharge summary
|
report
|
Admission Date: [**2199-4-2**] Discharge Date: [**2199-4-6**]
Date of Birth: [**2143-8-8**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
osteoarthritis right hip
Major Surgical or Invasive Procedure:
Right total hip replacement [**2199-4-2**]
History of Present Illness:
Pt with history of DJD right hip. She has failed conservative
management. The hip pain is interfering with her activities of
daily living. She presents now for operative management.
Past Medical History:
asthma,hemoglobin e trait,polyclonal IgG,lichen
amyloidosis,lupus anticoagulant
Social History:
vietnamese-speaking only
Family History:
n/c
Physical Exam:
On presentation:
NAD, A&O x 3
R hip with painful, limited ROM
neurovascularly intact distally RLE
Pertinent Results:
[**2199-4-2**] 07:15PM WBC-7.4 RBC-2.83*# HGB-7.6*# HCT-21.7*#
MCV-77* MCH-26.9* MCHC-35.2* RDW-14.0
[**2199-4-2**] 07:15PM PLT COUNT-111*
Brief Hospital Course:
On [**2199-4-2**] patient was brought to the operating room and
underwent right total hip replacement. The case was
uncomplicated. Please see Dr. [**Last Name (STitle) **] operative note for details.
Post-operatively, the patient was treated with 24 hours of
antibiotic for prophylaxis of infection. Lovenox was given for
DVT prophylaxis and TEDS and pneumoboots were used. The patient
was made WBAT on the operative extremity with posterior hip
precautions and physical therapy assisted with mobilization.
Home medications were restarted.
On POD#0 pt received 1u pRBC for Hct 21. Post tx Hct 25.6
On POD#1 a trigger event was called for chest pain. With
interpreter, chest pain was found to be pleuritic in nature and
gradually improving over time since surgery. EKG w/ nonspecific
changes anteriorly, BP 74/32, HR 65, T 99.6. Due to her
hypotension, pt was trasnferred to the ICU, & received 2u PRBC.
Hct improved to 27, VS improved, and she was transferred to the
orthopaedic floor less than 24 hours after admission.
On POD#2 2 additional trigger events were called for
asymptomatic hypotension. Pt was transfused 1 additional unit of
PRBCs. All narcotics were discontinued and tylenol 500mg q 4h
was started around the clock.
Prior to discharge the patient was afebrile with stable vital
signs. Hematocrit was stable and pain was adequately
controlled on a PO regimen. The operative extremity was
neurovascularly intact and the wound was benign. Patient was
discharged in stable condition.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): to prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 2 weeks.
Disp:*14 syringe* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Osteoarthritis
Discharge Condition:
Stable
Discharge Instructions:
Keep the incision/dressing clean and dry. Please apply a dry
sterile dressing daily as needed for drainage or comfort.
If you have any shortness of breath, new redness, increased
swelling, pain, or drainage, or have a temperature >101, please
call your doctor or go to the emergency room for evaluation.
You may bear weight on your right leg.
Please start all of the medications you took prior to your
admission. Take all medication as prescribed by your doctor.
Continue your Lovenox injections as prescribed to help prevent
blood clots. Then take an aspirin daily to help prevent blood
clots.
Feel free to call our office with any questions or concerns.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Partial weight bearing
Left lower extremity: Full weight bearing
Treatments Frequency:
Your skin staples may be removed 2 weeks after your surgery.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2199-4-19**]
2:00
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2199-5-21**] 10:40
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2199-5-21**] 11:00
|
[
"282.49",
"493.90",
"715.35",
"277.30",
"285.1",
"289.81",
"276.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2911, 2969
|
1061, 2568
|
339, 384
|
3028, 3037
|
894, 1038
|
3968, 4357
|
756, 761
|
2623, 2888
|
2990, 3007
|
2594, 2600
|
3061, 3717
|
776, 875
|
3735, 3860
|
3882, 3945
|
275, 301
|
412, 595
|
617, 698
|
714, 740
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,270
| 187,707
|
34487
|
Discharge summary
|
report
|
Admission Date: [**2198-9-17**] Discharge Date: [**2198-9-23**]
Date of Birth: [**2121-10-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
intraabdominal free air
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76-year-old female found down at home yesterday by family with
altered
mental status, brought to [**Hospital 1562**] hospital where noted to be
coagulopathic (INR > 9) and in rhabdomyolosis. Found to have
UTI. Admitted to
medical ICU, where imaging work-up ultimately revealed
significant pneumoperitoneum. In light of h/o PE/DVT,
coagulopathy, and possible need for exploratory laparotomy and
IVC filter, pt transferred morning of [**2198-9-17**] [**Hospital1 18**] for further
management. Per report, pt has been hemodynamically stable
throughtout her hospital course. Given 6u FFP and 10mg Vit K
overnight with subsequent improvement in INR to 1.8.
On interview, pt with little recall of events yesterday.
Admits to confusion pre-hospitalization but denies being found
'down'. Pt denies abdominal pain, chest pain, fever/chills,
SOB.
By report significant stooling, loose, prompting placement of
flexiseal rectal tube.
Past Medical History:
PMH: DM 2, HTN, hypothyroid, morbid obesity, cellulitis for LE
ulcers, PE/DVT
PSH: ectopic pregnancy (remote)
Social History:
Lives at home essentially alone, with help from neighbor.
Grandchildren visit regularly, denies tobacco and EtOH. Says she
does most of the cooking.
Family History:
FH: Mother dead from CAD, father with DM, sister with [**Name (NI) 11964**]
Physical Exam:
Initial:
PE: 99.0, 84, 138/61, 18, 97 on RA
A&Ox3. NAD. morbidly obese and hirsute
CTAB
RRR no M/R/G
soft, NT, ND. well-healed lower midline scar. absent BS.
BL LE with exophytic ulcers, 1+ edema
DP pulses triphasic
Foley with clear light-yellow, rectal tube with brown liquid
Pertinent Results:
Initial:
Labs:
CBC: 7.5 / 29.5 / 167
149 115 69 142
4.1 28 1.7
Ca: 8.5 Mg: 2.2 P: 2.2
ALT: 22 AP: 68 Tbili: 0.4 Alb: 3.1
AST: 58 LDH: 261 Dbili: TProt:
[**Doctor First Name **]: Pnd Lip: Pnd
CK: 2738 MB: 14 MBI: 0.5
PT: 18.9 PTT: 32.4 INR: 1.7
CXR [**9-16**]: free air beneath diaphragm
Chest CT: normal chest
Abd CT: pneumoperitoneum diffusely with diverticulosis
(non-contrast)
Most recent:
WBC 8.2, Hct 28.4, plts 191
Na 141, K 4.1, Cl 103, HCO3 32, BUN 28, Cr 1.3, gluco 170
INR 1.7
Chest CT.
Brief Hospital Course:
The patient was admitted to MICU East for close observation.
She had an abdominal pelvic CT scan which showed no active leak
of oral contrast, and the surgery team concluded that there was
no active bowel or intraperitoneal leak requiring surgery.
Serial exams revealed a completely benign abdomen in a patient
who maintained that she had no complaints. After a 24-hour stay
in the ICU, she was transferred to the floor.
On HD#2, she received a dose of warfarin to restart her
anticoagulation for her pulmonary embolism/DVT treatments. She
had an episode of hemoptysis x 1 (30cc) overnight, but remained
hemodynamically stable without complaints.
On HD#3, she was transferred to the Hospitalist East service due
to the fact that she still had ongoing issues of needing to be
anticoagulated, and acute-on-chronic renal failure.
Overall, the surgery service concluded that there was no acute
reason for surgical exploration, and she was transferred to the
medical service.
Medical Issues addressed during admission:
1. Rhabodmyolysis. She was admitted with elevated CK, and was
rehydrated. CK improved, and she had improvement in her renal
failure with hydration. Most recent CK 254.
2. Acute renal failure. She was admitted with acute on chronic
renal failure, with Cr 2.2. She was hydrated, her lasix was
held, as was her lisinopril, and her Cr returned to baseline
1.2. She was also hypernatremic in the setting of dehydration,
and was hydrated with free water with improvement.
3. Hemoptysis. She did have small volume of blood tinged
sputum. Given hx of PEs, she underwent CT scan which ruled out
large central PE. This did show interstitial changes, possibly
post infections or reflecting interstitial lung disease. This
was also thought to possibly reflect CHF. She will need follow
up imaging in [**7-15**] weeks.
4. Mild CHF exacerbation, likely diastolic, but unknown EF.
She received a single dose of IV lasix, and then was
transitioned back to oral lasix.
5. Hx of pulmonary emboli. Due to concern for free air under
diaphragm, and pneumo peritoneum, her anticoagulation was
reversed. She was restarted on coumadin on [**9-18**], and her most
recent INR was 2.2. Due to small volume hemoptysis, as well as
questionable abdominal event, she was not started on a heparin
drip. She was over 1 year out from her PEs as well and was
relatively stable from this perspective.
6. Chronic venous stasis with ulcers. She was seen by the
wound clinic and had wound care and ace bandaging of her LE with
improvement in her edema.
7. IDDM. She was restarted on her standing insulin once she
was taking a PO diet, and had good sugar control on a diabetic
diet.
8. Hypertension. Well controlled on home dose of lisinopril.
9. Morbid obesity with deconditioning. She worked with PT but
was found to be significantly below her baseline. She was
transferred to rehabilitation for strengthening and eventual
return home.
OUTSTANDING ISSUES:
She had an abnormal chest CT, and will need this repeated.
She is on coumadin, and has been loaded to elevate her INR, her
appropriate daily dose has not yet been determined.
Medications on Admission:
[**Last Name (un) 1724**]: lisinopril 20', lipitor 10', lasix 20', levothyroxine 100',
insulin 70/30 24qam / 27qpm, detrol LA 4', coumadin
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day): Until INR > 2.
2. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: x 4 more days.
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous Before breakfast.
10. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Sliding
scale Subcutaneous QAC, HS.
11. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 15
units Subcutaneous before dinner.
Discharge Disposition:
Extended Care
Facility:
Cape Code Nursing & Rehabilitation Center - [**Location (un) 10072**]
Discharge Diagnosis:
Free air under diaphragm.
Rhabdomyolysis.
UTI.
Acute Renal failure.
Stage II chronic kidney disease.
Hemoptysis.
Morbid obesity.
Chronic venous stasis ulcers.
Mild diastolic CHF exacerbation.
Insulin dependent diabetes mellitus.
Discharge Condition:
Good.
Discharge Instructions:
You were admitted after you were found in your house unable to
communicate. At the hospital in [**Hospital1 1562**], they found air in
your abdomen, and they sent you to [**Hospital1 18**] for evaluation. You
had kidney problems and muscle breakdown, which are all better
now. You had a urinary tract infection which might have caused
all of these problems. [**Name (NI) **] also had some blood that you coughed
up, you had a chest CT to evlauation this.
You should return to the emergency room if you have abdominal
pain, worsening shortness of breath, coughing, or increased
weakness. Also, if you start coughing up blood or having bloody
stools.
Followup Instructions:
You should follow up with your primary care doctor in 2 weeks
after leaving rehabilitation.
You should have a repeat chest CT scan to evaluate for fluid or
other changes in the lungs in approximately 6-8 weeks.
|
[
"250.00",
"707.12",
"403.90",
"276.51",
"E934.2",
"244.9",
"V12.51",
"584.9",
"786.3",
"459.81",
"728.88",
"V58.61",
"276.0",
"278.01",
"585.2",
"790.92",
"428.0",
"428.31",
"349.82",
"568.89",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6922, 7018
|
2553, 5706
|
340, 346
|
7291, 7299
|
2017, 2530
|
8002, 8217
|
1625, 1703
|
5895, 6899
|
7039, 7270
|
5732, 5872
|
7323, 7979
|
1718, 1998
|
277, 302
|
374, 1309
|
1331, 1443
|
1459, 1609
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,397
| 124,514
|
16973
|
Discharge summary
|
report
|
Admission Date: [**2107-5-7**] Discharge Date: [**2107-5-13**]
Date of Birth: [**2052-11-4**] Sex: M
Service:
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Patient is a 54-year-old man
without significant past medical history, who presented to
[**Hospital6 1109**] with 11 hours of substernal chest
pressure, associated dyspnea, and diaphoresis. The patient
reports pain initially woke him from sleep at 3 am, then
waxed and waned throughout the day. Electrocardiogram on
presentation at [**Hospital1 **] showed normal sinus rhythm at 90
with 1-[**Street Address(2) 1755**] elevations V1 through V4, 1-2 mm depressions
in II, III, and aVF. The patient was given aspirin, and
Heparin, Integrilin, IV Lopressor, and transferred to [**Hospital1 1444**] for cardiac catheterization.
Cardiac catheterization demonstrated left main circumflex
with disease. LAD total occlusion proximally. RCA 40% mid.
Underwent primary PCI with stent to the LAD, and left with a
90% untreated left circumflex lesion. PA pressure is 38/17
with a wedge of 18. Patient tolerated the procedure well.
Angio-Seal placed. He was transferred to the Cardiac Care
Unit to await further treatment of his left circumflex
region.
PAST MEDICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: None.
FAMILY HISTORY: No coronary artery disease.
SOCIAL HISTORY: No tobacco and no alcohol. He lives alone.
OCCUPATION: Traveling for car racing events.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.3, blood
pressure 148/86, pulse 87, respirations 21, O2 saturation is
97%. General: Obese man in no acute distress. HEENT:
Normocephalic, atraumatic. Extraocular movements are intact.
Pupils are equal, round, and reactive to light. Moist
membranes. Lungs are clear to auscultation anteriorly.
Heart: Regular, rate, and rhythm, no murmur. Abdomen is
soft, nontender, nondistended. Extremities: 2+ dorsalis
pedis pulses bilaterally. Right groin with pressure dressing
intact. No hematoma. Neurologic: Alert, oriented, and
appropriate.
LABORATORIES: White count 9.5, hematocrit 41.8, platelets
210. INR 1.5, PT 15.1, PTT 124. Chemistry: Sodium 138,
potassium 4.0, chloride 101, bicarb 22, BUN 11, creatinine
0.8, glucose 134.
ELECTROCARDIOGRAM: Normal sinus rhythm at 77, ST elevation 1
through 5 mm V1 through V3, normal limit intervals.
HOSPITAL COURSE: 1. Patient was status post stent placement,
who is maintained on Integrilin x18 hours. Will continue
Plavix therapy x9 months as well as daily aspirin
indefinitely.
On [**2107-5-9**], the patient returned to Cardiac Catheterization
Laboratory for successful stent of his left circumflex
lesion. The patient was maintained on anticoagulation
therapy. He was maintained on aspirin, Toprol XL, and ACE
inhibitor. The patient initially refused treatment with
lipid-lowering medications secondary to concerns about
interactions between lipid-lowering medications and alcohol.
Risks and benefits were explained daily and at time of
discharge, patient did agree to therapy with statin as well
as limiting his alcohol intake.
Patient underwent echocardiogram, which demonstrated an
ejection fraction of 35%. Given his large MI and depressed
ejection fraction, Coumadin therapy was initiated for
duration of likely 3-6 months with repeat echocardiogram to
be performed in [**4-10**] weeks. It is recommended that the
patient continue on IV Heparin until his Coumadin therapy was
therapeutic, however, the patient refused to continue IV
Heparin therapy. Therefore, he was treated with Lovenox
shots while hospitalized until his Coumadin therapy was
titrated and INR therapeutic.
2. Neuropsych: Patient with significant anxiety and
agitation surrounding his new diagnosis. Attention was
placed on the risks and benefits of therapy and importance of
compliance given his new diagnosis.
Patient's followup was scheduled with his primary care
physician, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Monday [**5-16**] at 11:30 am as well as
his cardiologist, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 46008**] on [**6-1**] at 11:45 am.
Follow-up care discussed carefully with patient as well as
his companion.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Myocardial infarction.
3. Stent placement in the left anterior descending artery and
left circumflex arteries.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q day.
2. Plavix 75 mg po q day x9 months.
3. Lipitor 10 mg po q day.
4. Toprol XL 100 mg po q day.
5. Lisinopril 5 mg po q day.
6. Protonix 40 mg po q day.
7. Warfarin with next INR check to occur three days after
discharge.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2107-7-10**] 15:24
T: [**2107-7-14**] 08:35
JOB#: [**Job Number 47758**]
|
[
"410.11",
"414.01",
"300.00",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"36.06",
"36.07",
"88.56",
"36.01",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
4454, 4461
|
1349, 1378
|
4289, 4432
|
4484, 5006
|
2415, 4268
|
1325, 1332
|
1510, 2397
|
144, 157
|
186, 1235
|
1258, 1303
|
1395, 1487
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,600
| 120,441
|
18437+18438
|
Discharge summary
|
report+report
|
Admission Date: [**2152-12-3**] Discharge Date: [**2153-1-2**]
Date of Birth: [**2098-2-7**] Sex: M
Service: Medicine
CHIEF COMPLAINT: Acute and chronic renal failure
HISTORY OF PRESENT ILLNESS: This is a 54 year old male with
Type 2 diabetes and aortic valve endocarditis secondary to
bacteremia and foot ulcer, complicated by a left MCA, septic
cerebrovascular accident and left hip septic arthritis,
status post hardware removal on [**2152-10-28**], status
post one month of Ceftriaxone via right PICC completed
[**11-27**]. He has been at [**Location (un) 582**] for
rehabilitation/assistant with activities of daily living.
The patient is NPO, has gastrostomy tube and expressive
aphasia. Able to answer yes/no questions and needs
assistance with activities of daily living. He was
discontinued from rehabilitation from [**Hospital6 1130**] on [**12-10**], after hardware removal with
hematocrit of 27.4, creatinine 2.2. Initial laboratory data
at [**Location (un) 582**] showed creatinine 1.6. Initially he did well but
then he was increasingly weak and laboratory data checked
there showed creatinine of 2.4. He was sent to [**Hospital6 2121**] where his liver function tests were within
normal limits, creatinine was 2.4 and he was guaiac negative.
He was hydrated and a renal ultrasound on [**11-27**] showed a
1.4 cm right renal mass, no hydro, normal-sized kidneys. He
was diagnosed with prerenal disease and discharged back to
rehabilitation. He was persistently weak, short of breath
and agitated, [**First Name8 (NamePattern2) **] [**Location (un) 582**] followed his BUN and creatinine over
the next few days. His creatinine was found to be 3.5 one
day and the patient was sent to [**Hospital6 1130**] but developed chest pain on route, so he was
diverted to [**Hospital1 **] [**Last Name (Titles) **]. There, he was noted to be
tachypneic, acidotic, afebrile and with no electrocardiogram
changes. Chest x-ray was concerning for mild congestive
heart failure. He was admitted to the Medicine Intensive
Care Unit on admission with blood pressure systolic in the
90s, bicarbonate of 13.
PAST MEDICAL HISTORY:
1. Type 2 diabetes, baseline creatinine 1.6.
2. Hypertension.
3. Gastritis.
4. History of alcoholism.
5. Chronic renal insufficiency.
6. Status post appendectomy.
7. Foot ulcer complicated by bacteremia, complicated by
Group B Streptococcus
8. Aortic valve endocarditis complicated by left MCA, septic
cerebrovascular accident in [**2152-6-15**] with residual right
hemiparesis and expressive aphasia.
9. Left hip open reduction and internal fixation seated,
leading to septic arthritis, status post hardware removal
[**2152-10-27**], at [**Hospital6 1129**].
MEDICATIONS ON ADMISSION:
1. RISS
2. Prozac 20 q.d.
3. Zantac 150 q.d.
4. Atrovent nebulizers
5. Lopressor 25 mg p.o. b.i.d.
6. PhosLo
7. Subcutaneous heparin
8. Colace
9. Folate/multivitamin/Vitamin B1
10. Remeron 30 mg q.h.s.
11. Senna
12. Reglan
13. Vicodin
14. Bowel regimen
15. Completed one month of Ceftriaxone 2 gm p.o. q.d.
ALLERGIES: Penicillin, unknown reaction.
SOCIAL HISTORY: Lives at [**Hospital 582**] Rehabilitation. Patient is
full code. Has brother, [**Name (NI) 2174**], who can be reached at
[**Telephone/Fax (1) 50730**].
PHYSICAL EXAMINATION ON ADMISSION: General: Chronically
ill, cachectic, no jaundice. Pale. Vital signs with
temperature of 97. Pulse 83 to 85. Blood pressure 99/32.
Respirations 18. Oxygen saturation 100% no 4 liters of nasal
cannula. Head, eyes, ears, nose and throat: Pupils equal,
round and reactive to light, extraocular movements intact.
Moist mucous membranes. Pulmonary: Clear to auscultation
bilaterally. Cardiovascular: Regular rate, normal point of
maximal impulse, III/VI systolic ejection murmur heard
loudest at apex. II/VI diastolic murmur. Abdomen: Soft,
nontender, nondistended, scaphoid, no hepatosplenomegaly. No
costovertebral angle tenderness. Normal bowel sounds.
Gastrostomy tube site intact. Extremities, no cyanosis,
clubbing or edema. 2+ left radial and trace right radial
pulses. Neurological: Intermittently awake, increased tone
on right. No asterixes.
LABORATORY DATA: Laboratory data at outside hospital
revealed white count 23.5, hematocrit 22.5, platelets 130.
Chemistry is notable for potassium 6.7, creatinine 4.1,
lactate 10.4.
HOSPITAL COURSE: 1. Cardiovascular - His MICU course was
notable for repeat transthoracic echocardiogram which showed
left ventricular ejection fraction of 35%. He had a troponin
leak without increase in creatinine kinase or MB. There was
a small vegetation that was continued to be noted on his
aortic valve and he was continued on Levofloxacin, Flagyl and
Vancomycin to treat presumed sepsis/endocarditis. After
transfer out of the MICU, the patient then developed
worsening heart failure which lead him to be admitted into
the CCU. He then was transferred out of the CCU on [**12-23**], after attempts at aggressive diuresis with Lasix and
Thiazide diuretic. Attempts on the floor after [**12-23**],
with Lasix at an increased dose, Aldactone and Natrecor were
unsuccessful. At the time of this dictation, low dose
Dopamine was considered to improve diuresis for the patient's
worsening congestive heart failure, anasarca and pulmonary
effusion. Despite all of these measures he continued to be
700 to 900 cc positive per day with increasing daily weights.
Congestive Heart Failure Service has been following him
during this admission. The patient was also noted in the CCU
to have moments of paroxysmal atrial fibrillation. He was
placed on beta blocker on transfer out of the CCU and when
started on Digoxin for his congestive heart failure to
improve contractions, he spontaneously converted to sinus and
has remained there at the time of this dictation. He is
still continue on low dose beta blocker at Lopressor 25 mg
b.i.d. We attempted to decrease afterload with low dose ACE
inhibitor, however, because his blood pressures remained very
low this was often held.
2. Infectious disease - The patient was initially on
multiple broad spectrum antibiotics early during his course
with the Infectious Disease Team following. Per Infectious
Disease Team, they believe that his vegetation which was
Group B Streptococcus had been already adequately treated.
However, during his admission he began to grow out
Vancomycin-resistant Enterococcus and despite weeks of
Ceftriaxone and Synercid, his blood cultures remained
positive. He had daily blood cultures drawn and was switched
to Linezolid after transfer out of the CCU on [**12-23**].
However, these sensitivities revealed that the pathogen was
sensitive to Synercid as well. He had a left PICC line in
which was pulled and the tip sent for culture, though the
culture was negative. Because of abdominal pain he had an
abdominal noncontrast computerized tomography scan which cut
through his left hip to evaluate for possible abscess/source
of persistent bacteremia. The scan, however, was negative.
He did have a gallium scan which showed increased uptake in
his left hip which suggested the team to call Orthopedics and
have the hip tapped. The left hip was drained under
fluoroscopy, however, the fluid was only remarkable for 1000
white blood cells, no organisms and culture was negative. At
the time of this dictation, cultures from [**12-27**] are
still negative and the patient has cultures pending from
[**12-29**] and [**12-30**] which are still negative. The
team had considered redoing a transesophageal echocardiogram
to evaluate for possible persistent valvular vegetation or
new vegetation to account for his persistent bacteremia,
however, given the sterile cultures since [**12-27**], the
team has held off on doing so. He will continue to be
treated with Linezolid and any further workup will be
repeated in a future discharge summary.
3. Chronic renal failure - The patient's creatinine
experience rises and falls, initially likely due to a
hypotension on admission. It had been stable for a few days
though at the time of this dictation creatinine is rising
into the 3.0 range. This is likely secondary to poor cardiac
output given the patient's 4+ aortic regurgitation on
transthoracic echocardiogram with resultant poor forward
flow. The patient also has very low albumin and thus has
intervascular volume depletion with total body volume
overload.
4. Heme - The patient was found to be anemic during
hospitalization but has been guaiac negative on several
occasions. This may be secondary to his renal
failure/chronic disease. He has had marked thrombocytopenia
with platelets in the 40s to 50s which has been worked up by
Hematology/Oncology extensively during the earlier part of
his hospitalization. This was thought to be secondary to
marrow dysfunction and DIC/HIT antibody was ruled negative.
5. Gastrointestinal - The patient was continued on
percutaneous endoscopic gastrostomy tube feeds and
intravenous proton pump inhibitors. His gastrostomy tube
clogged but was replaced on [**12-29**], and he received most
of his medications through this tube.
6. Diabetes 2 - The patient was started on NPH insulin 10
units q. AM and 10 units q. PM with coverage by regular
insulin sliding scale with good control of his blood sugar in
the mid 100s.
7. Clostridium difficile - The patient had constant watery
stools during admission secondary to tube feeds, however, he
was found to have Clostridium difficile sent for toxin assay
a few days prior to this dictation. He was started on Flagyl
500 mg b.i.d. with decrease in his abdominal pain but
continuation in watery stools.
8. Deep vein thrombosis - Because of the concern for
possible septic deep vein thrombosis as a source of his
consistent bacteremia, and right upper extremity edema,
greater than left, he was sent for a right upper extremity
deep vein thrombosis which showed an interluminal thrombus
extending from the junction of the right subclavian and right
brachiocephalic vein into the axillary vein. Thus, the
patient was started on heparin and received one dose of
Coumadin which was held in case he went for further
procedures.
9. Prophylaxis - The patient had proton pump inhibitors,
anticoagulation and pneuma boots.
10. Fluids, electrolytes and nutrition - The patient received
tube feeds and follow up electrolytes daily.
DISPOSITION: The patient stated full code status earlier
during admission, however, given the patient's deterioration
and lack of progress, after several weeks this admission, the
team may wish to address code status again with the patient
and his family.
This dictation is complete until [**2152-12-31**], any
further developments will be dictated in a future discharge
summary.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 1606**]
MEDQUIST36
D: [**2152-12-31**] 23:58
T: [**2153-1-2**] 08:34
RP: [**2153-1-4**]
JOB#: [**Job Number 50731**]
Admission Date: [**2152-12-3**] Discharge Date: [**2153-1-2**]
Date of Birth: [**2098-2-7**] Sex: M
Service:
DATE OF DEATH: [**2153-1-2**]
This is a discharge summary addendum summarizing events from
[**2153-1-1**] to [**2153-1-2**].
ADDENDUM: Over the course of [**2153-1-1**], the patient's
clinical status continued to deteriorate. As mentioned in
previous discharge summary, patient had a long and
complicated hospital course which began in [**6-/2152**] with AV
endocarditis. This was complicated by catastrophic CVA,
septic joint infection, destruction of the aortic valve, and
multiple infections and complications. Most recently,
patient had VRE bacteremia, subclavian venous thrombosis, and
decompensated heart failure, which lead to acute renal
failure, volume overload, acidosis, and finally respiratory
arrest on [**2153-1-2**]. From an ID standpoint, patient was
continued on linezolid and his [**2152-12-27**] cultures had no
growth to date, but it was still unclear if patient would be
able to proceed with valve surgery which would ultimately be
the therapy of choice, but with patient's poor clinical
status as well as his ongoing bacteremia, it was unclear if
patient could have surgery. He remained in very
decompensated CHF and failed many regimens including Lasix,
Natrecor, fluid challenge, etc. It was unclear what the next
course of action should be, given the fact of his rising
creatinine and his lack of renal perfusion. The only options
that remained include tailored therapy with an ionotrope, but
it was unclear what the endpoint would be with this type of
therapy or whether patient should have CVVH. His status
continued to decline and he became barely responsive on the
day of his death. He remained a full code until the day of
his death and his brother was his healthcare proxy in the
discussion that were made many times during his hospital
course about the patient's poor prognosis and the futility of
further interventions. On the day of his death, [**2153-1-2**],
his management was discussed with all of the consultants
involved, and it was determined there were no viable medical
or surgical options left for him. His brother and sister
were made aware and on [**2153-1-2**] at 4:30 p.m., the medicine
internist was called. The patient was unresponsive with O2
saturation of 50 percent. A code was called and the ICU and
CCU teams responded immediately. Patient still had a pulse,
normal sinus rhythm at 80 beats per minute. His ABG was 7.13
with a PAO2 of 64 and a PCO2 of 51. Patient was bagged and
then intubated, a repeat gas of 7.27, PCO2 of 30, and PAO2 of
124. The family was immediately notified and were present.
After intubation, the patient's family decided on extubation
at 5:00 p.m. to make the patient comfort measures only with a
morphine drip. At 6:10 p.m., the patient expired. Breath
sounds were absent, and the patient was without pulse. He
had no heart sounds. Pupils were nonreactive. Corneal
reflex was absent. He had no response to pain. [**Name (NI) **]
sister was present at his bedside. The attending, Dr.
[**Last Name (STitle) **] and admitting was notified. The patient's family
declined a postmortem exam.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Name8 (MD) 5706**]
MEDQUIST36
D: [**2153-7-17**] 13:10:24
T: [**2153-7-17**] 23:06:53
Job#: [**Job Number 50732**]
|
[
"570",
"585",
"421.0",
"008.45",
"038.9",
"428.0",
"287.5",
"584.9",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"88.72",
"96.6",
"34.91",
"38.93",
"97.02",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
2751, 3111
|
4392, 14551
|
152, 185
|
214, 2133
|
3321, 4374
|
2155, 2725
|
3128, 3306
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,241
| 126,220
|
28465
|
Discharge summary
|
report
|
Admission Date: [**2171-12-6**] Discharge Date: [**2171-12-13**]
Date of Birth: [**2098-4-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2171-12-6**] Ascending aorta and hemiarch replacement
History of Present Illness:
73 yo F with abdominal pain found to have AAA & TAAA. Referred
for surgical intervention.
Past Medical History:
Hypertension, Hyperparathyroidism, Gastroesophageal Reflux
Disease, WPW, SBO [**8-11**], Temporal arteritis, Hiatal hernia,
Osteoporosis, Nephrolithiasis, s/p L ureter surgery, s/p WPW
ablation [**2155**]/[**2157**]
Social History:
retired
lives with husband, daughter
quit [**Name2 (NI) **] [**2150**] (1 ppd x 15 years)
rare etoh
Family History:
NC
Physical Exam:
Gen: NAD, WDWN
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -bruit
Lungs: CTAB -w/r/r
Cardiac: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, minimal varicosities
Neuro: MAE, Non-focal, A&O x 3
Discharge
General no acute distress
Vitals SR 90, 106/55, rr 18 94% on ra, 97.0 F wt 58.3kg
Neuro a/o x3 non focal
Pulm: clear throughout but diminished at bilat bases
Cardiac RRR no murmur/rub/gallop
Sternal inc. no drainage, no erythema, steristrips, sternum
stable
Abd soft, nontender, nondistended, +BS, BM [**12-12**]
Ext warm pulses palpable, +1 LE edema
Left groin inc no erythema no drainage, steristrips
Pertinent Results:
Echo [**2171-12-6**]: Normal LV wall thicknesses and cavity size.
Markedly dilated ascending aorta. Mildly dilated descending
aorta. Simple atheroma in descending aorta. Mildly thickened
aortic valve leaflets (3). No AS. Mild(1+) AR. Mildly thickened
mitral valve leaflets. Mild to moderate ([**1-7**]+) MR. Mild to
moderate [[**1-7**]+] TR. Post- CPB: Preserved biventricular systolic
fxn. Trace/mild AI. Trace/mild MR. Proximal end of tube graft
well-seen on ascending aorta. Descending aorta intact.
CXR [**12-11**]: No significant abnormalities since the prior study of
[**2171-12-9**]. Specifically the pleural effusions, left greater
than right, are not significantly changed and there is no
evidence for CHF, pulmonary edema, or change in width of the
mediastinum.
[**2171-12-6**] 12:47PM BLOOD WBC-7.8 RBC-3.18* Hgb-8.6* Hct-24.7*
MCV-78* MCH-26.9*# MCHC-34.6 RDW-16.3*
[**2171-12-12**] 05:45AM BLOOD WBC-6.8 RBC-3.02* Hgb-8.2* Hct-23.8*
MCV-79* MCH-27.0 MCHC-34.3 RDW-19.7* Plt Ct-139*
[**2171-12-6**] 12:47PM BLOOD PT-18.1* PTT-55.6* INR(PT)-1.7*
[**2171-12-9**] 03:07AM BLOOD PT-12.3 PTT-28.8 INR(PT)-1.1
[**2171-12-6**] 02:00PM BLOOD UreaN-15 Creat-0.4 Cl-115* HCO3-20*
[**2171-12-12**] 05:45AM BLOOD Glucose-101 UreaN-17 Creat-0.5 Na-138
K-4.2 Cl-101 HCO3-29 AnGap-12
[**2171-12-12**] 05:45AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.1
[**2171-12-9**] 08:23PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
Brief Hospital Course:
She was taken to the operating room on [**2171-12-6**] where she
underwent a replacement of her ascending & hemiarch aorta with a
#28 gelweave graft. Please see opeartive report for surgical
details. She was transferred to the ICU in critical but stable
condition for invasive monitoring. She was extubated and weaned
from her vasoactive drips by POD #1. She was ready for transfer
to the floor on POD #2. Her chest tubes and epicardial pacing
wires were removed per protocol. Beta blockers and diuretics
were initiated and she was gently diuresed towards her pre-op
weight. A HIT panel was sent given her thrombocytopenia, but was
negative. And her platelet count improved. She continued to
improve post-operatively and worked with physical therapy for
strength and mobility. She was ready for discharge on post-op
day 7 with VNA and the appropriate follow-up appointments.
Medications on Admission:
actonel, atenolol, ecotrin, ketoprofen, zantac
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:*0*
2. 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*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Ascending aortic aneurysm s/p Asc. Aorta Replacement
PMH: Hypertension, Hyperparathyroidism, Gastroesophageal Reflux
Disease, WPW, SBO [**8-11**], Temporal arteritis, Hiatal hernia,
Osteoporosis, Nephrolithiasis, s/p L ureter surgery, s/p WPW
ablation [**2155**]/[**2157**]
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
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-8**] weeks ([**Telephone/Fax (1) 3183**]) please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2171-12-13**]
|
[
"530.81",
"252.00",
"443.29",
"272.4",
"401.9",
"441.2",
"733.00",
"287.5",
"426.7",
"V13.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"39.59",
"88.72",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
5420, 5467
|
2997, 3873
|
289, 347
|
5784, 5790
|
1508, 2974
|
6256, 6646
|
838, 842
|
3970, 5397
|
5488, 5763
|
3899, 3947
|
5814, 6233
|
857, 1489
|
235, 251
|
375, 466
|
488, 705
|
721, 822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,129
| 137,257
|
1398
|
Discharge summary
|
report
|
Admission Date: [**2178-1-29**] Discharge Date: [**2178-2-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
This is an 86M with hx of CLL who was recently admitted for a
pneumonia represents today with 2 weeks of SOB. The patient
denies any chest pain, n/v/d. He is unable to localize his
symptoms, but states that he has not been feeling well. Within
the past couple of days he has been started on home O2. He does
not recall what his O2 requirement or why it was Rx.
.
In the ED the patient's vitals were as follows: T 101.7, HR 100,
BP 109/62, O2 sat 98% on 6L. He received vancomycin, levaquin
and tylenol. A CXR was obtained which showed bilateral pleural
effusions, blunting of the lateral pleural sinuses and
increasing pleural effusion consistent with CHF.
.
Of note during his last admission ([**2178-1-9**] - [**2178-1-15**]) the patient
was treated for a pneumonia with Vancomycin/Levaquin. He was
scheduled to complete a 5 day course of Levaquin at discharge.
Sputum cultures were negative for growth. Prior to this
hospitalization the patient had been admitted for a legionella
pneumonia in [**9-10**].
Past Medical History:
--Acute rheumatic fever, which then required mitral valve
replacement (St. [**Male First Name (un) 1525**])
--CLL (dx [**2175**]/[**2176**])
--Three-vessel CABG for coronary artery disease
--Hyperlipidemia
--Skin cancer
--Thrush
--h/o CHF in setting of afib, last EF 40-45% in [**2176**]
--Anemia, BL Hct 24-30
--h/o afib in the setting of PNA [**9-10**]
--CRI--BL Cr 1.7-1.9
--h/o Legionella PNA [**9-10**]
--h/o prostate cancer
Social History:
The patient is a widower and former [**Company 378**] electronics mechanic. He
lives at [**Hospital3 **] here in [**Location (un) **]. He has three adult
children. He denies tobacco, alcohol, and IVDU.
Family History:
Non-contributory.
Physical Exam:
T98.2 HR85 BP 103/55 R35 100% on 3L
GEN: pleasant elderly Caucasian male using accessory muscles to
breath
HEENT: MM slightly dry, OP clear
HEART: irreg, S1S2, mitral valve click
LUNGS: crackles [**2-7**] way up, no wheezes
ABD: soft, round, no guarding, no rebound tenderness
EXT: 2+ DP, [**1-6**]+ pitting edema
Pertinent Results:
[**1-31**] CXR: Bilateral pleural effusions and edema. Right lower
lung
consolidation.
[**2178-1-29**] 12:00PM NEUTS-1* BANDS-0 LYMPHS-97* MONOS-1* EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2178-1-29**] 12:00PM WBC-64.3* RBC-2.55* HGB-8.9* HCT-27.0*
MCV-106* MCH-34.9* MCHC-33.0 RDW-21.9*
[**2178-1-29**] 12:00PM LACTATE-0.8
[**2178-1-29**] 12:00PM CALCIUM-9.5 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2178-1-29**] 12:00PM CK-MB-NotDone cTropnT-0.04* proBNP-[**Numeric Identifier 8418**]*
[**2178-1-29**] 12:00PM GLUCOSE-137* UREA N-34* CREAT-1.7* SODIUM-139
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14
Brief Hospital Course:
86M with CLL, admitted several times for pneumonia, who again
presents with RLL pneumonia, fever, CKD, anemia, and progressive
leukocytosis.
.
-Pt was thought to have pneumonia with an element of CHF/COPD
exacerbation. Ischemic event ruled out be CE's. PE also felt
to be unlikely. Pt treated with zosyn/vanco for presumed
pneumonia. However, he showed no improvement. He had
persistent fever and continued O2 requirement (100% face make).
Pt was diuresed without improvement. Blood cultures were
negative to date. Tried Bipap without improvement either.
Albuterol/ipratropium did not seem to help the pt.
Discussion was had with family (including HCP) and pt that his
situation was dire, particularly given the progressive and
nature of his underlying CLL. It was decided that care and
comfort measures should be undertaken. The pt died comfortably
within 24hrs of that decision.
Medications on Admission:
Docusate Sodium 100 mg [**Hospital1 **]
Atorvastatin 20 mg daily
Aspirin 81 mg Tablet
Lisinopril 2.5 mg daily
Metoprolol Tartrate 50 mg [**Hospital1 **]
Coumadin 5mg QHS
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
-Progressive Chronic Lymphocytic Leukemia
-Recurrent Pneumonia
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
|
[
"428.0",
"585.9",
"414.01",
"427.31",
"V43.3",
"486",
"204.10"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4169, 4178
|
3029, 3922
|
281, 285
|
4284, 4294
|
2389, 3006
|
4345, 4472
|
2020, 2039
|
4142, 4146
|
4199, 4263
|
3948, 4119
|
4318, 4322
|
2054, 2370
|
222, 243
|
313, 1329
|
1351, 1783
|
1799, 2004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,546
| 168,822
|
42906
|
Discharge summary
|
report
|
Admission Date: [**2141-11-12**] Discharge Date: [**2141-11-23**]
Date of Birth: [**2079-9-29**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache x 7days
Major Surgical or Invasive Procedure:
[**2141-11-12**] Cerebral angiogram for coiling of L PCOMM aneurysm
History of Present Illness:
Ms [**Known lastname 1140**] had a syncopal episode in the bathroom on [**11-11**] at
2pm,she woke up on the floor, possibly hitting her head on the
bath tub. Her daugther was in another room and heard the fall,
no
seizure activity. Her daugther helped her lay down and found her
to be confused and incontient a few hours later complaining of a
headache,she drove her to NSMC. He daughter than called EMS and
she was transported to NSMC. Ms [**Known lastname 1140**] states she has had
intermittent headaches over the last few days along with
bronchitis. She had a headache prior to her vasovagal episode. A
CT at [**Hospital6 28728**] Center showed a left frontal SAH. The
patient also had a BP of 220/114 at NSMC. She received Dilantin
and Vitamin K for an INR of 1.2. She was med flighted here for a
neurosurgery evaluation
Past Medical History:
PMHx:None
PSHX: C-Section
All:PCN
Social History:
Social Hx:Pt is [**Name (NI) 16042**] Witness and does not want blood
products. Lives with daughter
Family History:
Family Hx:Denies any family hx of subarachnoid hemorrhage
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 2 (for moderate headache) [**Doctor Last Name **]: 4
GCS: 15
O: T:98.9 BP:131/76 HR:69 R 18 O2Sats 95%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-10**] EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-9**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-13**] throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger,
Handedness Right
On Discharge:
A&ox3
PERRL
EOMs intact
Face symmetrical
No pronator drift
Motor: full
Pertinent Results:
CTA Brain [**2141-11-12**]:
Upon review of this study with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], endovascular
neuroradiologist, seen on images 55-57, series 3, and on coronal
reconstructed image 17, series 401b, is a probable aneurysm,
arising from the lateral aspect of the supraclinoid portion of
the left internal carotid artery, and directed in an unusual
anterolateral long axis.
The aneurysm appears to measure 1.5mm in maximal width, by
3.75mm in axial
length. Particularly in view of this revised finding, Dr. [**Last Name (STitle) **]
has informed me that the patient will undergo catheter
angiography today, with potential endovascular coiling as well.
CXR [**2141-11-12**]:
Relatively diminished lung volumes with crowding of the
pulmonary vasculature but no evidence of focal airspace
consolidation, pleural effusions, pulmonary edema, or
pneumothorax. Overall, cardiac and mediastinal contours are
upper limits of normal in size given portable technique. No
acute bony abnormality.
NCHCT [**2141-11-13**]:
IMPRESSION:
1. Stable moderate ventriculomegaly.
2. Stable, evolving distribution of subarachnoid and
intraventricular
hemorrhage.
3. Stable mild paranasal sinus disease.
ECHO [**2141-11-14**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric LVH with normal global biventricular
systolic function. Mild pulmonary hypertension.
CTA [**2141-11-18**]:
IMPRESSION:
No significant change in the size of the intracranial arteries
allowing for the artifact from the coils. Diminutive basilar
artery and P1 segments along with fetal PCA pattern and
prominent posterior communicating arteries withs lightly more
narrow size of the Basilar artery. Assessment for any residual
flow in the coiled aneurysm is limited on the present study.
Followup as clinically indicated. If there is concern for
parenchymal changes, MR can be considered if not CI.
[**2141-11-19**] CXR
IMPRESSION: AP chest compared to [**11-12**] through 10:
Although mediastinal vascular distention is no longer present,
pulmonary
circulation is engorged, and there is mild edema at the lung
bases. Elevation of the left lung base could be due to left
lower lobe atelectasis or upward displacement by abdominal
abnormality such as gastric distention. Right PIC line ends in
the region of the superior cavoatrial junction. No pneumothorax.
[**2141-11-21**] LENIES: No evidence of deep vein thrombosis in either
leg
Brief Hospital Course:
Ms. [**Known lastname 1140**] was evaluated in the Emergency room, sent for a CTA of
the brain which was suspicious for an underlying aneurysm as the
cause of her intracranial hemorrhage. She was taken to the
angio suite emergently where under general anesthesia she has a
cerebral angiogram with coiling of a right PCOM aneurysm.
She was extubated immediately after the procedure and
transferred to the ICU on a heparin drip.
ICU Course:
On [**11-13**], The Heparin drip was discontinued. Patient underwent
TCDs that showed no vasospasm. She was febrile and was cultured.
Her HR went up to the 150's and responded to Lopressor.
On [**11-14**], She developed some delerium over night with the
development of fevers and was given a dose of Haldol.
Priliminarly her UA revealed a UTI, she was started on
Ciprofloxicin . She remained stable. Overnight she was found to
be in afib with RVR, treated with lopressor, checked cardiac
enzymes which appeared negative.
On [**11-15**], She remained stable. TCDs showed mildly elevated
velocities but no vasospasm.
On [**11-3**], cardiology was consulted for the arrythmia's that
developed in the ICU, they believe that the underlying Afib was
not new, patient was taken off of the Amiodrone drip and started
on Sotalol. She underwent a CTA to rule out vasospasm after she
was found to have a new right pronator drift. The CTA was
negative.
on [**11-19**], Patient was found to be somewhat confused and
periodically halucinating. A CTA that was done on [**11-18**] was
reported as questionable for left A1 spasm. She remains in the
ICU with IV fluids and spasm watch.
Her anti-epileptics were discontinued and she was transferred to
the floor after stable TCD's. Screening lower extremity
dopplers were performed and were negative for DVT.
On [**11-21**] the foley catheter and IVF were discontinued. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consult was obtained for elevated blood sugars and the patient
was subsequently started on Amaryl [**First Name8 (NamePattern2) **] [**Last Name (un) 9718**] recommendations.
Nursing iniated diabetic teaching.
On [**11-22**] the patient experienced tachy-brady arrhythmias and
cardiology came to evaluate the patient. She was continued on
sotalol, and verapamil 40mg TID was added for rhythm
stabilization. No further medication titrations were required.
On [**11-23**], patient remained intact on examination, cardiology
recommended outpatient follow up and patient was decleared safe
from PT to be discharged home.
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. 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*
4. sotalol 80 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 WITH DINNER
().
6. verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*60 Tablet(s)* Refills:*2*
7. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 10 days.
Disp:*120 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Subarachnoid hemorrhage
Left PCOMM aneurysm
UTI
ATRIAL FIBRILLATION
ACUTE DELERIUM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.*****
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a MRI/MRA with
and without contrast ([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**]
to make this appointment.
Please schedule a follow up appointment after discharge with Dr.
[**Last Name (STitle) 83355**] [**Name (STitle) 77919**] of Clipper Cardiovascular in [**Location (un) 5028**], MA
([**Telephone/Fax (1) 65733**]
As always - follow up with your primary care physician and
notify them of your hospital stay.
Completed by:[**2141-11-23**]
|
[
"416.8",
"250.00",
"041.49",
"599.0",
"780.2",
"V85.41",
"780.61",
"430",
"293.0",
"278.01",
"427.31",
"427.32",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.75"
] |
icd9pcs
|
[
[
[]
]
] |
9346, 9395
|
6002, 8537
|
293, 363
|
9522, 9522
|
2969, 5979
|
11640, 12186
|
1413, 1473
|
8592, 9323
|
9416, 9501
|
8563, 8569
|
9673, 10698
|
10724, 11617
|
1488, 1841
|
2877, 2950
|
237, 255
|
391, 1220
|
2133, 2863
|
9537, 9649
|
1242, 1279
|
1295, 1397
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,150
| 122,400
|
38059
|
Discharge summary
|
report
|
Admission Date: [**2103-7-12**] Discharge Date: [**2103-8-3**]
Date of Birth: [**2041-11-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2103-7-12**]: placement of left external ventricular drain
[**2103-7-13**]: replacement of EVD in the operating [**2103-7-16**] replacement of EVD in OR
[**2103-7-27**]: Ventriculo-peritoneal shunt placement(left)
History of Present Illness:
Pt is a 61 yo female with PMHx sig for anxiety, depression,
hypercholesterolemia, and borderline diabetes transferred from
[**Hospital6 1597**] for R ICH. The patient has been complaining
of headaches over the last several weeks. This PM she fell to
the ground for unclear reasons and was difficult to get
up.Husband also noticed that she was not moving the left side of
her body well. She was brought to [**Hospital6 **] where she
was found to have a 4.0 cm x 3.5 cm R basal ganglia hemorrhage
with ventricular extension. She decompensated in the scanner
and required intubation. She was then transferred to [**Hospital1 18**].
Past Medical History:
anxiety, depression, hypercholesterolemia, borderline diabetes,
obesity.
Social History:
Lives with husband. On disability for anxiety and depression.
Two adopted children.
Family History:
Mother - CVA due to carotid disease. Father - [**Age over 90 **]yo.
Physical Exam:
Physical Exam:
Vitals: T ; BP 147/67; P 71; RR 16; O2 sat 100% on vent
General: intubated, sedated
HEENT: NCAT
Extremities: no c/c/e.
Neurological Exam: intubated, sedated, PERRL, 4-->2mm with
light, + VOR, + corneal, face symmetry difficult to assess due
to
ventilator tube/straps. Withdraws on the right purposefully to
pain. Does not withdraw on the L. Reflexes absent at the
patella and trace otherwise.
Exam upon discharge:
Afebrile, vital signs are stable. Spontaneous to light noxious
eye opening. LUE is spontaneous, with hand gripping. RUE w/draws
to nail bed pressure. Bilat LE triple flexion to deep
stimulation. Upgoing toes. Cranial wounds are clean dry and
intact.
Pertinent Results:
Labs on Admission:
132 94 12
- - - - - - gluc 192
4.4 27 0.7
Ca: 9.0 Mg: 2.1 P: 2.0
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
WBC 16.2 HCT 39.3 PLT 326
PT: 12.6 PTT: 25.6 INR: 1.1
LABS ON DISCHARGE:
xxxxxxxxxxxxxxxx
----------------
IMAGING:
----------------
CTA HEAD [**7-12**]:
CTA OF THE HEAD: The carotid and vertebral arteries and their
major branches are patent with no evidence of stenoses or
dissection. There is a moderate degree of atherosclerotic
calcification within the cavernous portion of the ICAs
bilaterally. There is no evidence of aneurysm formation or other
vascular abnormality.
IMPRESSION:
1. Unchanged right frontal hematoma with intraventricular
extension, now
status post shunt placement. Minimal leftward shift of midline
structures is seen, secondary to decompression of the left
lateral ventricle.
2. No new focus of hemorrhage.
3. No evidence for AVM or aneurysm. The carotid, vertebral and
major
intracranial arterial branches demonstrate no significant
stenosis or
dissection.
HEAD CT [**7-14**]:
IMPRESSION:
No significant change in the large right basal ganglia
intraparenchymal
hemorrhage with intraventricular extension. Stable ventricular
size.
HEAD CT [**7-16**]:
IMPRESSION:
Redemonstration of large right basal ganglia bleed with
surrounding edema and approximately 8 mm of right to left
midline shift. Redemonstration of
intraventricular extension and a small amount of right temporal
subarachnoid blood. Mild effacement of the perimesencephalic
cistern is unchanged.
HEAD CT [**7-17**]:
IMPRESSION:
1. A new right frontal approach shunt catheter ends in the left
periventricular white matter above the level of the thalamus,
with a new focus of parenchymal hemorrhage seen adjacent to its
tip.
2. No significant change in ventricular size.
3. Right intraparenchymal hemorrhage with intraventricular
extension, and
associated mass effect, are unchanged since prior study.
LENIS [**7-19**]:
IMPRESSION: No evidence of DVT.
CT Head [**7-21**]:
IMPRESSION:
1. Hypodense appearance of the right temporal lobe with
obliteration of the [**Doctor Last Name 352**]-white junction most likely represents
an infarct. Asymmetric attenuation of the cerebellar hemispheres
with right cerebellar hemisphere appearing more hypodense as
compared to left, represent an infarct as well; however,
evaluation is limited due to streak artifact from posterior
fossa, skull and motion.
2. Stable right basal ganglia and left frontal hemorrhage with a
transfrontal ventricular shunt in the area of the posterior limb
of internal capsule with adjacent hemorrhage. Intraventricular
extension of hemorrhage as well as right subarachnoid hemorrhage
is also grossly stable. No definite hydrocephalus at this time.
Upper Extrmity Doppler [**7-22**]:
IMPRESSION: No evidence of right upper extremity DVT. Please
note that this study is limited as the left subclavian vein was
not imaged for comparison.
CXR [**7-23**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The tracheostomy tube and the left-sided central venous
access line are in unchanged position. Low lung volumes with
borderline size of the cardiac silhouette but without evidence
of pulmonary edema. No focal
parenchymal opacities suggesting pneumonia. No evidence of
pleural effusions.
MRA Head [**7-23**]:
HEAD MRI: Allowing for differences in modalities, the right
frontal
parenchymal hematoma appears stable in extent compared to the
most recent CT scan ([**2103-7-21**]). The extent of associated edema in
the right frontal lobe, insula, and temporal lobe is stable.
Leftward shift of midline structures with mild right subfalcine
herniation is unchanged. The right
perimesencephalic cistern is narrowed, but no uncal herniation
is seen.
Bilateral subarachnoid hemorrhage is again noted along the
convexities.
Interventricular extension of hemorrhage also appears stable.
Compression of the frontal [**Doctor Last Name 534**] and body of the right lateral
ventricle is stable compared to [**2103-7-21**]. The right frontal
ventriculostomy catheter remains in unchanged position,
traversing the lateral ventricles and terminating in the region
of the left internal capsule and left thalamus. Blood products
are again seen surrounding the catheter tip. The ventricles are
stable in size. Blood products are also again noted in the left
frontal lobe, related to a prior ventriculostomy catheter, with
mild associated surrounding edema. Diffusion-weighted images
demonstrate expected signal abnormalities corresponding to the
above-described blood products. In addition, there are foci of
slow diffusion unrelated to the blood products, consistent with
evolving acute infarctions. These infarctions also demonstrate
high signal on T2-weighted/FLAIR images, indicating that they
are at least one day old. They include small infarctions in the
subcortical white matter of the superior frontal lobes (images
8:19-21, 3:23-24), in the right periatrial white matter (image
8:17), and the left lateral temporal cortex (images 8:12, 3:13),
and a
moderate infarction in the white matter lateral to the occipital
[**Doctor Last Name 534**] of the left lateral ventricle (images 8:8, 3:13). There is
no evidence of an acute infarction in the right temporal lobe or
right cerebellar hemisphere. Abnormal appearance of these
regions on the most recent CT scan was likely related to motion
artifacts. There is bilateral high T2 signal in the central pons
and anterior midbrain, without associated diffusion
abnormalities or blood products. These are nonspecific, but
could be related to prior microvascular ischemia. Their location
is not typical for diffuse axonal injury. There is mucosal
thickening and fluid in the sphenoid sinuses, as well as partial
opacification of the mastoid air cells bilaterally. This could
be related to prior intubation and current tracheostomy.
HEAD MRA: This study is limited by motion artifacts. Flow in the
A1 segments of the anterior cerebral arteries, M1 segments of
the middle cerebral arteries, and proximal P2 segments of the
posterior cerebral arteries is poorly visualized. While these
findings could be artifactual, vasospasm related to the known
subarachnoid hemorrhage cannot be excluded. The right
parenchymal hematoma abuts the M1 segment of the right middle
cerebral artery, as before.
IMPRESSION:
1. Multiple small evolving acute infarctions in the superior
bifrontal
subcortical white matter, right periatrial white matter, and
left lateral
temporal cortex. Moderate evolving acute infarction in the left
lateral
occipital periventricular white matter.
2. Compared to [**2103-7-21**], right frontal parenchymal
hemorrhage with
intraventricular extension, left frontal parenchymal hemorrhage
related to
prior ventriculostomy, left thalamic/internal capsule hemorrhage
related to
the current ventriculostomy, bilateral subarachnoid hemorrhage,
associated
mass effect, and size of the ventricles are all unchanged.
3. The head MRA is limited by motion artifacts. Poor
visualization of flow
in the A1 segments of the anterior cerebral arteries, M1
segments of the
middle cerebral arteries, and proximal P2 segments of the
posterior cerebral arteries could be artifactual, but vasospasm
cannot be excluded.
Abdominal US [**7-24**]:
IMPRESSION:
1. Gallbladder is unremarkable.
2. Extremely increased echogenicity of the liver throughout
without evidence of focal lesion. Findings are consistent with
fatty liver infiltration. Other forms of liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
CT Head [**7-27**]:
FINDINGS: The right basal ganglia hemorrhage, measures 3.7 x 2.6
cm compared to prior 3.6 x 2.5 cm, relatively unchanged. There
continues to be
perihemorrhagic edema and mass effect causing leftward
subfalcine herniation by 9.3 mm, slightly improved since the
prior study. There is mild medial displacement of the right
uncus without frank uncal herniation.
A VP shunt via the left frontal approach is terminating in the
third
ventricle. Trace intraventricular extension of hemorrhage is
seen in the
posterior [**Doctor Last Name 534**] of the lateral ventricle, unchanged. Mild edema
is seen along the previous right-sided catheter tract. Unchanged
hypoattenuation is present in the left parieto-occipital lobe
and frontal lobe. Small foci of subarachnoid hemorrhage are
present along the right parieto-occipital region, unchanged
(2:17). There are no new foci of hemorrhage. Osseous and soft
tissue structures are unremarkable. Unchanged fluid is present
in bilateral sphenoid air cells.
IMPRESSION: Unchanged right basal ganglia intraparenchymal
hemorrhage with 9mm leftward subfalcine herniation. No
significant interval change.
CT Head [**2103-8-2**]:
1. No new foci of ICH.
2. Right basal ganglia hemorrhage slightly smaller in size.
3. Slightly improved leftward shift, now 7mm from 9mm.
4. Unchanged tiny intraventricular hemorrhage layering in the
left occipital
[**Doctor Last Name 534**].
5. No developing hydrocephalus.
6. Unchanged VP position.
***Copies of three most recent head CT and Chest X-rays will be
provided by CD.
Brief Hospital Course:
Patient was admitted to the ICU under Dr. [**Last Name (STitle) **].She had EVD
placed. her exam improved and she was following commands
consistently with all 4 extremities by [**7-13**] and she was
extubated. EVD continued to become clogged so intrathecal TPA
was initiated. Shortly after the EVD became clogged and could
not be cleared. At this time she was taken to the operating room
for replacement of the left EVD catheter. this catheter again
became clogged requiring a second EVD replacement [**2103-7-16**]. Post
op CT showed good placement of catheter. She remained intubated
and closely followed in ICU.
On [**7-18**], neurology recommendations were to discontinue her
nardil for concern of PRES. Psychology was consulted and
recommended that nardil also be discontinued and it needed
phentolamine or nitroprusside could be used to control blood
pressure. Her exam remains poor with no eye opening to noxious
stimuli, no commands. She attempts to localize with the LUE, but
extensor postures in the RUE. She triple flexes the RLE and
withdraws her LLE to noxious stimuli. Continuous EEG was also
ordered to rule out seizure activity. Overnight patient spiked a
fever of 101.6 and was pancultured. Sputum grew 4+ gram negative
rods and she was placed on vancomycin/zoysn. CSF was also sent
which did not grow any microorganisms.
On [**7-19**], she had continuous EEG monitoring and continued to have
a poor exam, preliminary read of the EEG is not revealing for
epiliptiform acitivity. A fever work up is underway with added
LENIs and LFTs. Antibiotic coverage has been broadened with
Cefepime, Cipro and Vancomycin for ongoing fevers.
On [**7-21**] a repeat CT of the head was done, and she was noted to
have new areas of hypodensity of the right temporal and
cerebellar regions. This was attributed to.....
On [**7-23**], her external ventricular drain was raised from 10cm to
15cm in an attempt to determine her need of it. She tolerated
this well.
On [**7-24**] the EVD was raised to 20; however, overnight, the ICP
rose to 20 for 5 minutes sustained. The decision was made to
open the drain, and the ICP subsequently dropped to the low
teens. She was seen by ID, who recommended we continue her
current ABX regimen and postulated that the elevated WBC count
was likely not infectious, as she is not bacteremic and her PNA
has resolved.
On [**7-25**], the EVD was again clamped, but later in the day she was
unable to tolerate it, as her ICPs again rose to above over 23.
The decision was made to open the drain, and to place a
permanent VPS in the OR on [**2103-7-27**].
On [**2103-7-27**], she went to the operating room for a left sided
ventriculoperitoneal shunt placement, which was tolerated well.
Post-op she was returned to the SICU for continued managment of
her respiratory status.
On [**7-28**], she was determined neurologically stable to transfer to
the neurosurgery stepdown unit (pending her ability to tolerate
a trach mask). She completed her treatmetn for VAP, and on the
overnight of [**7-30**], had an episode of bronchospasm and was put on
albuterol and ipatropium. Since that time, she had no further
incidents.
On [**8-3**] she was accepted to [**Hospital3 **] in [**Hospital1 8**]. She was
discahrged as such, and Imaging was provided to the rehab
facility by CD.
Medications on Admission:
Nardil 15 mg tablets (2 3/4 tablets q day), Xanax,Lamictal 100
mg [**Hospital1 **], Simvastatin 20 mg q day.
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
4. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): HOLD if SBP <110, HR<60.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, headache.
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for SOB,
wheezing.
13. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Six (6) Puff Inhalation Q4H PRN () as needed for wheeze.
14. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
15. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
17. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
20. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO BID
(2 times a day): hold for Phos<2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Basal Ganglia Hemorrhage with Intraventicular Extension
Respiratory Failure
Coma
Protien/calorie malnutrition
Ventilator associated Pneumonia
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery.
MEDICATIONS
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
** Please call ([**Telephone/Fax (1) 2528**] to schedule and appointment to be
seen by the Neurologist within 4 weeks for follow up management
of your intracranial hemorrhage.
Completed by:[**2103-8-3**]
|
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icd9cm
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[
[
[]
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[
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[
[
[]
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16841, 16884
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1324, 1410
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1948, 2199
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,020
| 196,627
|
884
|
Discharge summary
|
report
|
Admission Date: [**2142-2-8**] Discharge Date: [**2142-2-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Tranfusion of 2 units of packed red blood cells
History of Present Illness:
88 yo M PMH of pancreatic CA, no recent tx, in clinic for
survaillence CT scan (which showed no change) mentioned that he
was tired to his oncologist, hct was 18.8 down from 28 in
[**Month (only) 359**], sent to ED for eval.
In the ED, vitals on presentation were T 97.7 BP 153/65 HR 70 RR
24 97%RA. On exam, he had no stool in rectal vault, but mucous
was guaiac (+). NG lavage negative. 2u pRBC ordered, but not yet
hung. He was given Protonix 40 mg IV x 1.
On transfer to unit, patient reports a 2 month history of
progressive DOE, now SOB when he walks to the bathroom. Was able
to walk a city block and work in his garden over the summer.
Denies PND, no orthopnea. No increased lower extremity edema -
has chronic on L side from vein harvest for CABG. Denies any
BRBPR, stool is always black as he is on iron, but no sticky
stool suggestive of melena. Occasionally has blood on toilet
paper when he wipes, but nothing that has turned the toilet bowl
red. Denies any hematemesis, no hemoptysis.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, PND, cough, urinary frequency,
urgency, dysuria, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
# Pancreatic CA localized to pancreatic tail s/p cyber knife
therapy, deemed a poor surgical candidate
# Anemia - Chronic GI bleed with recent hospitalization [**10/2141**]
# Coronary artery disease status post coronary artery bypass
graft in [**2127**], left internal mammary coronary artery to left
anterior descending coronary artery, saphenous vein graft to
posterior descending coronary artery, saphenous vein graft to
D1/OM1
# Noninsulin dependent diabetes mellitus
# Status post cholecystectomy
# Hypertension
# Hypercholesterolemia
Social History:
Positive tobacco times thirty five pack years. Quit
approximately twenty years ago. Lives with wife. Retired from
[**Company 2676**]. Rare EtOH, no drugs.
Family History:
No history of colon CA.
Physical Exam:
On Presentation:
Vitals: T: 98.1 BP:125/65 HR:78 RR:15 on 2l nc
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear. Pale conjunctiva, pale oral mucosa
NECK: No JVD no cervical lymphadenopathy, trachea midline
COR: regular rate, soft SEM at RUSB.
PULM: Lungs CTAB, no W/R/R
ABD: Obese, Soft, NT, ND, +BS, no HSM, no masses
EXT: 1+ pitting edema of LLE. 2+ distal pulses
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.
SKIN: Pale. Scattered sebhorric keratosis, delayed capillary
refill
Pertinent Results:
DISCHARGE LABS:
-[**2142-2-9**] 02:55PM BLOOD Hct-24.0*
-[**2142-2-9**] 04:42AM BLOOD Glucose-110* UreaN-30* Creat-1.4* Na-140
K-4.6 Cl-109* HCO3-22 AnGap-14
IMAGING: CT ABD with contrast;
1. Slight decrease in size of rim-enhancing but mostly necrotic
pancreatic
tail neoplasm with fiducial seeds. No evidence of progression
here.
2. Interval development of significant bibasilar
peribronchovascular axial
interstitial and peripheral interstitial thickening in the
context of
enlarging pleural effusions and focal nodularity. These findings
in the lung bases are incompletely assessed but have
significantly changed from [**2141-10-27**] and all prior
examinations. While they could be infectious, more sinister lung
disease, specifically lymphangitis carcinomatosis is not
excluded.Correlation with symptoms recommended:If the patient
has infectious symptomology then these are probably not too
concerning but if there are no symptoms then a formal HRCT chest
should be performed to further evaluate.
Brief Hospital Course:
88 yo M with PMH of pancreatic CA, CAd s/p CABG, DM, who
presents with acute on chronic anemia, guaiac (+) in ED, hct of
18.8 in clinic, VSS. Transferred to ICU for acute GI bleed.
Refused EGD. Received 2 units pRBC with rise of hct to 24.
Discharged in stable condition with plans for hct follow up as
outpatient.
# GIB: Sub-acute in nature given prior history. Baseline is high
30's. Was likely lower as NG lavage negative. He does have a
number of possible sources of bleeding both upper and lower -
diverticulosis, polyps, hemorrhoids, or bleeding from cyber
knife treatment. His last colonoscopy in [**2140**] shouwed internal
hemorrhoids and a polyp that was removed. He has been recent
hospitalized in [**10/2141**] for similar presentation. Refused EGD.
Transfused 2 units pRBC with hct rise to 24. Discharged in
stable condition with GI follow up and scheduled EDG.
Instructed to have follow up hct on [**2142-2-12**].
# Fatigue: Patient reported significant fatigue, very likely [**2-26**]
acute on chronic anemia. Treated and worked up as above.
# Pancreatic CA localized to pancreatic tail: s/p cyber knife
therapy x3. deemed a poor surgical candidate. CT scan today
showed no worsening. Not actively managed while in-patient.
Has follow up with priamry oncolgist.
# CAD s/p coronary artery bypass: Held BP meds and ASA given
bleed. Restarted on discharge.
# Noninsulin dependent diabetes mellitus: Covered with SSI and
discharged on home glyburide.
# Hypertension: BP meds held gived GIB and restarted on
discharge.
# Hypercholesterolemia: Continued home statin.
Medications on Admission:
Atenolol 25 mg PO daily
Lasix 20 mg PO 2X/week
Zocor 40 mg PO daily
Omeprazole 20 mg PO daily
Cozaar 25 mg PO daily
Compazine 10 mg PO PRN nausea
Imdur 30 mg PO daily
Glyburide 2.5 mg PO daily
Nitro SL PRN
Iron 325 mg PO TID
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a week.
7. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO three times a day.
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as needed as needed for chest pain: call 911 if you
need more than 2 doses.
10. Outpatient Lab Work
Please have you Hematocrit (Hct) checked on [**2142-2-12**].
Please have the results called in to your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1270**] ([**2142**]
Discharge Disposition:
Home
Discharge Diagnosis:
chronic blood loss anemia requiring transfusion
pancreatic cancer s/p XRT
coronary artery disease s/p coronary bypass grafting
diabetes mellitus
Discharge Condition:
fair; hemodynamically stable, eating, walking
Discharge Instructions:
You were admitted for anemia from chronic bleeding into the GI
tract. Your hematocrit was 18 on arrival, and you were
transfused 2 units of blood. GI consult saw you, and discussed
performing an EGD (you did not have hematochezia, so colonoscopy
was not deemed necessary), but you declined to have the
procedure done during this admission. As this was not urgent,
due to the chronicity of the bleeding, we have scheduled this
for you as an outpatient.
Please follow up with all of your appointments.
Please have you blood level (Hematocrit) checked on [**2142-2-12**].
Have the results called in to Dr. [**Last Name (STitle) 1270**],[**First Name3 (LF) **]
([**2142**].
Followup Instructions:
Gastroenterology (GI Doctors) for endoscopy:
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2142-3-2**] 9:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 6044**] (ST-3) GI ROOMS Date/Time:[**2142-3-2**] 9:00
-- procedure will start at 9, please arrive by 8:00am. Call
[**Telephone/Fax (1) 463**] for directions.
Keep the following, previously scheduled appointments:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2142-6-14**] 11:00
|
[
"V10.09",
"250.00",
"272.0",
"578.9",
"401.9",
"V45.81",
"280.0",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7062, 7068
|
4156, 5748
|
267, 317
|
7257, 7305
|
3126, 3126
|
8025, 8589
|
2389, 2414
|
6024, 7039
|
7089, 7236
|
5774, 6001
|
7329, 8002
|
3142, 4133
|
2429, 3107
|
220, 229
|
345, 1632
|
1654, 2197
|
2213, 2373
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,280
| 126,360
|
41256
|
Discharge summary
|
report
|
Admission Date: [**2195-3-16**] Discharge Date: [**2195-3-27**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary bypass grafting x4 of left internal mammary artery to
left anterior descending coronary artery; reverse saphenous vein
single graft from aorta to ramus ntermedius coronary artery;
reverse saphenous vein single graft from aorta to the second
obtuse marginal
coronary artery; reverse saphenous vein single graft from aorta
to the distal right coronary artery.
History of Present Illness:
88 year old female s/p PCI to RCA x 3,PTCA to LAD who presents
with worsening chest pain over the past month. She has been
experiencing intermittent chest pressure for the past year, both
with activity and with rest. Frequency has
increased in the past month and she has been using SL nitro more
frequently for pain (up to 4x/day). Chest pain is a midsternal
pressure radiating to right and left chest, around [**7-10**], lasts
10-15 minutes and comes and goes throughout the day. She has
associated SOB and vague feeling of fatigue, no diaphoresis,
nausea, or radiation. Pt says sometimes it occurs 2 days in a
row and other days she is CP free, though overall increased
frequency since [**Month (only) 404**]. Chest pain usually induced with
exertion though has occurred at rest, it is relieved with nitro.
Last episode was 4 days ago while she was taking out the
garbage, and she has been chest pain free since then. She called
her physician and was told to come to the ED. She was admitted
for further evaluation.
Past Medical History:
Past Medical History:
Dyslipidemia
Hypertension
s/p MI [**2181**], s/p PCI to RCA x 3, PTCA to LAD
Spinal stenosis
HSV
Osteoarthritis
Monoclomal gammopathy
Past Surgical History:
s/p right total hip replacement
s/p right shoulder surgery
Social History:
widowed, house wife, lives in 1-floor home. Has 1 son who live
10 min away. Does her own cooking and shopping, not able to
drive. Former smoker [**5-5**] cigs/day for 20 years. Rare EtOH use.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
VS: 103/47 56 18 94%RA
GENERAL: well-appearing woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, elevated JVP, no LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. bradycardic, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse wheezing and
rhonchi at bases, no rales, good inspiratory effort with
decreased breath sounds at bases
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
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:
Pertinent labs:
---------------
[**2195-3-16**] 03:15PM BLOOD WBC-9.0 RBC-4.42 Hgb-13.0 Hct-38.6 MCV-88
MCH-29.5 MCHC-33.7 RDW-13.4 Plt Ct-310
[**2195-3-16**] 03:15PM BLOOD Neuts-72.8* Lymphs-19.2 Monos-6.0 Eos-1.4
Baso-0.6
[**2195-3-16**] 03:15PM BLOOD PT-13.2 PTT-23.6 INR(PT)-1.1
[**2195-3-16**] 03:15PM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-139
K-4.5 Cl-97 HCO3-32 AnGap-15
[**2195-3-17**] 12:00PM BLOOD ALT-21 AST-27 LD(LDH)-110 CK(CPK)-29
AlkPhos-60 Amylase-63 TotBili-0.4 DirBili-0.1 IndBili-0.3
[**2195-3-16**] 03:15PM BLOOD cTropnT-<0.01
[**2195-3-16**] 09:10PM BLOOD CK-MB-2 cTropnT-<0.01
[**2195-3-17**] 06:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2195-3-17**] 06:30AM BLOOD Calcium-9.9 Phos-4.3 Mg-2.3
[**2195-3-17**] 12:00PM BLOOD %HbA1c-6.0* eAG-126*
Imaging/Procedures:
-------------------
CXR [**3-16**]: No acute cardiac or pulmonary process.
.
Cardiac cath [**3-17**]:
1. Coronary angiography in this right-dominant system
demonstrated three-vessel disease. The LMCA was heavily
calficied with a distal 60-70% stenosis. The LAD was also
heavily calcified and had an ostial 80%stenosis, a proximal-mid
60% stenosis. The septal branches supplied collaterals to the
RPDA. The LCx had an ostial 50% stenosis and a proximal-mid 30%
stenosis. The OM1 had an ostial 30-40% stenosis. The LPL was
occluded proximally and filled vial left-left collaterals; the
distal LCx supplied collaterals to the RPL. The RCA had ostial
50% in-stent restenosis extending to a recanalized total
occlusion within the previously placed stents. The distal RCA
filled via right-right collaterals.
2. Limited resting hemodynamics revealed normal left-sided
filling pressures with LVEDP 12mmHg. The systemic arterial blood
pressure was initially normal but there was subsequent severe
hypertension with SBP 170mmHg.
3. Left ventriculography demonstrated an ejection fraction of
54%. There was severe posterobasal hypokinesis, inferoapical
hypokinesis, anterobasal mild hypokinesis, and lateral mild
hypokinesis. There was 1+ mitral regurgitation.
4. Peripheral angiography revealed mild origin plaquing in the
left subclavian artery. The LIMA was a large, patent vessel.
FINAL DIAGNOSIS:
1. Severe LMCA and three-vessel coronary artery disease.
2. Chronic total occlusion of the RCA from in-stent restenosis.
3. Normal LV diastolic function.
4. Mild diffuse heterogenous LV systolic dysfunction.
5. Patent left subclavian artery and LIMA.
.
TTE: The left atrium is mildly dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with anteroseptal and anterior hypokinesis.
The apex is not well seen. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal. with borderline normal free
wall function. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
Carotid U/S: Right ICA with no stenosis. Left ICA stenosis <40%.
Brief Hospital Course:
Mrs. [**Known lastname 89857**] is 88 year old woman with CAD s/p PCI to RCA x 3,
PTCA to LAD presents with worsening chest pain over past month.
On [**2195-3-19**] she was taken to the operating room and underwent
Coronary bypass grafting x4 of left internal mammary artery to
left anterior descending coronary artery;reverse saphenous vein
single graft from aorta to ramus intermedius coronary artery;
reverse saphenous vein single graft from aorta to the second
obtuse marginal coronary artery; reverse saphenous vein single
graft from aorta to the distal right coronary artery with
Dr.[**Last Name (STitle) 914**]. Please see operative report for further details.
Cardiopulmonary Bypass Time:76 minutes.Cross Clamp Time 59
minutes. She tolerated the procedure well and was transferred to
the CVICU intubated and sedated for further invasive monitoring.
She awoke neurologically intact and was exubated without
incident. All lines and drains were discontinued in a timely
fashion. Beta- Blocker/Statin/Aspirin and diuresis were
initiated. She developed post -operative afib which was treated
with amiodarone and anticoagulated with coumadin. she was very
sensitve to coumadin and her INR rose quickly to 6.3- coumadn
was held and FFP was administered. Her INR responded
appropraitely and is 2.7 today and she recieved NO coumadin.
She was cleared for rehab on POD#8 by Dr. [**Last Name (STitle) 914**].
She was discharged to [**Doctor First Name 391**] [**Hospital **] rehab today.
Medications on Admission:
ASA 325
Acyclovir 400 mg [**Hospital1 **]
Imdur 120 mg daily
Lasix 20 mg [**Hospital1 **] MoWeFriSu; 40 mg qAM/20 mg qPM TuThSat
Detrol LA 4 mg daily
Toprol 150 mg daily
Simvastatin 80
MVI
NTG SL prn
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg daily for 7 days then decrease to 200mg daily.
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): until lower extremity edema resolves.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
16. Coumadin 1 mg Tablet Sig: [**2-1**] Tablet PO once a day: Cautious
coumadin dosing-senstitve
Goal 2.0-2.5
for Afib.
17. Outpatient Lab Work
check INR [**2195-3-28**]
Goal INR 2.0-2.5
for Afib.
*******sensitive to coumadin******cautious dosing
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery by pass graft x4
Dyslipidemia, HTN, MI, Spinal stenosis, HSV, OA, Monoclomal
gammopathy, s/p right TKR, s/p right shoulder surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
Edema 2+ lower extremity
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) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2195-4-14**] 1:30
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 3708**] [**Telephone/Fax (1) 68410**] in [**5-5**] weeks
Cardiologist: Dr. [**Last Name (STitle) 89858**] [**Name (STitle) **] [**Telephone/Fax (1) 2258**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw [**2195-3-28**]
Anticoagulation will be followed post discharge by Dr. [**Last Name (STitle) 89858**]
[**Name (STitle) **]
Completed by:[**2195-3-27**]
|
[
"414.2",
"412",
"273.1",
"285.1",
"427.31",
"414.01",
"V70.7",
"411.1",
"272.4",
"V45.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"88.53",
"36.15",
"37.22",
"88.56",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9935, 10055
|
6556, 8044
|
267, 636
|
10275, 10508
|
3196, 3196
|
11433, 12225
|
2172, 2287
|
8294, 9912
|
10076, 10254
|
8070, 8271
|
5372, 6533
|
10532, 11410
|
1886, 1947
|
2302, 2302
|
217, 229
|
664, 1684
|
2316, 3177
|
3212, 5355
|
1728, 1863
|
1963, 2156
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,002
| 102,884
|
14981
|
Discharge summary
|
report
|
Admission Date: [**2153-4-23**] Discharge Date: [**2153-4-28**]
Date of Birth: [**2102-7-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Viral Syndrome NOS
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
50-year-old gentleman with HIV since [**2145**] (last cd4 463, vl <50
[**2153-4-16**]), who recently stopped his ARVs about 1 week ago.
Presented [**4-23**] to [**Hospital **] clinic with complaints of 3 days of fevers
to 103-104, chills, sore throat, myalgias, and HA, intermittent
RLQ pain, photophobia, and neck stiffness.
.
He says he began to feel ill which started with fevers and
chills
3 days prior to presentation (early saturday morning). He also
reports HA that was diffuse and that responded to tylenol,
although he says the fevers did not. He also reports mylagias,
sore throat, nausea, no emesis or diarrhea. HAs not been eating
much over the weekend, but has tried to drink fluids. No sick
contacts. [**Name (NI) **] travel. Per [**Hospital **] clinic notes, says that this feels
"just like I did when I converted."
.
He does report unprotected receptive and insertive anal sex over
the past few weeks with a partner of unknown status. One episode
3 days ago of dysuria.
.
Initial VS in the ED: 102.2, HR 72, BP 106/67, RR16, 02 sat 97.
Given Decadron, CTX, Vanco, Acyclovir and Motrin.
Past Medical History:
1. HIV (per clinic notes)
Diagnosed with HIV in [**2146-2-2**], risk factor being MSM. On
diagnosis, his initial CD4 count was 300 and his viral load was
>100,000. By record, his known CD4 nadir was 60 from his initial
years in care in [**Location (un) 9012**]. He started HAART in [**2145**] with Epivir,
Sustiva, and d4T. He was on that regimen for about 60 days and
had ?lactic acidosis so his Epivir was switched Videx at that
time. He discontinued all medications in [**2147**] and moved to
[**Location (un) 86**]. He had been off medications until [**2148**] when he started
the regimen of Truvada and Kaletra which he has been on since
that time. (Of note, his viral load was 3,160,000 on [**12-6**], when
he started haart.) Good response to that regimen with viral load
becoming undetectable by [**6-5**].
2. Rheumatic fever as a child.
3. h/o non-cardiac chest pain (negative cath in [**2147**])
4. major depressive disorder (hospitalized at [**Hospital 8**] Hospital
in [**2147**])
5. chronic renal insufficiency (baseline 1.4-1.6)
6. chronic elevation in CPK.
7. h/o genital herpes
Social History:
Works as a social worker, [**Name (NI) **] tobacco, EtOH, or IV drug use. Rare
marijuana.
Family History:
NC
Physical Exam:
PE 101.6 108/68 60 93RA
Gen: laying in bed, non-toxic, but uncomfortable appearing
HEENT: MMM
Neck: supple but pain with neck movement JVD flat, no carotid
bruits
Chest: CTAB, no wheezes, rales or rhonci
CVS: rrr, no m/r/g
Abd: soft, NABS, ND, no rebound. Mild vol gaurding and mild RLQ
tenderness to palpation
Extrem: no c/c/e
Neuro: CN II-XII intact, no kernigs or brudzinskis
MSK: no joint effusions, normal ROM
Pertinent Results:
Ehrlichia/Babesia Ab: P
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] HCV Ab-NEGATIVE
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] ALT-81* AST-57* AlkPhos-118* TotBili-0.3
[**2153-4-26**] 06:15AM [**Month/Day/Year 3143**] ALT-74* AST-76* AlkPhos-76 TotBili-0.3
[**2153-4-26**] 06:15AM [**Month/Day/Year 3143**] Glucose-95 UreaN-10 Creat-1.6* Na-136
K-4.1 Cl-103 HCO3-27 AnGap-10
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] WBC-6.8 Lymph-25 Abs [**Last Name (un) **]-1700 CD3%-60
Abs CD3-1027 CD4%-19 Abs CD4-330* CD8%-38 Abs CD8-642
CD4/CD8-0.5*
[**2153-4-24**] 07:25AM [**Month/Day/Year 3143**] Parst S-NEGATIVE
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] WBC-6.8 RBC-4.62 Hgb-15.0 Hct-44.5 MCV-96
MCH-32.5* MCHC-33.7 RDW-12.5 Plt Ct-309
[**2153-4-26**] 06:15AM [**Month/Day/Year 3143**] WBC-2.6* RBC-3.96* Hgb-13.2* Hct-37.6*
MCV-95 MCH-33.3* MCHC-35.0 RDW-11.8 Plt Ct-183
[**2153-4-23**] 11:30AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0
Lymphs-75 Monos-25
[**2153-4-23**] 11:30AM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-66
.
Micro
Crypto Ag negative ([**Month/Day/Year **]/CSF)
RPR: positive
HIV VL: Greater than 100,000 copies/ml
Urine GC/CT: negative
HBV VL pending
.
CT abd/pelvis: Unremarkable CT of the abdomen and pelvis.
.
CT head w and w/o: No acute intracranial hemorrhage or enhancing
mass. Please note most often CT is normal in meningitis.
.
pCXR: No acute cardiopulmonary process.
.
Brief Hospital Course:
#+RPR: Felt to be primary Syphillis given lack of rash and
recent gential lesions; LP bland making tertiary syphillis
unlikely. Intially started on Doxycycline given PCN allergy;
however, ID eventually recommended PCN desensitization.
Transferred to the ICU, where he underwent desensitization.
After the desensitization he was treated an infection of 2.4 mU
IM PCN. This will be followed immediately by PCN VK 250 mg po
qid X2 weeks with weakly PCN shots for 3 shots total.
#Febrile Syndrome NOS: No evidence of meningitis or other
intraabdominal process. CSF, Urine and [**Month/Day/Year **] cutlures pending.
Likely rebound syndrome from withdrawl of HAART (Retroviral
Rebound Sydrome) vs spirochetemia vs infection with new HIV
strain as HIV VL was >100,000. However, given pulse/temp
disconnect, Ehrlichia and Babesia were sent and was (penidng at
time of d/c).
.
#Unprotected sexual encounter: RPR and HIV results as above; Hep
C Ab negative. Hepatits B panel with evidence of prior
infection; Hep B VL pending.
.
#Elevated LFTs: Hep B/C as above; ?secondary to HIV viremia of
syphillis. LFTs stable during Hospital course.
.
#HIV: per ID, holding HAART initally held until Cr improves
.
#ARF: Cr above baseline, likely secondary to dehydration. Was
given aggressive IVF and recheck in am
.
#Post LP headache: Pt developed worsening positional HA after
LP. Given Caffeine, hydration, and Morphine tried with limited
success. Seen by Chronic pain service who recommended PCA for
pain control. Felt that a [**Month/Day/Year **] patch was too risky of leading
to epidural abscess. Headache subsequently improved.
.
#Leukopenia: during the hospitalization developed mild
leukopenia (6.8-->2.6), felt to be likely secondary to HIV
Viremia.
Medications on Admission:
Kaletra, Truvada (recently discontinued)
Wellbutrin SR 150 [**Hospital1 **]
Androgel
Ativan
Trazodone 50 qhs prn
Discharge Medications:
1. Penicillin V Potassium 250 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours): Take until 3 days after rash resolves. .
Disp:*30 Capsule(s)* Refills:*2*
5. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Kaletra 200-50 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain for 3 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
syphilis
HIV
post-LP headache
Discharge Condition:
stable
Discharge Instructions:
During this hospiltalization you were diagnosed with syphillis
as well as possible rebound syndrome from stopping your HIV
meds. You were desensitized to penicillin and treated with
acyclovir for possible herpes infection. Please restart your
Truvada and Kaletra.
It is extremely important that you take your penicillin every
six hours - if you miss a dose you could be at risk for having
an allergic reaction again. It is also imperative that you
attend your Nurse appointments and your appointment with Dr.
[**Last Name (STitle) **].
Please resume your HIV medications.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 12082**],PECK PSYCHIATRY HMFP Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2153-5-3**] 2:00pm
2. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 250**] Call to schedule
appointment.
3. Please follow up with ID nurse [**5-3**] at 9am and on [**5-10**] at 9am for your penacillin shot in the basement of the [**Hospital Unit Name 3269**].
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43851**], RN Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2153-5-3**] 9:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43851**], RN Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2153-5-10**] 9:00
4. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**First Name (STitle) 3143**] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2153-5-14**] 10:00am
|
[
"E879.4",
"585.9",
"091.2",
"349.0",
"276.51",
"042",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
7487, 7493
|
4704, 6456
|
301, 319
|
7567, 7576
|
3151, 4681
|
8197, 9078
|
2696, 2700
|
6620, 7464
|
7514, 7546
|
6482, 6597
|
7600, 8174
|
2715, 3132
|
243, 263
|
347, 1455
|
1477, 2573
|
2589, 2680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,388
| 154,266
|
50041
|
Discharge summary
|
report
|
Admission Date: [**2123-11-1**] Discharge Date: [**2123-11-8**]
Date of Birth: [**2049-10-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
1. Pancreatic tail mass.
2. Renal cell carcinoma.
Major Surgical or Invasive Procedure:
[**2123-11-1**]:
1. Distal pancreatectomy with splenectomy.
2. Intraoperative ultrasound.
3. Partial right nephrectomy
History of Present Illness:
The patient is a 74-year-old gentleman who has an
incidentally-identified mass in the tail of his pancreas. He
was being worked up for renal cell carcinoma and imaging
indicated a hyper-enhancing lesion in the distal aspect of the
pancreas. The patient was determined to require a large open
approach of partial
nephrectomy by the urology team led by Dr. [**Last Name (STitle) 770**] and it was
planned to do the exploration together.
Mr. [**Known lastname **] went to the operating room on the morning of the
[**2123-11-1**], with the intent of performing an exploration
of the retroperitoneum and a possible distal pancreatectomy with
splenectomy. This would follow after a partial nephrectomy to
be performed through a thoracoabdominal incision by Dr.
[**Last Name (STitle) 770**] from under our Urology Group.
Past Medical History:
stress [**2116**] neg, HTN, chronic LBP, atrophic left kidney, R renal
mass, h/o SCC, 120 pack yr h/o smoking
L TKR, b/l cataract, sternal fx repair, hemorrhoidectomy, VC bx
Social History:
Married with 5 children. Denies EtOH, history of cigarette
smoking for 60 years, quit one week prior the surgery.
Family History:
Brother and sister with brain tumors
Physical Exam:
On Discharge:
VS: 98.2, 98, 120/68, 20, 94% RA
Gen: NAD
CV: RRR, no m/r/g
Lungs: CTAB, diminished on bases b/l
Abd: Right thoracoabdominal incision open to air with sterti
strips and c/d/i. Abdomen large, obese, positive BS x 4.
Extr: Warm, no c/c/e
Pertinent Results:
[**2123-11-2**] 02:03AM BLOOD WBC-16.1*# RBC-3.99* Hgb-12.3* Hct-36.3*
MCV-91 MCH-30.7 MCHC-33.8 RDW-13.4 Plt Ct-318
[**2123-11-1**] 03:19PM BLOOD Glucose-182* UreaN-23* Creat-1.4* Na-137
K-4.8 Cl-103 HCO3-19* AnGap-20
[**2123-11-1**] 03:19PM BLOOD Calcium-9.0 Phos-6.9* Mg-1.5*
[**2123-11-4**] 06:35AM BLOOD WBC-9.7 RBC-4.10* Hgb-12.7* Hct-38.2*
MCV-93 MCH-31.1 MCHC-33.4 RDW-13.5 Plt Ct-406
[**2123-11-7**] 08:55AM BLOOD Glucose-152* UreaN-28* Creat-1.0 Na-139
K-4.2 Cl-101 HCO3-27 AnGap-15
[**2123-11-7**] 08:55AM BLOOD Calcium-9.3 Phos-4.5# Mg-1.9
[**2123-11-1**] INTRAOPERATIVE ULTRASOUND:
IMPRESSION: Focal hypoechoic abnormality in distal tip of the
pancreatic tail which is far smaller than that which was
demonstrated on the recent
contrast-enhanced CT scan. A focal metastatic lesion may have
this
appearance. Alternatively, chronic pancreatitis may also appear
hypoechoic.
[**2123-11-1**] CHEST PA/LAT:
IMPRESSION: No large pneumothorax. Left basilar atelectasis.
[**2123-11-1**] PATHOLOGY REPORT:
Pending
Brief Hospital Course:
The patient is a 74-year-old gentleman who has an
incidentally-identified mass in the tail of his pancreas and
right renal cell carcinoma. Mr. [**Known lastname **] was taken to the
operating room on [**2123-11-1**] by pancreatic surgery and urology. A
right partial nephrectomy along with a distal pancreatectomy and
partial splenectomy were performed. The operation proceeded
without complication but he was sent to the PACU intubated after
the procedure to the length and extensive nature of the
operation. He was extubated in the ICU later in the evening of
[**Date Range **] 0 and transferred to the floor on [**Date Range **] 1 without incident.
The patient's post-operative course was largely uncomplicated.
Patient's NGT was dc'd on [**Date Range **] # 2, he was OOB to a chair and he
reported flatus. His epidural was removed on [**Date Range **] # 3 and he was
switched to a PCA which he [**Date Range 8337**] well. His foley was
removed six hours later but was reinserted after failure to
void. The foley catheter was discontinued at midnight of [**Date Range **]#
3. At this time patient subsequently voided without problem. On
[**Name2 (NI) **] 4, Mr. [**Known lastname **] [**Last Name (Titles) 8337**] clear liquids, was out of bed, on PO
pain medications, and his IV fluids were stopped. A second
attempt to remove the foley catheter was made on [**Last Name (Titles) **] # 3, the
creatinine level of the fluid in the first JP drain (placed by
urology) was checked four hours later and was consistent with
serum creatinine levels (0.8). Unfortunately, due to difficulty
voiding, the foley had to be reinserted once again. The foley
catheter was discontinued at midnight of [**Last Name (Titles) **]# 5. At this time
patient subsequently voided without problem. On [**Name2 (NI) **] # 5 and [**Name2 (NI) **]
# 6, the patient was advanced to fulls and regular diet, both of
which he [**Name2 (NI) 8337**] well. His JP drains were removed on [**Name2 (NI) **] # 6.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Oral diabetics medications were
restarted when advanced to regular diet. Labwork was routinely
followed; electrolytes were repleted when indicated. Physical
Therapy followed the patient during hospitalization, and
recommended to be discharge home with continue home PT.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. Surgical staples were removed and steri strips were
applied on incision site. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
glyburide/metformin 10/1000", avapro 150', ASA 81', Actos 30',
Hydralazine 50"', Lisinopril, Diphenhydramine-acetaminophen,
simvastatin 40'
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Glucovance 5-500 mg Tablet Sig: Two (2) Tablet PO twice a
day.
6. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
1. Pancreatic tail mass.
2. Renal cell carcinoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please take any new medications as prescribed.
Please do not continue to take Lisinopril and Avapro until
follow up with Urology service.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-21**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2123-12-3**] 10:15 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2124-1-31**] 10:45
.
Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2124-2-1**] 11:30
.
Please call [**Telephone/Fax (1) 5727**] to arrange a follow up appointment with
Dr. [**Last Name (STitle) 770**] (Urology) in [**3-17**] weeks after discharge.
Completed by:[**2123-11-8**]
|
[
"250.00",
"724.5",
"189.0",
"585.9",
"305.1",
"403.90",
"V43.65",
"753.0",
"577.1",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"52.52",
"55.4"
] |
icd9pcs
|
[
[
[]
]
] |
7209, 7276
|
3044, 6123
|
365, 486
|
7370, 7370
|
1999, 3021
|
8602, 9307
|
1676, 1714
|
6313, 7186
|
7297, 7349
|
6149, 6290
|
7521, 8074
|
8089, 8579
|
1729, 1729
|
1743, 1980
|
275, 327
|
514, 1331
|
7385, 7497
|
1353, 1529
|
1545, 1660
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,903
| 172,112
|
21888
|
Discharge summary
|
report
|
Admission Date: [**2117-11-15**] Discharge Date: [**2117-12-1**]
Date of Birth: [**2044-6-20**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Sulfa (Sulfonamides) / Codeine / Aspirin / Allopurinol
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Increasing dyspnea on exertion and worsening peripheral edema
Major Surgical or Invasive Procedure:
ultrafiltration
History of Present Illness:
Pt is a 73 year-old female with past medical history significant
for CHF, HTN, COPD, and chronic renal insufficiency (baseline
creatinine 2.0) who presented to an outside hospital with
complaint of worsening dyspnea on exertion and peripheral edema
over weeks. Pt reported easily fatigue, inability to climb
stairs or perform simple ADL with 26 lb wt gain in approx [**7-5**]
wks along with decreased urine output. Pt denied
CP/PND/Orthopnea. In the OSH, pt was found to have hypotension
started on levophed gtt, in acute renal failure with urine
output of 10-35cc/hr and Cr 4.7 and has rising BNP ?CHF. Pt was
started on rocephin 1g, solumedrol 125mg q6h, flagyl 250mg q8h,
and digoxin load iv. Transferred to [**Hospital Unit Name 153**] on [**11-15**] for sepsis,
and then transferred to now to CCU for ?cardiogenic shock and AF
w/ RVR to 130's, hypotension on levophen and vasopressin.
Past Medical History:
chronic renal failure, arthritis, Afib on coumadin, HTN, COPD.
s/p hysterectomy, cholecystectomy, cath in [**2117**] (clean cath no
stent required), appendectomy, tonsillectomy.
Social History:
50 pack-year smoking history (quit in [**Month (only) **]), denies recent
heavy EtOH and illicits; lives alone in apartment
Family History:
non-contributory
Physical Exam:
-VS: afebrile, P 89, BP 89/40, RR 16, O2 sat 100% on 5L nc
-Gen: A+O x 3, NAD
-HEENT: perrl, eomi, anicteric sclerae, MMM
-neck: JVD to angle of jaw while upright
-Heart: S1S2 irregular and diminished, II/VI holosystolic murmur
heard best at left sternal border
-Lungs: decreased BS bibasilarly
-Abd: multiple surgical scars consistent with past surgical
history, +BS, soft, nt, nd, no masses or hepatosplenomegaly
appreciated
-Ext: 3+ pitting edema throughout lower extremities, no cyanosis
or clubbing; DP pulses poorly palpable
-Skin: diffuse, erythematous, scaling rash
Pertinent Results:
[**2117-11-15**] 03:21PM GLUCOSE-198* UREA N-77* CREAT-4.7* SODIUM-144
POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-12* ANION GAP-24*
[**2117-11-15**] 03:21PM ALBUMIN-3.5 CALCIUM-8.0* PHOSPHATE-7.6*
MAGNESIUM-1.9
[**2117-11-15**] 03:21PM WBC-10.5 RBC-3.66* HGB-11.3* HCT-36.0 MCV-98
MCH-31.0 MCHC-31.5 RDW-16.9*
[**2117-11-15**] 03:21PM PLT COUNT-212
[**2117-11-15**] 03:21PM PT-31.4* PTT-36.4* INR(PT)-6.2
[**2117-11-15**] 03:21PM ALT(SGPT)-26 AST(SGOT)-30 CK(CPK)-113 ALK
PHOS-59 TOT BILI-0.3
[**2117-11-15**] 03:21PM CK-MB-5 cTropnT-0.04*
[**2117-11-15**] 03:23PM LACTATE-2.5*
[**2117-11-15**] 03:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2117-11-15**] 03:35PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2117-11-15**] 03:35PM URINE RBC-114* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2117-11-15**] 03:23PM TYPE-MIX PO2-41* PCO2-32* PH-7.16* TOTAL
CO2-12* BASE XS--17
[**2117-11-16**] 04:23AM BLOOD WBC-11.4* RBC-3.43* Hgb-10.6* Hct-33.3*
MCV-97 MCH-30.9 MCHC-31.8 RDW-16.3* Plt Ct-210
[**2117-11-18**] 02:47AM BLOOD WBC-5.6 RBC-2.77* Hgb-8.8* Hct-27.3*
MCV-99* MCH-31.8 MCHC-32.3 RDW-16.4* Plt Ct-114*
[**2117-11-19**] 09:39PM BLOOD WBC-4.7 RBC-3.09*# Hgb-9.9*# Hct-28.9*
MCV-94 MCH-31.9 MCHC-34.1 RDW-16.2* Plt Ct-90*
[**2117-11-21**] 03:27AM BLOOD WBC-5.7 RBC-3.19* Hgb-10.1* Hct-29.8*
MCV-93 MCH-31.8 MCHC-34.0 RDW-16.1* Plt Ct-96*
[**2117-11-23**] 05:07AM BLOOD WBC-7.4 RBC-3.42* Hgb-10.8* Hct-31.5*
MCV-92 MCH-31.6 MCHC-34.3 RDW-16.5* Plt Ct-152
[**2117-11-26**] 06:45AM BLOOD WBC-9.4 RBC-3.48* Hgb-10.9* Hct-32.1*
MCV-92 MCH-31.4 MCHC-34.0 RDW-16.7* Plt Ct-214
[**2117-11-29**] 04:40PM BLOOD WBC-7.0 RBC-2.90* Hgb-9.3* Hct-26.8*
MCV-93 MCH-32.0 MCHC-34.5 RDW-16.7* Plt Ct-205
[**2117-12-1**] 06:00AM BLOOD WBC-5.6 RBC-2.72* Hgb-8.8* Hct-25.3*
MCV-93 MCH-32.2* MCHC-34.7 RDW-16.8* Plt Ct-233
[**2117-11-27**] 07:11AM BLOOD PT-13.5 PTT-25.4 INR(PT)-1.2
[**2117-11-30**] 06:15AM BLOOD PT-13.9* PTT-27.3 INR(PT)-1.2
[**2117-12-1**] 06:00AM BLOOD PT-14.6* PTT-26.7 INR(PT)-1.3
[**2117-11-16**] 04:23AM BLOOD Glucose-195* UreaN-84* Creat-4.4* Na-142
K-4.5 Cl-113* HCO3-15* AnGap-19
[**2117-11-18**] 02:47AM BLOOD Glucose-76 UreaN-88* Creat-3.5* Na-142
K-4.1 Cl-115* HCO3-16* AnGap-15
[**2117-11-20**] 04:05AM BLOOD Glucose-114* UreaN-84* Creat-3.3* Na-142
K-4.7 Cl-112* HCO3-15* AnGap-20
[**2117-11-22**] 04:10AM BLOOD Glucose-130* UreaN-84* Creat-2.9* Na-143
K-4.4 Cl-113* HCO3-17* AnGap-17
[**2117-11-25**] 06:45AM BLOOD Glucose-98 UreaN-66* Creat-2.3* Na-146*
K-4.0 Cl-107 HCO3-27 AnGap-16
[**2117-11-28**] 08:45AM BLOOD Glucose-138* UreaN-52* Creat-2.5* Na-137
K-4.2 Cl-98 HCO3-24 AnGap-19
[**2117-11-29**] 06:30AM BLOOD Glucose-106* UreaN-56* Creat-2.6* Na-137
K-4.0 Cl-99 HCO3-26 AnGap-16
[**2117-12-1**] 06:00AM BLOOD Glucose-99 UreaN-68* Creat-2.7* Na-138
K-4.3 Cl-101 HCO3-26 AnGap-15
[**2117-11-16**] 10:55AM BLOOD ALT-21 AST-22 LD(LDH)-169 AlkPhos-49
TotBili-0.3
[**2117-11-24**] 06:22AM BLOOD ALT-16 AST-25 AlkPhos-59 Amylase-89
TotBili-1.5
[**2117-11-27**] 12:30PM BLOOD ALT-18 AST-22 LD(LDH)-283* AlkPhos-77
Amylase-77 TotBili-2.7*
[**2117-11-19**] 02:00AM BLOOD Lipase-28
[**2117-11-24**] 06:22AM BLOOD Lipase-72*
[**2117-11-27**] 12:30PM BLOOD Lipase-45
[**2117-11-15**] 03:21PM BLOOD CK-MB-5 cTropnT-0.04*
[**2117-11-16**] 04:23AM BLOOD CK-MB-5 cTropnT-0.07*
[**2117-11-16**] 10:55AM BLOOD Albumin-3.4
[**2117-11-18**] 10:36PM BLOOD Calcium-9.0 Phos-5.8* Mg-1.8
[**2117-11-23**] 05:07AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.7
[**2117-11-25**] 05:41PM BLOOD Mg-1.5*
[**2117-11-30**] 06:15AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8
[**2117-12-1**] 06:00AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.9
[**2117-11-15**] 03:21PM BLOOD TSH-0.68
[**2117-11-19**] 02:00AM BLOOD Hapto-114
[**2117-11-15**] 03:21PM BLOOD Free T4-0.9*
[**2117-11-18**] 02:47AM BLOOD Cortsol-40.7*
[**2117-11-15**] 03:21PM BLOOD Digoxin-1.9
[**2117-11-17**] 05:10AM BLOOD Digoxin-0.9
[**2117-11-19**] 02:00AM BLOOD Digoxin-0.7*
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is a large right
pleural effusion with atelectasis of the adjacent right lower
lobe. There is also a small left pleural effusion with left
basilar atelectasis. As noted by CT [**2117-11-19**], the left
kidney is markedly atrophic with a prominent collecting system,
measuring 23 x 31 mm. The right kidney also contains a 4.6 x 5.0
cm cyst arising from it's lower pole. In addition, there are two
subcentimeter high attenuation foci within the parenchyma of the
right kidney, unchanged in the interval, and most likely
representing hemorrhagic renal cysts, but not well evaluated on
this noncontrast CT. The right psoas hematoma has decreased in
size in the 8 day interval, now measuring 6.8 x 6.5 cm, vs. 9.0
x 9.8 cm previously.
The liver, spleen, adrenal glands, and bowel are unremarkable.
There are several punctate calcification within the tail of the
pancreas, possibly related to splenic artery calcifications or
the residua of prior pancreatitis.
CT OF THE PELVIS WITHOUT IV CONTRAST: The visualized portions of
the bowel are unremarkable. There are multiple sigmoid colonic
diverticuli, but there is no adjacent mesenteric stranding and
there are no fluid collections. A Foley catheter is present
within a decompressed bladder.
The osseous structures are unremarkable.
IMPRESSION: 1. Decreased size of the right psoas hematoma in the
eight day interval.
2. Large right, and small left pleural effusion with bibasilar
atelectasis.
3. Markedly atrophic left kidney (3.2 cm in length), with a
prominent collecting system, not well evaluated on this
noncontrast CT. There is also a right lower pole renal cyst and
two high attenuation foci within the right kidney, which
probably represent hemorrhagic renal cyst.
CT ABDOMEN W/ ORAL CONTRAST ONLY: There is a large hematoma in
the right psoas muscle that measures 9.8 x 9.0 x 7.4 cm. It is
hyperdense, which suggests it is an acute hematoma. There is no
evidence of free fluid in the abdomen.
There are bilateral pleural effusions, and associated
atelectasis. The size of the pleural effusions is
moderate-to-large. There is no pericardial effusion. There is a
Swan ganz catherer is to the right of the heart.
The liver is fatty, but there are no focal lesions in the liver.
The left kidney is atrophic. The right kidney contains a cyst in
the lower pole, measuring 4.7 cm. It also contains a small
hyperdense area in the lower pole that measures 5 mm, and a
hyperdense area in the mid pole that measures 6 mm. They are not
well-characterized in this study. The pancreas is unremarkable.
The aorta is calcified.
CT PELVIS W/ ORAL CONTRAST ONLY: There is a Foley catheter
within the urinary bladder. There is a small amount of air in
the pelvis that is probably within the dome of the urinary
bladder. There is a small amount of free fluid in the pelvis.
The rectum is unremarkable. There are diverticula within the
sigmoid colon, without evidence of diverticulitis. There is no
thickening of the sigmoid colon. There is significant edema of
the abdominal wall and subcutaneous tissues.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
There are degenenerative changes of the lumbar spine.
IMPRESSION
1. The findings are consistent with a large hematoma in the
right psoas
muscle as described above.
2. Atrophic left kidney.
3. One (1) simple cyst in the left kidney, and two (2)
hyperdense areas that
are too small to characterize in this study. They could
represent
hemorrhagic cysts.
4. A small amount of free fluid in the pelvis.
BILATERAL LOWER EXTREMITY ULTRASOUND: The study was limited by
patient body habitus. Grey scale and color Doppler son[**Name (NI) 1417**]
were performed of the common femoral, superficial femoral,
popliteal and calf veins bilaterally. Normal flow,
compressibility, wave forms, and augmentation was demonstrated
though again imaging is suboptimal. No intraluminal thrombus is
seen.
IMPRESSION: Limited study. No evidence of DVT.
Brief Hospital Course:
1. Hypotension: Admission BP 90's/40's. Initially treated
with vancomycin and levaquin for possible sepsis. TSH and
random cortisol levels did not support myxedema or adrenal
crisis, respectively. Ms.[**Known lastname **] came from OSH on IV solumedrol
for possible adrenal insufficiency, which was subsequently
tapered off. ECHO revealed preserved EF of 55%, with 4+MR and
3+TR. Worry about cardiogenic component prompted PA line
placement: CVP mid 20's, elevated PAP's (diastolics 30's-40's),
PCWP mid-high 20's, cardiac index [**4-1**] with SVR in the 400's. Pt
initially requiring fluid boluses and levophed for BP
augmentation, transferred to CCU still in shock of uncertain
etiology. Pt remained afebrile, without leukocytosis or
positive source of fever. Pt was in AF, anticoagulated with
heparin and unfortunately developed an RP bleed. Amio drip was
also stopped [**3-1**] hypotension. Cardiogenic component treated
with nesiritide and lasix drip which was not tolerated [**3-1**]
increased hypotension. TEE revealed 30% EF with severe MR [**First Name (Titles) **] [**Last Name (Titles) **]R. Levophed weaned and vasopressin titrated. HCT drop from
33->23 with back pain served as impetus for CT belly--> right
psoas bleed (PTT at time was 150). Anticoagulation stopped and
BP slightly improved, still requiring pressors. Abx stopped to
allow possible infection to manifest and declare itself. At
that time current thought etiology was multifactorial with
cardiogenic (high wedge) vs sepsis (low SVR) as major
contributors. Off antibiotics, Pt did well without
decompensation. No obvious source of infection found. Likely
explanation was that mostly likely cardiogenic shock secondary
to brief unknown insult, possibly infectious. Remaining of
hospitalization BP well controlled with SBP stable in the low
90's to 100's.
2. CHF: Pt with moderately depressed EF ~30-35% with severe MR
and TR. Etiology unclear (mild dz in RCA and [**Name (NI) **] and clean
LAD/LMCA) but major contibutor from valvular disease. Pt also
in rapid atrial fibrillation, contributing to elevated
pressures. Pt did not tolerate natrecor or lasix drip and
initially diuresed with lasix boluses. [**Name (NI) 57398**] Pt underwent
Ultrafiltration with great result. After which continued to
diurese on lasix continuous infusion. Over the last few days,
transitioned to lasix PO daily. Pt to be discharged home on a
daily dose of 20 mg PO which will need to be increased as
necessary. Pt to follow up with PCP in one [**Name9 (PRE) 57399**] help
determine approriate dose. Pt to be d/c home on BB and ACEi.
Weight on admission 113 kg and upon discharge 80kg. Pt
instructed to limit salt to 2gm daily and keep daily weights
with close follow up with PCP and [**Hospital 1902**] clinic. In the future,
she will require evaluation for MVR/repair +/- TV annuloplasty.
3. Rhythm: Pt with paroxysmal atrial fibrillation. Ms.[**Known lastname **]
did go into rapid atrial fibrillation, with ventricular rates in
the 130's. Levophed and transient dopamine resulted in rapid
rates and contributed to hypotension. Her rate decreased to
50's-60's when levophed and dopamine weaned. Attempt at
cardioversion during TEE failed to control rhythm. Pt
spontaneously self-cardioverted [**11-18**] and remained in NSR for a
significant amount of time after which she was found to be in
and out of afib throught the day. Anticoagulation held
secondary to psoas bleed. Once bleed stable Pt restarted on
Coumadin at dose 5mg qhs. Pt subtherapeutic at time of discharge
and will have INR checked by PCP in one week. Pt to be d/c home
on BB and amiodarone.
4. Renal: Pt does have chronic renal insufficiency since
childhood with baseline Cr in the ~2's. Max Cr 4.7 on
admission, decreased with diuresis and improved renal perfusion
[**3-1**] improved forward flow from diuresis. FENA 0.2% and current
GFR 16 ml/min by MDRD. The patient did not require dialysis
while in house. Pt did undergo ultrafiltration for CHF and did
well. Cr at time of dishcarge stable at 2.3.
5. Retroperitoneal Bleed: Pt was anticoagulated with heparin
for paroxysmal AF. She was found to have a supratherapeutic PTT
(>150) and her heparin drip was accordingly decreased according
to protocol. Unfortunately her hematocrit dropped from 33-23
and she developed back pain and was found to have a right psoas
hematoma [**11-18**]. Surgery consulted and decided no intervention
was necessary other than stopping Ms.[**Known lastname **] anticoagulation,
which was done. Off anticoagulation Hct stable. One week
later, coumadin restarted and HCT remained stable. Pt to have
Hct checked next week by PCP.
6. ID: Pt's low SVR (~400's) in the setting of shock was
worrisome for sepsis. The patient did have 1/4 bottles
coagulase negative Staph grow at OSH and did have a dirty UA,
but failed to show any objective signs of infection at [**Hospital1 18**]
including fever, rigors, leukocytosis, positive cultures or
fluid collection on imaging. She was transiently put on
antibiotics for emperic coverage, but were quickly d/c'd with
the hope of unmasking an infection. Pt continued to do well off
antiobiotics. No infectious etiology ever determined; cultures
all without growth.
7. Rash: Pt noted to have pruritic rash at home in early [**8-1**].
Initially over bilateral LE's and UE's and progressing in no
discernable pattern. Pt recently started allopurinol for gout,
which was stopped, with no improvement in the rash. Dermatology
consulted while in house and also felt rash was [**3-1**] allopurinol.
Treated with triamcinalone cream mixed with Aquaphor and
applied to rash [**Hospital1 **]. Rash resolved off allopurinol.
Medications on Admission:
Home meds:
-spironolactone 25 mg daily
-furosemide 80 mg [**Hospital1 **]
-metoprolol 50 daily
-warfarin 5 mg daily
-lisinopril 10 mg qhs
-advair 100/50
-allopurinol 300 mg daily
Meds on transfer:
-vancomycin 1 g x 1 dose
-ceftriaxone 1 g q24
-metronidazole
-solumedrol
Discharge Medications:
1. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)
for 2 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
Disp:*qs * Refills:*2*
4. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): stop using with complete
resolution of rash. avoid face.
Disp:*qs * Refills:*2*
5. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): stop using with complete
resolution of rash. Avoid face.
Disp:*qs * Refills:*2*
6. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed: stop using with complete
resolution of rash.
Disp:*qs * Refills:*0*
8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 976**] VNA Inc
Discharge Diagnosis:
CHF
AFib
acute renal failure
chronic renal insufficiency
HTn
Discharge Condition:
good
Discharge Instructions:
please call PCP or return to ED if suffering from chest pain,
worsening shortness of breath, fever greater than 101.4,
inability to speak or understand conversation, inability to
moves ones extremities.
Please carefully watch your diet keeping total salt consumption
as low as possible (less than 2 gm per day). Record daily
weights and call PCP with changes.
Followup Instructions:
Please follow up Dr [**Last Name (STitle) 57400**] ([**Telephone/Fax (1) 57401**]) next Thursday [**12-9**] at 3:30 PM. You will need your INR checked and coumadin
adjusted if necessary.
If after seeing Dr [**Last Name (STitle) 57400**] you wish to make a follow
appointment with the [**Hospital 1902**] clinic here at [**Hospital1 18**] please feel free
to call ([**Telephone/Fax (1) 7179**].
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,740
| 143,670
|
33263
|
Discharge summary
|
report
|
Admission Date: [**2104-12-15**] Discharge Date: [**2104-12-17**]
Date of Birth: [**2026-4-10**] Sex: M
Service: MEDICINE
Allergies:
Zithromax / Erythromycin Base
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
PICC placement [**2104-12-16**]
History of Present Illness:
The pt is a 78 yo with COPD (non compliant with home o2), CAD,
DM II, PAD, A fib, HTN, HL, and [**Last Name (un) **] body dementia who presented
with respiratory distress and was found to have a new RLL PNA.
.
Per nursing home notes at approximately noon the pt came out of
the bathroom with increased respiratory distress and some
increased confusion. VS at the time were BP 160/90 HR 130 RR40s
02 sat 85% RA. RN form states o2 sats baseline in the 80s and
that he is non-compliant with oxygen at home. Also reports pt
with baseline tremors and recently completed a course of abx for
UTI. He is also on lactulose for an elevated ammonia level.
.
In the emergency department, vs were 99.9 133/62 HR 100 RR40 o2
sat 89% on 4L. FS was 246. CXR showed RLL infiltrate. Exam was
notable for crackles in the RLL. WBC 11 with 82% neutrophils. Pt
received tamiflu 75 po x1, ceftriaxone 1g IV, levoquin 750mg IV,
prednisone 60mg po, and combivent nebs. Flu swab was sent. He
was admitted to the ICU for PNA.
.
On arrival to the floor patient was drowsy but arousable. Denies
current CP, SOB, nausea, diarrhea, dysuria, hematuria.
.
Patient unable to give reliable ROS.
Past Medical History:
1. COPD on 2LO2
2. Multivessel CAD s/p BMS to the RCA and LCX [**4-30**], PTCA/BMSx2
to mid-LAD [**6-30**]
3. DMII
4. PAD s/p L SFA stent
5. Atrial fibrillation
6. Hypertension
7. Hyperlipidemia
8. [**Last Name (un) 309**] body dementia
9. Duodenal ulcer [**8-30**] EGD
Social History:
Currently lives in Stone [**Hospital3 **] home. He continues to
smoke at least one pack of cigarettes a day (smoked for 60
years). Denies etoh use, h/o IVDU.
Family History:
Non-contributory.
Physical Exam:
GENERAL: Sleepy but arousable
HEENT: Normocephalic, atraumatic. No scleral icterus. PERRL.
MMM. OP clear. Neck Supple, No LAD.
CARDIAC: Mild tachycardic. Normal S1, S2. No murmurs, rubs or
[**Last Name (un) 549**].
LUNGS: Very poor air movement throughout lungs, especially at
right lung base.
ABDOMEN: +BS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis. +
erythema and ulcers of the calves.
NEURO: A&Ox3. Sleepy but arousable. Unable to answer questions
well about recent history. CN 2-12 intact. 5/5 strength
throughout. [**1-25**]+ reflexes, equal BL. Normal coordination. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2104-12-15**] 02:00PM BLOOD WBC-11.0 RBC-4.34* Hgb-13.5* Hct-42.9
MCV-99* MCH-31.0 MCHC-31.4 RDW-16.9* Plt Ct-152
[**2104-12-15**] 02:00PM BLOOD Glucose-211* UreaN-32* Creat-0.8 Na-141
K-4.5 Cl-102 HCO3-30 AnGap-14
[**2104-12-15**] 02:00PM BLOOD ALT-24 AST-30 LD(LDH)-297* AlkPhos-66
TotBili-0.6
[**2104-12-16**] 03:09AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.9
.
CXR [**2104-12-15**]:
FINDINGS: AP portable upright view of the chest is obtained.
There has been
interval removal of the right arm PICC line. There is a
consolidation in the
right lower lung concerning for pneumonia. There may be a small
associated
right pleural effusion. Heart size remains mildly prominent.
There may be
mild central pulmonary [**Month/Day/Year 1106**] engorgement, though this may be
exaggerated
due to technique. Slight motion artifact also limits evaluation.
Mediastinal
contour is stable with faint atherosclerotic calcification along
the aortic
knob. Bony structures appear intact.
IMPRESSION: Findings concerning for pneumonia in the right lower
lung, small
right pleural effusion, mild congestion.
.
CXR [**2104-12-16**]:
Right PICC appears to end at lower SVC. discussed with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 468**], IV nurse,
at 7:20 pm. opacity at right lower lung remains unchanged.
.
Blood cx [**12-15**]: NGTD
MRSA screen: positive
Flu DFA: Negative
Legionella: Negative
Brief Hospital Course:
78M with COPD, CAD, DM2, HTN, with recent admission for
pneumonia, presents from his NH with recurrent HAP
.
.
HAP: Patients altered mental status in the setting of cough and
SOB suggested pneumonia, confirmed by CXR. He was admitted for
pneumonia in the past. He was given ceftriaxone and
levofloxacin in the ED and admitted to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] he
was broadened to vanco/cefepime/levoflox. Flu swab was
negative, as were legionella and blood cultures. Sputum culture
was contaminated. He improved markedly over 24hrs and was
transferred to the medical floor. A PICC was placed on
[**2104-12-16**]. He must complete a 10 day course of all antibiotics
through [**2104-12-24**]
.
COPD Exacerbation: He was felt to have an exacerbation
superimposed on his pneumonia. He was started on prednisone
60mg daily. His oxygen requirement returned to his baseline of
2L NC. He must continue his usual nebulizers and complete a
brief prednisone taper: [**2020-12-14**] 60mg, [**2022-12-17**] 40mg, [**2024-12-19**]
20mg, [**Date range (1) **] 10mg then stop.
.
Shin, buttock wounds: He was found to have multiple wounds due
to his friable skin. Wound care evaluated the patient and made
recommendations for wound care dressings (see page 1).
.
CAD, native: Continued ASA, Plavix, BB, ACE-I, statin at usual
dose
.
Dementia: Continued aricept, depakote
.
Type 2 Diabetes mellitus, poorly controlled with comps:
Continued HISS in house with good control in the high 100s.
.
Afib: Continued BB, digoxin and ASA. Dig level was acceptable
range.
.
HTN, benign: Stable, continued home regimen.
.
DNR/DNI for this admission
Medications on Admission:
Novolog
Lactulose 30ml daily
Anascol PR daily prn
depakote ER 500mg po daily (9pm
Aricept 10mg po daily (9pm)
Digoxin 125mcg daily
Lasix 20mg po daily
paroxetine 20mg daily
Plavix 75mg po daily
Spiriva 18mcg 1 capsule by mouth daily
Metoprolol 100mg po bid
Mirtazapine 7.5mg qhs
simvastatin 40mg qhs
Vitamin B1 100mg po daily
Lisinopril 5mg po daily
Prednisone 5mg po daily
Aspirin 325mg po daily
MVI po daily
Acidophillus 2 cups po tid (last day 28th)
Nitroglycerin 0.3mg po SL
Albuterol 0.083% solution
Bisacodyl 10 mg PR prn constipation
MOM 30ml po daily prn constipation
Mylanta 30ml po q6hrs prn
tylenol 650mg po q 4hr prn pain/temp
robitussin 10 ml (200mg) po q4hrs prn cough/congestion
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: 1-10 units
Subcutaneous ASDIR (AS DIRECTED): [**Last Name (LF) **], [**First Name3 (LF) **] sliding scale per
protocol.
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
3. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
11. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
17. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q4H (every
4 hours) as needed for cough.
18. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation.
19. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
21. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: through [**2104-12-24**].
22. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 7 days: through
[**2104-12-24**].
23. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 7 days: through [**2104-12-24**].
24. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
25. Prednisone 20 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily):
40mg [**12-18**], [**12-19**]
20mg [**12-20**], [**12-21**]
10mg [**12-22**], [**12-23**]
then STOP.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4657**] - [**Location 1268**]
Discharge Diagnosis:
Health care associated pneumonia
COPD exacerbastion
CAD, native vessel
Dementia, multi-infarct
Type 2 diabetes mellitus, uncontrolled with complications
Atrial fibrillation
Hypertension, benign
Discharge Condition:
Good
Discharge Instructions:
Patient admitted for healthcare associated pneumonia. Being
treated empirically with vancomycin/cefepime/levofloxacin. Will
need a 10 day course of therapy. Is also being treated
concurrently for a mild COPD exacerbation with prednisone.
Please continue home oxygen as before. Please resume all
previous medications as prescribed.
.
Please have patient follow up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4321**] in the next 2
weeks
.
Have patient return if feveres recur, shortness of breath
recurs, chest pain, altered mental status, or any other
concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2105-1-29**] 10:50
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2105-2-12**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2105-2-12**] 1:20
|
[
"427.31",
"294.10",
"331.82",
"486",
"250.02",
"443.9",
"272.4",
"305.1",
"491.21",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8975, 9044
|
4177, 5850
|
301, 335
|
9282, 9289
|
2758, 4154
|
9933, 10319
|
2009, 2028
|
6594, 8952
|
9065, 9261
|
5876, 6571
|
9313, 9910
|
2043, 2739
|
254, 263
|
363, 1524
|
1546, 1817
|
1833, 1993
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,600
| 156,356
|
6791
|
Discharge summary
|
report
|
Admission Date: [**2187-9-3**] Discharge Date: [**2187-9-12**]
Date of Birth: [**2119-11-23**] Sex: M
Service: MEDICINE
Allergies:
Latex / Valium / Flagyl / Sulfa (Sulfonamides) / Talwin Nx /
Dilaudid / Zestril / Aspartame
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
chest pain with abnormal cardiac stress test transferred for
cardiac cath
Major Surgical or Invasive Procedure:
Cardiac catheterization with PCI to distal LAD with bare metal
stent
History of Present Illness:
67 M with a history of spina bifida complicated by paraplegia,
hydrocephalus with a VP shunt, colitis s/p colostomy, stage III
decub on the buttocks, barrett's esophagus, 2 prior cardiac
caths with normal coronaries (last in [**2182**]), who presents from
an OSH for cardiac catheterization after an abnormal stress
test. The patient presented to his PCP's office with chest pain
on [**2187-8-30**]. The patient was sent to [**Hospital3 7569**]. His pain
resolved with SL NTG. He was ruled out for an MI negative
cardiac enzymes. A stress test completed on [**2187-8-31**] revealed a
reversible anteroseptal apical wall defect and a fixed
inferolateral wall defect with an EF of 32%. He was placed on a
nitroglycerin drip (2cc/hr, 12mcg/min), clopidogrel 75mg QD
(started on [**2187-9-1**] without loading dose) held in the morning
prior to cath, and aspirin.
.
He was transferred to [**Hospital1 18**] for cath that revealed 60% distal
LAD lesion, OM2 w/ 50% lesion, and no obstructive disease in
LMCA and RCA. The LAD lesion was stented with a BMS. The cath
was notable for difficult access in the right groin and
eventually the left groin was used. He was admitted from the
cath lab to the [**Hospital1 1516**] service on [**Hospital Ward Name 121**] 3, but shortly after
arriving to the floor he developed a large hematoma in the right
groin. His BP was noted to have dropped from 140s systolic on
arrival to the floor to 100s. HR was stable in the 60s-70s.
Pressure was held for more than 1 hour. An central line in the
left groin was placed. The arterial sheath in the left groin was
left in for a-line readings. A stat Hct from the a-line was 29;
last Hct from OSH was 33.8. The pt was given 1U PRBC and
transferred to the CCU for further monitoring.
Past Medical History:
-- CAD s/p 2 prior cardiac catheterizations: [**2181-9-2**] with 30%
RCA,
[**2182-12-3**] without significant disease
-- CHF (last EF 32%)
-- Spina bifida complicated by paraplegia
-- Hydrocephalus s/p VP shunt placement
-- DM II
-- trifasciular block
-- bradycardia
-- Stage III decub ulcer
-- TIA in [**2172**] and [**2177**]
-- Colitis s/p colectomy and colostomy
-- s/p urostomy and neobladder
-- HTN
-- GERD with h/o barrett's esophagus and esophageal strictures
-- Obstructive sleep apnea
-- H/o recurrent small-bowel obstructions
-- Abdominal hernia
-- H/o hyperuricemia complicated by nephrolithiasis
-- Depression
Social History:
The patient lives alone with extensive, well managed, services,
is mobile with his wheelchair. Patient denies any alcohol, or
smoking, or intravenous drug use.
Family History:
no premature CAD, non-contributory
Physical Exam:
VS: 97.5, 70, 126/66
GEN: NAD
HEENT: sclera anicteric, OP clear, MMM, no LAD, no carotid
bruits. No JVD.
CV: regular, nl s1, s2, no m/r/g.
PULM: CTAB, no r/r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL, no femoral bruits.
NEURO: alert & oriented x 3, CN II-XII grossly intact. [**4-6**]
strength symmetric @ triceps, biceps, delts, 0/5 below waist
(paraplegia), though does have some abilty to transfer himself
chronically.
Pertinent Results:
.
CARDIAC CATH [**2187-9-3**]:
1. Selective coronary angiography of this right dominant system
demonstrated a one vessel and a branch vessel CAD. The LMCA had
no flow
limiting lesions. The LAD had a 60% distal stenosis. The LCx
had no
obstructive disease in the main vessel but had a 50% stenosis in
the OM2
branch. The RCA was free of angiographically apparent
epicardial
disease.
2. Left ventriculography was deferred.
3. Successful PCI of the distal LAD with a 2.0x12mm bare metal
stent
deployed at 14 atm with excellent final results.
.
FINAL DIAGNOSIS:
1. Single vessel and a branch vessel CAD.
2. Successful PCI of the distal LAD with a bare metal stent
.
ECHO [**2187-9-4**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Basal systolic
function appears good. The more distal segments could not be
visualized (no apical or subcostal windows). A mid-ventricular
lateral wall motion abnormality is suggested in some views, but
could not be confirmed. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. 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 [**2181-9-14**], symmetric left ventricular
hypertrophy is suggested, and a regional wall motion abnormality
cannot be excluded.
.
If clinically indicated, a RVG/MUGA scan or cardiac MRI
([**Telephone/Fax (1) 9559**]) would be better able to assess regional and
global left ventricular systolic function.
.
.
[**2187-9-12**] 07:00AM BLOOD WBC-8.0 RBC-3.33* Hgb-9.8* Hct-29.4*
MCV-88 MCH-29.5 MCHC-33.5 RDW-17.9* Plt Ct-328
[**2187-9-11**] 07:00AM BLOOD WBC-7.7 RBC-3.43* Hgb-10.1* Hct-30.0*
MCV-88 MCH-29.4 MCHC-33.6 RDW-17.6* Plt Ct-284
[**2187-9-10**] 07:00AM BLOOD WBC-8.5 RBC-3.24* Hgb-9.6* Hct-28.3*
MCV-87 MCH-29.8 MCHC-34.0 RDW-17.4* Plt Ct-258
[**2187-9-9**] 05:30PM BLOOD WBC-9.4 RBC-3.40* Hgb-9.9* Hct-30.0*
MCV-88 MCH-29.2 MCHC-33.0 RDW-17.5* Plt Ct-257
[**2187-9-9**] 06:09AM BLOOD WBC-7.5 RBC-3.27* Hgb-9.4* Hct-28.8*
MCV-88 MCH-28.8 MCHC-32.7 RDW-17.6* Plt Ct-233
[**2187-9-3**] 06:56PM BLOOD Hct-29.6*
[**2187-9-3**] 09:01PM BLOOD Hct-30.8* Plt Ct-184
[**2187-9-4**] 04:53AM BLOOD WBC-9.6 RBC-3.55* Hgb-9.9* Hct-30.6*
MCV-86 MCH-27.9 MCHC-32.3 RDW-18.3* Plt Ct-181
[**2187-9-4**] 01:14PM BLOOD Hct-28.3*
[**2187-9-6**] 06:40AM BLOOD WBC-7.4 RBC-2.81* Hgb-8.2* Hct-24.3*
MCV-87 MCH-29.3 MCHC-33.8 RDW-17.2* Plt Ct-119*
[**2187-9-6**] 11:00AM BLOOD WBC-7.4 RBC-2.59* Hgb-7.6* Hct-22.6*
MCV-87 MCH-29.4 MCHC-33.7 RDW-17.5* Plt Ct-124*
[**2187-9-12**] 07:00AM BLOOD Glucose-136* UreaN-45* Creat-1.1 Na-147*
K-4.4 Cl-107 HCO3-32 AnGap-12
[**2187-9-11**] 07:00AM BLOOD Glucose-112* UreaN-50* Creat-1.2 Na-144
K-4.3 Cl-105 HCO3-33* AnGap-10
[**2187-9-3**] 09:01PM BLOOD Glucose-141* UreaN-30* Creat-0.9 Na-138
K-4.0 Cl-101 HCO3-30 AnGap-11
[**2187-9-4**] 04:53AM BLOOD Glucose-138* UreaN-31* Creat-1.0 Na-139
K-4.4 Cl-102 HCO3-31 AnGap-10
[**2187-9-6**] 06:40AM BLOOD Glucose-164* UreaN-57* Creat-2.4*# Na-136
K-5.1 Cl-98 HCO3-26 AnGap-17
[**2187-9-6**] 03:29PM BLOOD Glucose-169* UreaN-58* Creat-2.4* Na-132*
K-5.1 Cl-97 HCO3-25 AnGap-15
[**2187-9-12**] 07:00AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.3
[**2187-9-11**] 07:00AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.1
[**2187-9-10**] 07:00AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1
[**2187-9-4**] 04:53AM BLOOD Calcium-8.0* Phos-4.6* Mg-2.2 Cholest-149
[**2187-9-6**] 06:40AM BLOOD Mg-2.2
Brief Hospital Course:
CCU COURSE:
Pt was transferred to [**Hospital1 18**] for cath that revealed 60% distal
LAD lesion, OM2 w/ 50% lesion, and no obstructive disease in
LMCA and RCA. The LAD lesion was stented with a bare metal
stent. Cardiac cath was notable for difficult access in the
right groin with multiple attempts made, and eventually the left
groin was used was used after repeated attempts there also. Pt
was breifly admitted from the cath lab to the [**Hospital1 1516**] service on
[**Hospital Ward Name 121**] 3, but shortly after arriving to the floor he developed a
large hematoma in the right groin. His BP was noted to have
dropped from 140s systolic on arrival to the floor to 100s. HR
was stable in the 60s-70s. Pressure was held for more than 1
hour. An central line in the left groin was placed. The
arterial sheath in the left groin was left in for a-line
readings. A stat Hct from the a-line was 29; last Hct from OSH
was 33.8. The pt was given 1U PRBC and transferred to the CCU
for further monitoring.
.
Patient's anti-hypertensives were initially held overnight until
patient was assessed to be hemodynamically stable. On [**2187-9-4**]
left sheath pulled with additional small hematoma despite
compression. The patient continued to receive ASA, Plavix and
lipitor. The patient tolerated reintroduction of metoprolol
without incident. The patient was transfused with 2U [**Date Range **]
during his ICU stay, most recently at 5pm on [**2187-9-5**] for Hct of
24 (Hct 28.3 -> 25 -> 24) from [**9-4**] to [**9-5**]. No imaging of
either groin was performed. The patient had a TTE performed
although limited secondary to poor windows.
.
[**Hospital1 **] MEDICINE COURSE:
Pt was returned to the [**Hospital1 1516**] service on [**2187-9-6**]. He was
hemodynamically stable and chest pain free.
.
# groin hematomas - pt's hematocrit on the morning of his
arrival declined from 28->22, although pt remained
hemodynamically stable and without symptoms. Clinically, his
groin exam appeared unchanged from his CCU stay (bilateral
hematomas were marked in CCU and again on admission to medicine
service). No bruits were appreciated, distal pulses were 2+.
Pt received another 2U PRBC, with only modest improvement in his
hematocrit. A stat CT was obtained to rule out retroperitoneal
bleed, which showed no retroperitoneal bleed, but stable large
hematoma on the left and right groin. Serial monitoring of HCT
were stable, but failed to improve substantially with ongoing
transfusion x 3 Units, suggesting ongoing blood loss.
(28->22->26.5->27.5->26.7->27 ([**2187-9-8**]). Throughout this period
pt remained clinically stable with SBP in 130-140s.
Antihypertensive agents were held in light of question of
ongoing bleeding, however once his hematocrit became stable on
[**9-8**], his antihypertensive regimen was restarted. Specifically,
his dose of Toprol XL was increased to 50mg po qdaily, he was
started on [**First Name8 (NamePattern2) **] [**Last Name (un) **] (losartan 25mg po qd). These medications were
favored over his prior norvasc given his recent acute coronary
syndrome. Pt was also restarted on a lower dose of his imdur at
30 mg po qdaily to provide anginal releif.
.
.
# tranfusion reaction - while receiving his 4th unit of [**Name (NI) **],
pt was noted to have chills, and a low grade tremor.
Transfusion was stopped, and tranfusion reaction was evaluated,
but was felt not to be immune mediated. Pt has no restrictions
for receiving future transfusions.
.
.
# cardiac - after catherization, pt remained chest pain free
until [**2187-9-7**], when a breif <10 min episode of central chest
pain, without SOB/diaphoresis/n/v resolved with sl ntg x 1. EKG
was obtained which was unremarkable for changes when compared to
baseline. A second simliar episode occurred on [**9-11**], with no
EKG changes and resolution with 1 sl ntg. Pt was therefore
restarted on [**9-12**] on his prior regimen of imdur at slightly
lower dose (30 mg po qd) given recent adjustment of his BP
medications. Pt was continued on aspirin and plavix. He was
switched to Toprol XL 25 mg po qdaily on [**2187-9-8**] to reduce
ischemic symptoms and manage hypertension. Given his recued EF,
he was started on losartan, which was then held in the setting
of elevated creatinine (peak 2.4), which was attributed to
post-contrast nephropathy. ACE inhibitors were not used given
his history of zestril sensitivity. Once his creatine was
trending downward, his losartan was restarted (25 mg po qdaily).
Pt's prior use of norvasc was discontinued in favor of toprol
and losartan given his recent ACS. Pt was continued on his home
dose of lasix 80 mg po qdaily. Atorvastatin was continued.
.
Pt remained in normal sinus rythym throughout his
hospitalization. Given his history of trifasicular block, and
concern for using multiple nodal blocking agents, and normal
sinus rythym during this hospitalization, we have recommended
that he discontinue his dofetilide, in favor of continuing beta
blockade with toprol which should also provide benefit in the
setting of his acute coronary syndrome.
.
.
# [**Doctor First Name 48**] - Pt's creatine rose from 1.0 on admission to 2.4 s/p
cath, likely related to post-contrast nephropathy, fena 1.4%
(though on lasix), urine na 32, not clearly dehydrated, however
modest improvement overnight with 2U PRBC and 500cc bolus. A
renal usn was obtained which was unremarkable for hydronephrosis
in the setting of stable groin hematomas. Pt' creatinine slowly
trended back [**Last Name (un) 8636**], to 1.1 on [**2187-9-12**].
.
.
# spina bifida/paraplegia - pt has a h/o of spina bifida with
some degree of lower extremity paraplegia. He has chronically
been with colostomy [**1-4**] colitis and is s/p urostomy with
neobladder. No change was made in his usual regimen of wound
care and microdantin (presumably for UTI prophylaxis). He
experienced no acute bleeding from his colostomy on both aspirin
and plavix daily.
.
.
# decubitus ulcer - pt presented with a chronic sacral decubitus
ulcer, for which he received wound care, a pneumatic bed, and
frequent repositioning. He was afebrile throughout his hosiptal
course, and without WBC elevation.
.
.
# DM2 - pt was continued on his usual outpatient regimen of NPH
50U/40U qam/qhs with additional sliding scale coverage.
.
.
#. GERD - pt has a h/o Barrett's with strictures for which he
was continued on his usual regimen of protonix.
.
.
#. Depression - pt not currently on any medications. He was in
good spirits throughout his hospitalization, despite groin
hematomas bilaterally.
.
# Obstructive Sleep Apnea - pt has a h/o sleep apnea, but is not
using CPAP currently, and declines to do so presently.
.
#. Back pain - pt has a history of chronic back pain, reportedly
from lying flat in bed, for which he was continued on his usual
home regimen of Percocet PRN.
.
.
# disposition - pt was discharged on [**9-12**] to an rehabilitation
facility with plan for him to gain strength with intensive PT,
at which time he could return to his prior living situation at
home with VNA services, which he has received chronically.
PAFFAR was waived due to less then 30 days anticipated rehab
admission. His groin hematoma's were clinically unchanged since
his admission to the medicine service. His HCT at the time of
discharge was 29.4 which has been stable (29-30 since [**9-9**]).
.
He was instructed to follow-up with his regular cardiologist
within 2-3 weeks and his PCP [**Name Initial (PRE) 176**] 2-4 weeks.
Medications on Admission:
Allopurinol 300mg qd
Lasix 80mg qd
Norvasc 10mg qd
Protonix 40mg qd
Asacol 400mg qd
Reglan [**12-4**] tab with PO
Isosorbide 90mg qd
Macrodantin 100mg qd
Simethicone 80mg qd
Tikosyn 125mg qd
NPH insulin (50U in am, 40U in pm)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
PCI.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for PCI.
Disp:*30 Tablet(s)* Refills:*1*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
4. Nitrofurantoin Macrocrystal 100 mg Capsule Sig: One (1)
Capsule PO HS (at bedtime).
5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Omega-3 Fatty Acids 550 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Allopurinol 300 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.
Disp:*qs * Refills:*0*
13. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
15. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
16. INSULIN NPH
50 UNITS QAM and 40 UNITS QPM
17. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed): place under tongue with
chest pain, may repeat three times, take 5 minutes apart, if
chest pain persits, call 911. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
primary:
coronary artery disease
bilateral groin hematoma
acute renal insfuciency
Discharge Condition:
stable.
Discharge Instructions:
please continue to take all of your medications as prescribed.
.
if you have any symptoms of chest pain, shortness of breath,
palpitations, fevers, or chills, please contact your primary
care physician or the emergency department.
Followup Instructions:
please follow-up with your primary care physician [**Name Initial (PRE) 176**] [**1-5**]
weeks.
.
please follow-up with your cardiologist within 2-4 weeks.
|
[
"401.9",
"V44.3",
"311",
"707.05",
"250.00",
"741.00",
"599.0",
"593.9",
"999.8",
"327.23",
"V45.2",
"344.1",
"998.12",
"530.81",
"E879.0",
"V44.6",
"428.0",
"724.5",
"V12.59",
"414.01",
"530.85",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"00.66",
"88.56",
"00.45",
"36.06",
"00.40",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
16960, 17046
|
7367, 14881
|
426, 496
|
17172, 17182
|
3647, 4194
|
17461, 17620
|
3125, 3161
|
15158, 16937
|
17067, 17151
|
14907, 15135
|
4211, 7344
|
17206, 17438
|
3176, 3628
|
313, 388
|
524, 2284
|
2306, 2931
|
2947, 3109
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,023
| 123,722
|
33902
|
Discharge summary
|
report
|
Admission Date: [**2171-12-4**] Discharge Date: [**2171-12-10**]
Date of Birth: [**2114-10-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Asymptomatic with known RV mass
Major Surgical or Invasive Procedure:
[**2171-12-6**]:
1) Right ventricular mass removal/debulking
2) Tricuspid valve replacement (29mm porcine tissue)
[**2171-12-4**]:
Cardiac Catheterization
History of Present Illness:
This is a 57 year old male with metastatic melanoma. He has a
known right ventricular mass and has been followed with serial
echocardiograms and chest CT's which have revealed significant
increase in size. Given these findings, he has been referred for
possible surgical intervention.
Past Medical History:
- Metastatic Melanoma (including lung, liver, bone,
subcutaneous,
small bowel, and brain metastasis - cyber knife [**2171-10-1**])
- Hypertension
Past Surgical History:
- s/p Scalp melanoma incision with sentinel lymph node biopsy,
and modified lymph node dissection [**2168**]
- s/p Right lower lobe lung nodule for which he had a VATS
lobectomy for metastatic melanoma [**2169**]
- s/p Exploratory laparotomy and small bowel resection x 2 [**2171**]
- s/p Tonsillectomy
- s/p Right neck vein removal
- s/p Varicose vein excision right leg
Social History:
Race: Caucasian
Last Dental Exam: N/A
Lives with: Wife
Contact: Wife Phone #
Occupation: CEO of a manufacturing fiberoptic company
Cigarettes: Smoked no [] yes [X] Hx: Remote use greater than 25
yrs ago.
ETOH: < 1 drink/week [] [**2-25**] drinks/week [X] >8 drinks/week []
Illicit drug use: Denies
Family History:
No premature coronary artery disease. Grandfather had melanoma.
Physical Exam:
Pulse: 80 Resp: 16 O2 sat: 100
B/P Right: 118/87 Left: 114/82
Height: 5'[**70**]" Weight: 210 lbs
General: Well-developed male in no acute distress
Skin: Dry [X] intact [X] Multiple healed incisions on chest and
abdomen
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema-none
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:
[**2171-12-6**] 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 or left atrial appendage. No other mass in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LV.
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%). No
masses or thrombi are seen in the left ventricle. The right
ventricular cavity is markedly dilated with severe free wall
hypokinesis. There is a echogenic mass in the right ventricle
(6.8cm x 4.6cm, measured in 4 chamber view). Components of the
mass are mobile. Components of the mass abut & encompass the
tricuspid valve. A portion of the septal leaflet of the
tricuspid valve is mobile, remaining leaflets are unable to be
seen. The mass appears adherent to the free wall of the RV, with
flow passing along the septum. There is trace TR. Mean gradient
across the TV is 1mmHg. The mass is encroaching into the RVOT,
and the pulmonic valve appears free from tumor. The diameters of
aorta at the sinus, ascending and arch levels are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a small pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room.
POSTBYPASS: Patient is on epipnephrine 0.04 mcg/kg/min. Severe
RV global dysfunction. LVEF 55%. The bioprosthesis in the native
tricuspid position is stable, functioning well with a residual
mean gradient of 2mm of Hg. There are no paravalvular leaks.
Intact thoracic aorta. The RV cavity has some echogenic 1cm x
1cm masses which are consistent with papillary muscle. There is
no VSD or RV to pericardial leaks.
[**2171-12-4**] Cardiac Catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated no significant coronary artery disease. There was
no
angiographically apparent flow-limiting stenosis in the LMCA,
LAD, LCx,
or RCA. 2. Limited resting hemodynamics revealed systemic
arterial normotension. FINAL DIAGNOSIS: 1. Non-obstructed
coronary arteries. 2. Hemostasis achieved of radial artery with
Terumo Band.
[**2171-12-9**] CXR: 1. Bilateral lower lobe pneumonia in a pattern
concerning for aspiration etiology. 2. Stable left superior
mediastinal mass and multiple lung nodules as a result of
metastatic melanoma.
[**2171-12-4**] 07:15AM BLOOD WBC-5.7 RBC-4.93 Hgb-15.2 Hct-44.3 MCV-90
MCH-30.9 MCHC-34.4 RDW-13.2 Plt Ct-153
[**2171-12-9**] 04:23AM BLOOD WBC-4.5 RBC-2.66* Hgb-8.4* Hct-23.9*
MCV-90 MCH-31.8 MCHC-35.4* RDW-13.8 Plt Ct-137*
[**2171-12-10**] 05:08AM BLOOD Hct-26.4*
[**2171-12-4**] 07:15AM BLOOD PT-12.2 PTT-22.8 INR(PT)-1.0
[**2171-12-6**] 01:59PM BLOOD PT-14.2* PTT-31.3 INR(PT)-1.2*
[**2171-12-4**] 07:15AM BLOOD Glucose-97 UreaN-25* Creat-1.2 Na-139
K-4.3 Cl-101 HCO3-27 AnGap-15
[**2171-12-9**] 04:23AM BLOOD Glucose-92 UreaN-15 Creat-1.0 Na-136
K-3.9 Cl-102 HCO3-27 AnGap-11
[**2171-12-10**] 05:08AM BLOOD UreaN-18 Creat-0.9 Na-138 K-3.8 Cl-100
[**2171-12-10**] 05:08AM BLOOD Mg-2.1
[**2171-12-4**] 07:15AM BLOOD ALT-43* AST-53* AlkPhos-113 TotBili-0.6
DirBili-0.2 IndBili-0.4
[**2171-12-4**] 07:15AM BLOOD %HbA1c-5.8 eAG-120
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2171-12-4**] for surgical
management of his RV mass. He underwent a cardiac
catheterization which revealed non-obstructive coronary disease.
He was worked-up in the usual preoperative manner. On [**2171-12-6**]
he was taken to the operating room where he underwent
removal/debulking or his right ventricular mass and replacement
of his tricuspid valve with a tissue. Please see operative note
for details. Postoperatively he was taken to the intensive care
unit for monitoring.
Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. He was started and
beta-blockers and diuretics and diuresed towards his pre-op
weight. On post-op day two he was transferred to the step-down
unit for further recovery. Chest tubes and epicardial pacing
wires were removed per protocol. His HCT trended down and on
post-op day two and three he was transfused with a rise in HCT
to 26.4. He worked with physical therapy for strength and
mobility. On post-op day four he appeared to be doing well and
was discharged to home with VNA services and the appropriate
medications and follow-up appointments.
Medications on Admission:
FEXOFENADINE - (Prescribed by Other Provider) - 180 mg Tablet -
1 Tablet(s) by mouth once a day
LORAZEPAM - 0.5 mg Tablet - [**1-20**] Tablet(s) by mouth twice a day
as needed for anxiety or insomnia
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily
VALSARTAN [DIOVAN] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 40 mg Tablet - 1 Tablet(s) by mouth
once a day
Medications - OTC
NAPROXEN - (OTC) - 250 mg Tablet - 1 Tablet(s) by mouth at
bedtime
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA and Hospice
Discharge Diagnosis:
Right ventricular mass (probable metastatic melanoma) s/p
excision and tricuspid valve replacement
Past medical history:
- Metastatic Melanoma (including lung, liver, bone,
subcutaneous,
small bowel, and brain metastasis - cyber knife [**2171-10-1**])
- Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema - 1+
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**]
Cardiologist: Have PCP refer you to a cardiologist.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 78338**] in [**4-23**] weeks [**Telephone/Fax (1) 78338**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
In addition, you have f/u appointments with:
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2171-12-24**]
11:30
Provider: [**First Name8 (NamePattern2) 20062**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2171-12-24**] 2:00
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2171-12-24**] 10:35
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2171-12-10**]
|
[
"198.3",
"198.89",
"197.7",
"401.9",
"196.0",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"35.27",
"88.56",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
8612, 8683
|
6050, 7237
|
343, 499
|
8993, 9161
|
2555, 4872
|
10134, 11265
|
1719, 1784
|
7787, 8589
|
8704, 8803
|
7263, 7764
|
4889, 6027
|
9185, 10111
|
1004, 1377
|
1799, 2536
|
272, 305
|
527, 813
|
8825, 8972
|
1393, 1703
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,394
| 142,086
|
31409
|
Discharge summary
|
report
|
Admission Date: [**2127-8-24**] Discharge Date: [**2127-8-27**]
Date of Birth: [**2094-10-4**] Sex: M
Service: MEDICINE
Allergies:
Tylenol / Benadryl / Advil Cold & Sinus / Penicillins
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
History of Present Illness:
32 yr old male with a history of schizophrenia, suicide attempt,
and cutting behavior, who presented from [**Hospital1 1680**] JP with altered
mental status, slurred
speech, and unsteady gait. Mr. [**Known lastname 9449**] had been admitted to
[**Hospital1 1680**] JP on [**2127-8-21**], following discharge from another hospital
after a suicide attempt. He was subsequently transferred to
[**Hospital1 18**] ICU where he was determined to be obtunded and hypercapnic
and was intubated.
Past Medical History:
Schizophrenia
Cutting behavior
Previous suicide attempts
Benzodiazepine abuse
Cocaine abuse
Social History:
Lives with his mother. Denies alcohol or IVDU. Smoke 3.5 packs
per day.
Family History:
Adopted. Mother has history of polysubstance abuse.
Physical Exam:
GEN: Intubated and sedated.
Eye: anicteric
ENT: ETT C/D/I
CV: RRR No MRG
Pulm: CTA
Abd: SNT NABS no HSM
GU: WNL
Skin: dry
[**Last Name (un) **]: No lymphadenopathy
Neuro: unable to assess due to sedation
Pertinent Results:
[**2127-8-24**] 01:55PM WBC-6.2 RBC-4.82 HGB-15.5 HCT-43.7 MCV-91
MCH-32.1* MCHC-35.4* RDW-14.1
[**2127-8-24**] 01:55PM AMYLASE-44
[**2127-8-24**] 01:59PM GLUCOSE-109* LACTATE-1.9 NA+-144 K+-3.8
TCO2-25
[**2127-8-24**] 01:55PM UREA N-14 CREAT-0.7
[**2127-8-24**] 04:42PM CALCIUM-9.1 PHOSPHATE-4.0 MAGNESIUM-2.1
[**2127-8-24**] 04:42PM CK(CPK)-392*
[**2127-8-24**] 04:42PM CK-MB-3 cTropnT-<0.01
[**2127-8-24**] 02:09PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS
amphetmn-NEG mthdone-NEG
[**2127-8-24**] 01:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Head CT ([**8-24**]): No evidence of acute intracranial hemorrhage.
AP CXR ([**8-24**]): 1. Near complete right upper lobe collapse with
interposed consolidation and retrocardiac opacity. These
findings are most likely secondary to aspiration/mucous
plugging. 2. Satisfactory positioning of lines and tubes.
AP CXR ([**8-25**]): The patient has been extubated and right upper
lobe has almost entirely reexpanded. Very small regions of
peribronchial opacification are present in the left lower lung,
and adjacent to the left hilus. These should be followed to
exclude developing pneumonia. Lungs are otherwise clear. Heart
is of normal size and there is no pleural abnormality.
ECG ([**8-24**]): NSR with early repolarization
Brief Hospital Course:
1. Respiratory failure: the patient was briefly intubated for
less than 24 hours and extubated without incident. His
respiratory failure was attributed to benzodiazepine overdose.
2. Altered mental status: also thought to be related to
benzodiazepine overdose, he quickly returned to his baseline
mental status without incident.
3. Schizophrenia: the patient was managed by the psychiatry
liaison with adjustment of his psychotropic medications
4. Suicide attempt: the patient had no further self-harm
attempts or ideation during this hospitalization
5. Cocaine abuse: the patient was not hypertensive during this
hospitalization.
6. Nicotine dependence: the patient was maintained on two 21mg
nicotine transdermal patches daily with good control of his
withdrawal symptoms
7. Mechanical fall with residual nonspecific low back pain: the
patient fell on hospital day 2 and landed on his buttocks. He
had some nonspecific low back pain which was initially
controlled with ibuprofen and cyclobenzaprine. On discharge, he
was receiving only ibuprofen.
Medications on Admission:
Geodon 80 mg [**Hospital1 **]
Celexa 40 mg daily
Remeron 30 mg qhs
Klonopin 1 mg tid
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: Two (2) Patch 24 hr
Transdermal DAILY (Daily) as needed for nicotine withdrawal: 21
mcg x2.
6. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
klonopin overdose/suicide attempt
schizophrenia
nicotine dependence
chronic low back pain
Discharge Condition:
medically stable
Discharge Instructions:
You were hospitalized for a klonopin overdose. You are being
transferred to an inpatient psychiatry facility.
Followup Instructions:
You will be an inpatient in a psychiatric facility [**Hospital1 **] in
[**Location (un) 18293**].
|
[
"970.8",
"E950.3",
"295.90",
"E950.4",
"969.4",
"518.81",
"724.2",
"305.1",
"E849.8",
"304.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
4846, 4861
|
2768, 2960
|
334, 373
|
4995, 5014
|
1402, 2745
|
5173, 5274
|
1109, 1162
|
3959, 4823
|
4882, 4974
|
3850, 3936
|
5038, 5150
|
1177, 1383
|
275, 296
|
401, 889
|
2975, 3824
|
911, 1004
|
1020, 1093
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,998
| 176,304
|
53607
|
Discharge summary
|
report
|
Admission Date: [**2200-3-25**] Discharge Date: [**2200-3-28**]
Date of Birth: [**2156-5-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / fish / Ativan
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
43M with reported PMH of TBI s/p craniotomy/VP shunt, seizure
disorder, polysubstance abuse and depression, who was
transferred here after intubation for seizures at [**Hospital **]
[**Hospital 1459**] Hospital.
.
History was as below from OSH record: Pt was found
down/unresponsive in a motel, given narcan by EMS and he became
more responsive, was following some commands and was taken by
ambulance to an OSH. There, he had an EKG done, which showed
afib with RVR with HR of 150. He was given IV diltiazem 25 mg
with improvement in his HR. He was also given 5mg of IV haldol
for agitation, and was then drowsy with mildly slurred speech.
He was sent for a CT of head/neck, which was read as probable
postop changes from his known TBI and R frontal craniotomy.
After returning from the CT, he went to the bathroom, and was
noted to have 1 GTC as he was returning from the bathroom.
Unclear duration of seizure. He was given 2mg of IV ativan. He
then had another GTC when he was back on his stretcher, and was
given 2 mg more of IV ativan, intubated for airway protection
with etomidate/succ at 2315, and was noted to have pinpoint
pupils (unclear if this was the initial exam also), and sent to
[**Hospital1 18**]. While at the OSH, he was noted to have a tab of dilantin
in his pocket.
.
Of note, his tox screen were positive for opiates and alcohol,
and lithium level was <0.2. He also had an elevated AST of 65,
and an elevated CPK of 614, but were otherwise unremarkable.
.
In ED, initial vitals were: HR: 86, RR: 13, BP: 136/80, O2Sat:
99, on vent, Temp: 100.6 ??????F (38.1 ??????C). He was intubated and
unsedated, and following most commands per neurology note. He
was then put on propofol as he was trying to remove his ETT, and
became more sedated, not following commands. He had a phenytoin
level drawn which was <0.6. He also had an elevated lipase of 61
and a lactate of 3.8.
.
Prior to transfer to ICU, patient noted to have temp of 103F,
neurosurgery consulted at that time to access VP shunt given
concern for intracranial/CNS infection. BCx also sent. Started
on vancomycin and ceftriaxone.
.
On arrival to the ICU, patient is unable to give further history
or complete ROS as he is intubated and sedated.
Past Medical History:
Past Medical History (per OSH records):
- depression
- TBI s/p VP shunt
- seizure disorder (no further info is available at this time)
- EtOH and substance abuse
- DJD
- hepatitis C
Social History:
positive for EtOH, tobacco and illicits
Family History:
unable to obtain
Physical Exam:
ADMISSION EXAM:
.
General: intubated and sedated
HEENT: Sclera anicteric, pinpoint pupils, unable to visualize
oropharynx, ?dentures in place
Neck: JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no
wheezes/rales/rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, quiet bowel sounds, no
rebound tenderness or guarding, no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Left shoulder with erythematous abrasions, track mark
along L forearm, scabs over left hip and left heel. shallow pink
ulceration on medial aspect of right heel, clean base without
drainage.
.
DISHCARGE EXAM:
.
AAOx3. Able to comprehend benefits of ongoing hospitalization,
and risks of leaving the hospital against medical advice. Pt
currently appears non-toxic. Linear thoughts, conversant.
Pertinent Results:
ADMISSION LABS:
.
[**2200-3-25**] 12:45AM BLOOD WBC-6.3 RBC-3.79* Hgb-11.9* Hct-35.7*
MCV-94 MCH-31.5 MCHC-33.4 RDW-14.0 Plt Ct-162
[**2200-3-25**] 07:21AM BLOOD Neuts-53.0 Lymphs-36.9 Monos-4.4 Eos-5.2*
Baso-0.6
[**2200-3-25**] 12:45AM BLOOD PT-11.5 PTT-30.3 INR(PT)-1.1
[**2200-3-25**] 12:45AM BLOOD Fibrino-222
[**2200-3-25**] 07:21AM BLOOD Glucose-73 UreaN-10 Creat-0.9 Na-143
K-4.1 Cl-109* HCO3-25 AnGap-13
[**2200-3-25**] 07:21AM BLOOD ALT-24 AST-56* LD(LDH)-247 CK(CPK)-822*
AlkPhos-80 TotBili-0.9
[**2200-3-25**] 12:45AM BLOOD Lipase-61*
[**2200-3-25**] 07:21AM BLOOD Albumin-3.4* Calcium-8.3* Phos-3.3 Mg-1.9
.
DISCHARGE LABS:
.
Micro:
[**2200-3-25**] Blood culture - pending
[**2200-3-25**] Blood culture - pending
[**2200-3-25**] CSF fluid - pending
[**2200-3-25**] Urine culture - no growth
[**2200-3-25**] Legionella antigen - no growth
[**2200-3-25**] MRSA screen - negative
[**2200-3-25**] Sputum culture - pending
.
Images:
CT Head from OSH:
[**2200-3-25**] CXR (per my read): small lung volumes, haziness
throughout lung parenchyma concerning for pulmonary congestion.
possible retrocardiac opacity as some of L hemidiaphragm is
obscured. No other obvious consolidations.
.
[**2200-3-25**] CTA HEAD AND NECK W&W/OC & RECON:
No acute intracranial hemorrhage or mass effect.
Encephalomalacic changes
in the right frontal and the right parietal lobe along with
post-surgical
changes with right-sided craniotomy and cranioplasty.
Ventricular catheter is seen through the left frontal approach,
ending in the right caudate head. Correlate clinically if this
is desired position and with catheter function. Patent major
arteries as described above, without focal flow-limiting
stenosis, occlusion, or aneurysm more than 3 mm within the
resolution of CT angiogram. CT angiogram of the head is somewhat
suboptimal due to delayed arterial phase imaging. Paranasal
sinus disease with mild mucosal thickening in the maxillary and
the sphenoid and ethmoid air cells. Degenerative changes in the
cervical spine, inadequately characterized.
[**2200-3-28**] 06:40AM BLOOD WBC-3.3* RBC-4.17* Hgb-13.1* Hct-39.3*
MCV-94 MCH-31.4 MCHC-33.2 RDW-14.2 Plt Ct-137*
[**2200-3-28**] 06:40AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-142 K-4.0
Cl-109* HCO3-25 AnGap-12
[**2200-3-27**] 04:39AM BLOOD ALT-27 AST-93* LD(LDH)-260* CK(CPK)-1049*
AlkPhos-78 TotBili-1.2
[**2200-3-28**] 06:40AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.7
[**2200-3-25**] 07:21AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE
[**2200-3-25**] 12:45AM BLOOD Phenyto-<0.6*
[**2200-3-25**] 12:45AM BLOOD ASA-NEG Ethanol-34* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2200-3-25**] 07:21AM BLOOD HCV Ab-POSITIVE*
[**2200-3-25**] 12:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2200-3-25**] 11:56 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2200-3-26**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
[**2200-3-25**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2200-3-25**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2200-3-25**] URINE URINE CULTURE-FINAL INPATIENT
[**2200-3-25**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2200-3-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2200-3-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
Brief Hospital Course:
Assessment and Plan: 43M with reported PMH of TBI s/p
craniotomy/VP shunt, seizure disorder, polysubstance abuse and
depression, intubated for airway protection given 2 GTC at OSH
and found to have temp to 103 in ED.
# AMS/Seizures: unclear history, patient found down in a motel
room, appears that his mental status initially improved with
narcan administration which points to medication effect.
However, given the temp to 103 and 2 episodes of seizures at
OSH, concerning for CNS infection initially. Other etiologies
for seizures could include substance abuse, etoh withdrawal,
trauma, CNS bleed or medication noncompliance. Alcohol level of
49 here, less likely to have withdrawal seizures at this time,
though concerning in the future. CT head/neck from OSH did not
show acute abnormalities or intracranial bleed, which was
reassuring. Unclear what medications he is on as an outpatient
for his seizures. Pt found with Dilantin in his pocket, but his
level is subtherapeutic. CSF obtained and was without evidence
of infection. Vancomycin and Ceftriaxone was received in the ED
and was not continued. CSF HSV PCR was also negative. He did
require Haldol and Diazepam for intermittent agitation concerns;
and we continued Keppra dosing per Neurology.
# Fevers: concerning for infection vs. CNS fever given
intracranial pathology vs. seizures vs. medication induced.
Infection most concerning given unclear immune status (HIV or
?IVDU). Infection could be blood/endocarditis given concern for
IVDU, aspiration pneumonia given alcohol use, or CNS infection
given hardware. CSF with protein 43 and glucose of 73, not
suggestive of bacterial meningitis but of high concern. CXR with
? aspiration pneumonia in a patient with unclear risk factors
for MDR organism. Sputum, blood and urine cultures were
unrevealing. Following clear CSF, his antibiotics were
discontinued. Patient remained afebrile afterwards.
# Intubation for Airway Protection: patient intubated for airway
protection/after being given 4 mg IV of ativan at OSH. Started
on propofol for sedation given attempts to self-extubate in the
ED. Mental status appears close to baseline following
extubation.
# Polysubstance abuse: patient with OSH toxicology screen
positive for oxycodone and alcohol. unable to give further
history about substance abuse, however, etoh level found to be
34 in [**Hospital1 18**] ED. This was initially concerning for alcohol
withdrawal and he was dosed Haldol and Diazepam with good
effect. Social work was consulted for coping issues.
# Transaminitis: likely from alcohol use, no corroborating data
at [**Hospital1 18**] to see how significant his alcohol use and liver damage
have been. Per [**Hospital1 2025**] record, patient has history of hepatitis C,
which was confirmed by serology here.
# Reported afib with RVR: patient with reported afib with RVR to
150-160s at OSH, improved with diltiazem. On tele, pt appears
sinus at this time. Afib could have been triggered by infection,
hypovolemia, or underlying heart disease. Repeat EKG was stable.
.
The morning following transfer from the ICU to the medical
floor, pt chose to leave the hospital against medical advice. Pt
was evaluated for capacity, and was determined to have capacity
to decide to leave the hospital against medical advice. Pt set
paperwork before physically leaving the hospital. Neurology,
NeuroSurgery, and Social work notes were reviewed. Per
Neurology consult recommendations, pt was provided a
prescription for increased Keppra dose to 1000 mg po BID, to
minimize the risk of further seizures.
Medications on Admission:
Medications (per OSH records, uncomfirmed with patient):
- lithium
- keppra
- fioricet
- prozac
- ? dilantin, pt had a pill in pt's pocket
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
2. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO
twice a day.
3. Prozac 20 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
# SEIZURE, CONVULSIVE
# HISTORY OF TRAUMATIC BRAIN INJURY
# DRUG USE/DEPENDENCE, ALCOHOL
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized at [**Hospital1 18**] intubated for airway protection
after a seizure. You were evaluated for infection. While it
currently does not appear that you have an infection, lab
results are not final yet. Your hospitalization is not yet
complete, and we have discussed our concerns about your decision
to leave the hospital against medical advice. As we discussed,
there are many possible complications from your decision, which
may include more seizures, falls, injuries, including head
injuries, and possible death. You were able to understand these
risks as well as the possible benefits of remaining in the
hospital, and you have decided to leave the hospital against
medical advice.
During this hospitalization, Neurology has recommended
increasing your Keppra to 1000 mg po BID. We have provided a
prescription for this increased dose.
Followup Instructions:
You have chosen to leave the hospital against medical advice. We
strongly encourage you to follow up closely with your primary
care physician, [**Name10 (NameIs) **] continue to address the issues of this
hospitalization.
|
[
"518.81",
"305.50",
"311",
"303.90",
"291.81",
"070.70",
"345.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
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11608, 11614
|
7575, 11153
|
296, 308
|
11747, 11747
|
3778, 3778
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12787, 13012
|
2841, 2860
|
11342, 11585
|
11635, 11726
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11179, 11319
|
11898, 12764
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4414, 6944
|
2875, 3759
|
6985, 7552
|
249, 258
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336, 2561
|
3794, 4398
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11762, 11874
|
2583, 2767
|
2783, 2825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,132
| 151,018
|
24161
|
Discharge summary
|
report
|
Admission Date: [**2166-4-29**] Discharge Date: [**2166-5-3**]
Date of Birth: [**2101-11-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
1. Intubation/extubation
2. Persantine MIBI
3. Tunneled hemodialysis catheter placement
History of Present Illness:
64 year old female with history of PVD, ESRD, BKA, CAD, presents
with episode of chest pain 2:30 am on day of admission and
bradycardia/presyncope on transit to hospital. Patient was
intubated in the field, transferred here from [**Hospital3 3583**].
On transfer, hemodynamically stable, intubated, started on hep
gtt, transferred for possible catheterization.
Past Medical History:
1. CAD s/p catheterization several years ago (details unknown)
2. ESRD, [**2-26**] DM, on HD T, TH, Sat
3. Anemia [**2-26**] ESRD
4. DM
5. UTI, recurrent
6. HPL
7. HTN
8. Osteoporosis
9. Depression
10. H/o bilateral CEA
11. S/p CVA
[**73**]. Peripheral vascular disease, s/p R BKA
13. Melanoma
14. Ureteral stenting
15. Left ao-fem and fem-fem left to right bypass
Social History:
H/o smoking 1-2 packs x 46 years, quit 2 months ago. No h/o
EtOH. Widow. Lives with her son.
Family History:
NC
Physical Exam:
138/80 74 14 95% RA
General: alert and oriented x 3, NAD
Neck: no JVD; RSC tunneled catheter; no erythema
Pulm: CTA bilaterally
CV: regular, nl S1 S2, [**3-2**] syst murmur at LLSB, left carotic
bruit
Abd: + BS, soft, NT, ND
Extr: no edema, bilateral femoral bruits, s/p R BKA stump w/o
signs or symptoms of infection
Pertinent Results:
[**2166-4-29**] Admission Labs:
WBC-17.0*# RBC-2.83* Hgb-8.5* Hct-27.5* MCV-97 MCH-29.9
MCHC-30.8* RDW-17.0* Plt Ct-491*
PT-13.8* PTT-29.2 INR(PT)-1.2
Glucose-131* UreaN-53* Creat-4.9*# Na-134 K-5.0 Cl-93* HCO3-27
AnGap-19
Calcium-8.5 Phos-5.7* Mg-1.9
calTIBC-138* Ferritn-739* TRF-106*
PTH-479*
[**2166-4-29**] 08:15AM BLOOD CK(CPK)-23*
[**2166-4-29**] 04:43PM BLOOD CK(CPK)-16*
[**2166-4-30**] 03:47AM BLOOD CK(CPK)-7*
[**2166-4-29**] 08:15AM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2166-4-29**] 04:43PM BLOOD CK-MB-NotDone cTropnT-0.28*
[**2166-4-30**] 03:47AM BLOOD CK-MB-NotDone cTropnT-0.22*
.
[**2166-5-3**] Discharge Labs:
WBC-8.0 RBC-3.84* Hgb-11.4* Hct-36.1 MCV-94 MCH-29.8 MCHC-31.7
RDW-16.1* Plt Ct-397
Glucose-148* UreaN-52* Creat-5.5*# Na-133 K-4.5 Cl-94* HCO3-23
AnGap-21*
Calcium-9.2 Phos-4.9* Mg-2.0
.
P-MIBI [**2166-5-2**]
No anginal symptoms and no additional ECG changes from
baseline with IV dipyridamole infusion.
1) Mild reversible inferolateral defect (circumflex
distribution).
2) Severe defect at base of inferior wall is likely related to
diaphragmatic attenuation. 3) EF 60%
.
CXR [**2166-5-1**]
Interval removal of the ET tube and the NG tube. No evidence of
pneumothorax. Interval clearing of congestive heart failure.
.
ECG Study Date of [**2166-4-30**] 7:43:06 AM
Sinus rhythm. Probable left ventricular hypertrophy with ST-T
wave abnormalities. Poor R wave progression - could be due in
part to left ventricular hypertrophy and/or lead placement but
consider also anteroseptal myocardial infarct, age indeterminate
Cannot exclude in part ischemia - clinical correlation is
suggested Since previous tracing of [**2166-4-29**], further ST-T wave
changes present
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 154 68 [**Telephone/Fax (2) 61386**] 33 84
.
ECHO Study Date of [**2166-4-30**]
The left atrium is normal in size. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with focal basal inferior hypokinesis. Overall left
ventricular systolic function is mildly depressed. Right
ventricular chamber size and free wall motion are normal. 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
structurally normal. Physiologic mitral regurgitation is seen
(within normal limits). The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. There is a
slight left to right shunt across the interatrial septum
consistent with a small atrial septal defect or stretched
patent foramen ovale.
.
TUNNELED W/O PORT [**2166-4-30**] 12
Successful exchange of a temporary right IJ dialysis line to a
23 cm tunneled dialysis catheter via the right internal jugular
vein. The catheter tip to cuff length measures 23 cm. The tip of
the catheter is present in the high right atrium. The catheter
is ready for immediate use.
Brief Hospital Course:
64 year old female, history of PVD, ESRD, DM, BKA, CAD status
post recent cath w/PTCA for recurrent chest pain presented after
episode repiratory distress 2:30 am on day of admission and
question of bradycardia/presyncope on transit to hospital.
Patient was intubated in the field, transferred here from [**Hospital1 3325**]. On transfer, patient was hemodynamically stable,
intubated, and given heparin intravenously. Patient presented
with CHF exacerbation requiring intubation and emergent
dialysis. During the hospital course, she had sparse
coffee-ground emesis via NGT.
.
1. Coronary artery disease: Risk factors include DM, lipids,
HTN, age. Patient was status post cardiac cath with PTCA of OM1
for 2VD (LM 40%, OM ostial 80%, mid 90% ballooned w/20%
residual, +collaterals) and presented with CHF exacerbation that
resolved with daily hemodialysis. TnT was elevated at baseline
due to ESRD. She was continued on BB, ASA, plavix, nitrate, and
ACEI. A CCB and statin were added. Also, her BB and ACEI were
titrated up for improved BP control. Consider adding verapamil
if needed. Persantine MIBI revealed 1) Mild reversible
inferolateral defect (circumflex distribution).
2) Severe defect at base of inferior wall is likely related to
diaphragmatic
attenuation. 3) EF 60%. Patient preferred medical management and
was discharged in stable condition with plans for close follow
up.
.
2. Diastolic CHF: Echocardiogram [**2166-4-30**] showed EF 45% with focal
basal HK, 1+ MR/AR, sm ASD. CXR [**2166-4-29**] was indicative of CHF
that cleared on repeat CXR [**2166-5-1**] due to daily hemodialysis x3
and lasix 80mg IV x1. Faint bibasilar crackles were noted on
exam.
.
3. Rhythm: NSR was maintained.
.
4. ESRD: The renal service was consulted for daily hemodialysis.
Sevalemer was continued. IR placed a tunneled SVC line for
permanent HD access. Volume loss with HD was documented as the
following: [**2166-4-30**] -3L; [**2166-5-1**] -2L, [**2166-5-2**] -3L. Patient was to
resume TTHSa schedule for outpatient HD.
.
5. Respiratory: Patient arrived intubated for respiratory
distress with possible aspiration event; she was successfully
extubated [**5-2**]. Antibiotics that had been started for suspected
pneumonia were discontinued after the sputum culture was
negative for growth.
.
6. h/o Leukocytosis, Low Grade Temp: Sputum culture initially
grew gram pos cocci in clusters/pairs. Then the patient was
started on renally dosed vancomycin and levoquin IV on [**4-30**] for
presumed ventilator-associated pneumonia. Vancomycin was
discontinued after final sputum culture results revealed growth
of sparse normal flora. Levoquin was continued for urinary tract
infection with UA +mod bact, >50 WBC, and LE. Blood and urine
cultures were negative for growth.
.
7. UGIB (coffee ground emesis) was noted to be produced via NG
tube and was thought likely related to patient's history of
peptuc ulcer disease. She received proton pump inhibitor twice
daily and the heparin drip had been discontinued. Close
monitoring of hematocrit showed a drop for which the patient was
given 2u PRBCs; however, the hematocrit change was suspected due
to volume shifts with daily dialysis. GI service was consulted
and EGD was deferred per patient preference as outpatient
followup.
.
8. Heme: Patient known to have ESRD on HD. She received 2u PRBCs
[**4-30**] for decreased HCT with good response. Stools were guaiac
negative.
.
9. DM: Patient received sliding scale insulin coverage during
her stay.
Medications on Admission:
NTG prn
Metoprolol 50 mg po bid
Lisinopril 5 mg po qd
ASA 325 mg po qd
Avandia 4 mg po qd
Clonidine 0.2 mg [**Hospital1 **]
Ditropan XL 5 mg po qd
Isosorbide mononitrate
Lasix 20 mg po qd
Folic acid
Renagel
Discharge Medications:
1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
Disp:*30 ML(s)* Refills:*2*
4. Aspirin 325 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*
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Cardiac Rehab
Please undergo cardiac rehabilitation under the supervision of
your PCP/Cardiology.
1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
Disp:*30 ML(s)* Refills:*2*
4. Aspirin 325 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*
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Cardiac Rehab
Please undergo cardiac rehabilitation under the supervision of
your PCP/Cardiology.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary diagnosis:
1. Coronary artery disease, s/p angioplasty.
2. Chronic renal insufficiency
3. End stage renal disease, on hemodialysis
4. CHF exacerbation. Arrived intubated. Successfully extubated.
5. Urinary tract infection
6. Upper GI bleeding
7. Diabetes
Secondary diagnoses:
1. Peripheral vascular disease
2. Depression
3. Osteoporosis
4. Diabetes
5. Hypertension
6. Arteriovenous malformation in the stomach
Discharge Condition:
Vital signs stable. Breathing comfortably on room air in no
distress.
Discharge Instructions:
Please take all medications as prescribed. Take an aspirin and
your plavix (clopidogrel) every day, you can NOT miss a dose of
your aspirin or plavix.
Medication changes:
1. Lisinopril was increased from 5mg to 20mg once daily
2. Norvasc 10mg once daily was added
3. Lipitor 80mg once daily was also added
4. Isosorbide mononitrate 30mg once daily
5. Metoprolol was changed to Toprol XL 150mg once daily.
Please review the medication changes with your PCP.
You were started on a lipid lowering medication during this
hospital admission. Please follow up with your primary doctor
because you will need to have labs checked periodically while on
this medication.
Please follow up with Dr. [**Last Name (STitle) 18998**] if doses of your other
medications need to be adjusted.
Please have labs drawn by a visiting nurse and follow up with
Dr. [**Last Name (STitle) 18998**] regarding the results.
Please follow up as listed below.
Please return to your usual physical activity level gradually.
Please avoid exertion for the next 2 weeks. You should not lift
anything more than 5 pounds for the next two weeks.
Continue with hemodialysis treatments as you did before. You may
need to have your hemodialysis regimen changed as you received 4
extra runs of HD while admitted.
Please return to care if you develop chest pain, shortness of
breath, fever, chills, leg pain or numbness or other concerning
symptoms.
Followup Instructions:
Please call ([**Telephone/Fax (1) 18999**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 18998**] within one week after discharge.
Please follow up with your cardiologist in the next 1-2 weeks.
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,168
| 165,672
|
18585
|
Discharge summary
|
report
|
Admission Date: [**2123-11-7**] Discharge Date: [**2123-11-12**]
Date of Birth: [**2064-9-16**] Sex: M
Service: MEDICINE
Allergies:
Iodine / Ativan / Lipitor
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Echocardiography
Foley catheter
History of Present Illness:
59 year old man with PMH significant for CAD s/p CABG and
stents; atrial fibrillation; ETOH abuse; and pancreatitis.
Presented to ED w/ severe [**9-4**] epigastric pain radiating to
back. Admitted to ED with suspected severe pancreatitis
recurrence.
.
In the ED, VS were 98.8 73 [**Telephone/Fax (2) 51055**]% RA. Labs were
significant for a lipase of 4276 and an amylase of 761. He also
had an anion gap of 28. A surgery consult was obtained but did
not feel that pt had current surgical needs. Imaging revealed
uncomplicated pancreatitis.
.
He was initially planned to be admitted to the floor, but then
CXR showed new pulmonary edema, and there was concern over
giving iv fluids on the floor and so Mr. [**Known lastname 51051**] was admitted
to the [**Hospital Unit Name 153**] for further monitoring and treatment. [**Hospital Unit Name 153**] course
included:
-Aggresive IVF and dilaudid PCA for pain control
-Increasing abdominal distension, pt passing flatus, NGT was
placed for decompression which he self-dc'd c/o severe
discomfort.
- TTE showed mild LVH, preserved biventricular systolic function
- He was placed on a CIWA scale for DT but did not need any
valium
- Electrolytes were aggresively repleted
.
He was called out to the floor on [**11-8**] but did not receive a
bed until [**11-10**] at 11pm.
.
On [**11-11**] in a.m. of admission to main team on floor, he c/o very
little abd pain ([**1-4**] epigastric), was able to ambulate w/o
difficulty and Foley to d/c'ed; requesting PO intake.
Past Medical History:
1. Atrial fibrillation- Pt developed atrial fibrillation
approximately twelve years ago. He reports that he was
anticoagulated on coumadin for several years. He was then placed
on amiodarone following his CABG in [**2120**] and converted to sinus
rhythm. He was then taken off the anticoagulation and has
remained in sinus rhythem per his report.
2. Coronary artery disease- Pt is s/p one vessel CABG from the
LIMA to the LAD on [**2121-10-17**]. He then went to cardiac cath on
[**2121-10-20**] at which time three stents were placed to the RCA and
one to the distal circumflex. He has not had any further stress
tests since that time. His cardiologist is Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **].
3. Pancreatitis- First episode of pancreatitis was in [**2103**]. He
has had approximately 10 flares since that time. He reports that
his current pain is epigastric when in the past his
"pancreatitis" pain was more localized to his left lower
abdomen/flank.
4. Ethanol abuse- Pt denies any history of DTS. He reports that
he normally quits drinking for a couple of months each winter
with [**Last Name **] problem. However, there is a record of an episode of DTs
at an OSH in [**2119**]. He attributes these symtpoms to receiving too
much ativan.
5. Hypertriglyceridemia
6. Hypertension
7. Gout
8. Spinal stenosis
9. MRSA infection- Pt had a MRSA PNA at an OSH when he was
intubated during an episode of pancreatitis. He had a sputum
positive for MRSA here at [**Hospital1 18**] in [**2120**].
Social History:
5 pack-year smoking hx, quit 30 years ago. Longstanding hx of
EtOH consumption, three double-EtOH drinks/day. Works as
insurance salesman.
Family History:
Significant for hypertriglyceridemia though no FH of early-onset
CAD
Physical Exam:
VS 99.5 90 154/94 24 93% RA UOP 775 cc on morning of [**11-11**],
substantial increase over ED
Gen/psych- AOX3. He is alert and ambulating. He has some
insight into his illness though seems confused into thinking
that some of our interventions are causing the problems which
they are actually treating. Seems intermittently agitated, not
at staff but very frustrated about his general health, observed
in one case to rip shirt cuff off arm when having difficulty
undoing a button.
HEENT- NC/AT. EOMI. Anicteric sclera. Moist mucous membranes.
NECK: JVP at 2 cm above sternal notch
Cardiac- RRR nl S1 S2. No m,r,g.
Pulm- Decreased bibasilar breath sounds with faint wheezes at R
base. No rales or rhonchi.
Abdomen- Soft but visibly distended. Mildly tender to palpation
in epigastric region while not complaining of significant pain.
No rebound tenderness or guarding. Positive bowel sounds.
Extremities- Warm. No c/c/e.
Genital: Diminished penile and scrotal edema from before
Neuro- CN II-XII intact. 5/5 strength in the upper and lower
extremities bilaterally.
Pertinent Results:
[**2123-11-7**] 08:30PM GLUCOSE-147* UREA N-12 CREAT-0.5 SODIUM-145
POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-21* ANION GAP-31*
[**2123-11-7**] 08:30PM ALT(SGPT)-21 AST(SGOT)-30 CK(CPK)-45 ALK
PHOS-93 AMYLASE-761* TOT BILI-0.5
[**2123-11-7**] 08:30PM LIPASE-4276*
[**2123-11-7**] 08:30PM CK-MB-2 cTropnT-<0.01
[**2123-11-7**] 08:30PM CALCIUM-9.7 PHOSPHATE-2.7 MAGNESIUM-1.7
[**2123-11-7**] 08:30PM WBC-11.7* RBC-4.37*# HGB-14.7# HCT-40.5#
MCV-93 MCH-33.6* MCHC-36.2*# RDW-13.3
[**2123-11-7**] 08:30PM NEUTS-89.2* BANDS-0 LYMPHS-7.1* MONOS-1.8*
EOS-1.5 BASOS-0.3
[**2123-11-7**] 08:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2123-11-7**] 08:30PM PLT COUNT-234
[**2123-11-7**] 08:30PM PT-12.5 PTT-27.4 INR(PT)-1.0
Brief Hospital Course:
59 year old man with PMH significant for CAD s/p CABG and
stents; atrial fibrillation; ETOH abuse; and recurrent
pancreatitis admitted with active severe pancreatitis.
.
## GI
.
#. Pancreatitis: Due to EtOH. Amylase and lipase steadily
improved since admission to nearly normal levels. No
complication seen on abdominal CT. He initially had prerenal
azotemia and was bolused, urine output fully recovered by day of
discharge.
- Able to tolerate PO clears by day prior to discharge, no
epigastric pain reported on discharge on [**11-12**], able to ambulate
well.
- dilaudid PCA initially, d/c'ed on [**11-11**].
- Had some minor non-bloody diarrhea night before discharge
perhaps s/p stool softeners and laxatives; K repleted and bowel
regimen d/c'ed.
## Pulmonary
.
# Low Grade Fever:
- Initial suspicion of ? aspiration pneumonia based on CXR w/
RUL infiltrates but CXR gradually resolved over course of stay.
- Continued w/ some low grades temps and fever until day prior
to admission when temp fully normalized.
# Pulmonary edema:
- Found to be volume overloaded on exam and by CXR early in
stay, perhaps s/p aggressive initial rehydration in wake of
prerenal azotemia on admission.
- TTE showed normal EF and no sign of diastolic dysfunction but
sub-optimal windows.
- Excellent urine output by day before discharge w/o need for
diuresis.
.
# Wheezes on Lung Exam:
- No prior hx of such wheezes. No h/o COPD. Improved with
albuterol nebs.
- Could be due to volume overload, but could also be from
metoprolol.
- Received nebs prn.
- Consider pulmonary function tests as an outpatient
.
##Neuro/psych/tox
.
# EtOH abuse- Mr. [**Known lastname 51051**] has a history of ETOH withdrawal per
records and required prolonged intubation for this at an OSH. He
has a reported history of allergy to ativan, but this actually
seems to have been a result of oversedation from too much ativan
administered.
- He was maintained on a diazepam CIWA scale for ETOH withdrawal
throughout hospitalization. Given hypertension and tachycardia
on admission, treated with diazepam 10iv x 1 and monitored
throughout.
- On [**11-11**] he had a ? withdrawal picture pulling out IV and
becoming somewhat agitated in late afternoon, mildly
diaphoretic.
- On morning of [**11-12**] he vigorously expressed desire to leave
hospital, became somewhat agitated. However, though
hypertensive in both cases of agitation, he had no tachycardia.
Seemed frustrated with situation but aware and no indication of
MS changes or confusion. No indication of DT.
- Placed on fall precautions.
- Given thiamine and folate qd
.
##Renal
.
#. Anion gap- He initially p/w a significant anion gap of 28 on
his admission labs. Likely from saline repletion; gap resolved
by end of admission w/ no indication of acidosis.
.
#. Hypokalemia- Potassium of 3.0 early on day of discharge as
noted above, probably s/p diarrhea night before. K normalized
on PO, IV repletion.
.
## Cardio
.
#. CAD/HTN- He has a history of one vessel CABG and multiple
stents in [**2120**].
- Ruled out for MI x three sets of cardiac enzymes.
- Continued on ASA.
- Restarted fenofibrate and quinapril.
- Was started on Metoprolol in the [**Hospital Unit Name 153**] for hypertension. HTN
continued to be a problem during stay and he spiked to 170s on
[**11-11**] afternoon and up to 180 on [**11-12**] midnight. His quinapril
dose increased to 10 mg PO DAILY and discharged on 20 mg. Sent
home on the metoprolol.
- Recommend follow-up and adjustment of BP meds as needed.
.
#. Atrial fibrillation- He has a long history of atrial fib but
is not anticoagulated.
- Continued on amiodarone.
## Heme
.
# Low Hct: Apparently hemodilution, stable throughout
hospitalization to baseline for him, though may benefit from
further work-up.
.
## Endocrine
.
# Glucose control
- No known h/o diabetes, but continued with a sliding scale
during hospitalization, QID FS.
- Glucose stabilized on [**11-11**]; outpt. follow-up and Rx of
presumed DMII if high HbA1c
.
## FEN/PPx summary- SC heparin; MRSA precautions; Fall
precautions, withdrawal precautions/CIWA scale.
.
# Communication- With Mr. [**Known lastname 51051**] and family members.
.
# Code status- Full code.
Medications on Admission:
Meds on transfer to floor:
Heparin 5000 UNIT SC TID
Hydromorphone 0.1 mg
Insulin SC Sliding Scale
Amiodarone HCl 200 mg PO DAILY
Metoprolol 12.5 mg PO TID
Aspirin 300 mg PR DAILY
Quinapril 5 mg PO DAILY
Bisacodyl 10 mg PR DAILY
Senna 1 TAB PO BID
Diazepam 10 mg IV Q2H:PRN
Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrence of acute pancreatitis in the setting of labile blood
pressure, apparent EtOH withdrawal w/o frank DT (on CIWA
protocol)
Discharge Condition:
Stable
Discharge Instructions:
Please call a physician if you experience sudden chest pain,
shortness of breath, high fever, seizures, severe headache,
fainting, severe and prolonged confusion, or rapid and
substantial weight loss.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 51052**] at your already scheduled time on Monday
[**2123-11-15**]; please mention that your blood pressure became high
late in your hospitalization (to 180/100) and this is why we
have increased your Accupril dose to 20 milligrams per day.
Please mention also that your potassium became low (to 3.0) on
your day of discharge after you'd had some diarrhea the night
before, and that we repleted your potassium.
Please schedule an appointment with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] within
two weeks and mention the same issues to him, especially your
blood pressure.
To PCP: [**Name10 (NameIs) 357**] consider ordering pulmonary function tests for
Mr. [**Known lastname 51051**] as PE and CXR both seem to indicate substantial
difficulty in deep inhalation. No indication of pulmonary
fibrosis from amiodarone but ? other restrictive process.
Follow-up anemia work-up if necessary.
|
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icd9cm
|
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icd9pcs
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4,962
| 148,761
|
23967
|
Discharge summary
|
report
|
Admission Date: [**2141-4-11**] Discharge Date: [**2141-5-1**]
Date of Birth: [**2088-9-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Placement of AV fistula, left arm, revised on [**2141-4-28**]
History of Present Illness:
52 yo man with hx of HTN, Hep B, IVDA and Etoh p/w seizure. Pt
was sitting at home on couch surrounded by family, mentating
normally. Suddenly whole body stiffened, then began seizing. No
evidence of bowel, bladder incontinence. No evidence of tongue
biting. EMS called, patient un-responsive on arrival. O2 placed
by face mask with some improvement in mental status. Arrived at
[**Hospital 4199**] Hospital, had another 3 minute seizure. Found to have
ABG 6.95/33/77, and rectal temp 101. Pt became combative, was
intubated and given paralytics. Given 2LNS, 2amps bicarb,
ativan2mg x5, morphine5mg and tylenol once. Repeat ABG
7.33/29/291. Head CT there negative except frontal volume loss.
CXR with possible bilateral opacities. Patient was then
transferred to [**Hospital1 18**].
*
Per family had been feeling "under the weather" as has everyone
else in the family who has had colds as well. He has not had a
history of seizures or renal disease that they know of. He had
had a history of IV drug abuse, but no recent use they know of.
They note that he does drink regularly [**3-16**] heavy drinks most
days of the week and had recently lost his job as his company
had moved so has been feeling depressed.
Past Medical History:
Hep B
HTN
IVDA
ETOH use
Social History:
SHx: lives with mother, recently [**Name2 (NI) 61044**], heavy regular etoh
use, hx of IVDA
Family History:
Mother with ESRD on HD (unknown etiology)
Physical Exam:
PE:
T 98.8 P 96 BP 140/96 Sat 100% on AC 650/12/5/50% ABG
7.34/29/35/16 on 100%FiO2
GEN sedated, responds to painful stimuli
HEENT PERRL, 2mm bilaterally, constricted, minimally reactive,
Right pupil introverted, dry MM with ETT in place
CHEST CTAB no wheezes or crackles
ABD soft, distended, +BS, non tender, no appreciable
organomegaly
EXT 2+pitting edema bilaterally up to knees, 2+DP pulses
bilaterally, "track mark" scars on forearms
Pertinent Results:
CXR: An ET tube is seen, with the tip approximately 4 cm above
the carina. An NG tube is seen with tip in the stomach. A
rounded opacity is seen within the left mid lung zone which
represents the inferior contour of the left scapula. No other
opacities are identified within the lung fields. No pleural
effusions. The cardiac and mediastinal contours are within
normal limits. The soft tissues and osseous structures are
normal.
*
EKG: NSR, with peaked Twaves- im,proved from OSH EKG, nl
intervals
*
Renal US: The study is somewhat limited by portable .... and the
patient to cooperate. The right kidney measures 10.2 cm, and the
left kidney measures 9.9 cm. No hydronephrosis, renal masses,
renal calculi are demonstrated. The visualized urinary bladder
appears unremarkable. Trace amount of ascites is seen.
[**2141-4-11**] 09:39PM TYPE-ART PO2-163* PCO2-36 PH-7.24* TOTAL
CO2-16* BASE XS--11 INTUBATED-INTUBATED
[**2141-4-11**] 09:39PM LACTATE-1.6 K+-6.0*
[**2141-4-11**] 06:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-22
GLUCOSE-94
[**2141-4-11**] 06:30PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-0
LYMPHS-0 MONOS-0
[**2141-4-11**] 05:40PM GLUCOSE-122* UREA N-103* CREAT-15.0*
SODIUM-142 POTASSIUM-5.4* CHLORIDE-114* TOTAL CO2-16* ANION
GAP-17
[**2141-4-11**] 05:40PM ALT(SGPT)-37 AST(SGOT)-65* CK(CPK)-1241* ALK
PHOS-71 AMYLASE-228* TOT BILI-0.2
[**2141-4-11**] 05:40PM LIPASE-45
[**2141-4-11**] 05:40PM ALBUMIN-1.7* CALCIUM-5.8* PHOSPHATE-7.0*
MAGNESIUM-2.5
[**2141-4-11**] 05:40PM WBC-11.4* RBC-3.16* HGB-9.9* HCT-29.8* MCV-94
MCH-31.4 MCHC-33.4 RDW-13.5
Brief Hospital Course:
1. ARF: Pt had nephrotic syndrome with spot prot/creat 13,
hypoalbumin to 1.7, and edema. Family unaware of prior renal
diagnosis. Renal U/S neg. DDx includes FSG (more common in
blacks), membranous or membranoproliferative GN (c/w h/o Hep B),
minimal change dz, or systemic dz such as DM, amyloidosis, SLE.
Rhabdomyolysis can explain elevated CK, hyperphos, hypoCa and
renal failure though would not expect such a high level of
proteinuria and hypoalbuminemia. Hepatitis serologies were
checked and he was positive for hepatitis C. Cryoglobulins were
negative. [**Doctor First Name **], SPSP/UPEP were all negative while complement
levels were slightly low. HIV test was checked and was also
negative. Antistreptococcal antibodies were also negative.
After he was transferred out of the intensive care unit,
aggressive hemodialysis was started with good success. His
mental status began to clear, his metabolic acidosis improved,
and his electrolyte imbalances and fluid status improved. He
received dialysis in-house for 3 weeks before his insurance came
through to cover outpatient hemodialysis. He will follow up at
his outpatient hemodialysis site and with nephrology here as
needed. He never had a renal biopsy, so the cause of his renal
fialure is still unknown. He was advised to have a slit lamp
exam at [**Last Name (un) **] upon discharge to evaluate for signs of diabetes
(blood sugars were within normal limits while in-house).
2. Seizure: Unclear inciting event. Confusion, agitation likely
include post-ictal component. Ddx includes Etoh withdrawal,
uremia, electrolyte abnormality eg hypocalcemia, drug overdose
or drug withdrawal, trauma. Ethylene glycol was negative. CT
head negative for acute bleed. Do not suspect sepsis/infection
at this time, LP negative for meningitis. He was initially
intubated on admission for airway protection. After extubation,
he had no further episodes. The initial seizure was likely in
the setting of uremia, and he had no further events.
3. Metabolic acidosis: AG initially >30 at OSH, now down to 18
(if corrected for alb 1.7). Potential causes for acidosis
include uremia, seizure activity producing elevated lactate,
ketones from EtOH or fasting, or ingestions. Renal failure can
cause both a gap and non-gap acidosis. Nl osmolar gap makes
ethylene glycol ingestion unlikely. As he began to receive
dialysis, his acid/base status improved and was stable upon
discharge.
4. Anemia: Normocytic. [**Month (only) 116**] or may not be related to renal
failure depending on chronicity. Anemia workup was consistent
with anemia of chronic disease. He was started on epogen at
dialysis, and his hematocrit remained stable while in-house
5. Substance abuse: He was initially on a versed drip while in
the intensive care unit, and after transfer to the floor, he had
no signs of withdrawal.
6. Hypertension: He had some hypertension while in-house and
was started on ACEI that was continued at low dose at time of
discharge.
7. Disposition: He was discharge in stable condition, to
continue outpatient dialysis at [**Hospital1 3494**] center. He will
follow up with nephrology and with [**Company 191**] for primary care
initiation
Medications on Admission:
lisinopril 10 mg po daily
Discharge Medications:
1. 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*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 4 days.
Disp:*32 Tablet(s)* Refills:*0*
5. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. End stage Renal Disease
Discharge Condition:
Good
Discharge Instructions:
1. Please take all your medications as prescribed and described
in this discharge paperwork.
2. Please follow up with Transplant and Dialysis as described
below.
3. Please call your PCP if you are experiencing chest pain,
shortness of breath, fever, chills, or with any other concerns
Followup Instructions:
1. Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-5-11**] 10:20
2. Please call [**Hospital6 733**] ([**Telephone/Fax (1) 1300**]) to
schedule an appointment as soon as possible to establish primary
care.
3. Please follow up at [**Hospital1 3494**] Dialysis Center on Wednesday,
[**5-3**], to initiate dialysis. Please arrive at 2:30 pm for your
dialysis appointment. The kidney doctors here at [**Name5 (PTitle) 18**] will be
in touch with the dialysis center so that you can receive follow
up for your renal disease.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
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icd9cm
|
[
[
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[
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321, 384
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,193
| 126,217
|
16109
|
Discharge summary
|
report
|
Admission Date: [**2137-4-18**] Discharge Date: [**2137-5-2**]
Date of Birth: [**2067-9-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / Tape [**12-23**]"X10YD / Morphine / Atorvastatin / Zocor /
Tobramycin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
OSH Transfer for increasing confusion/hallucinations/lethargy
Major Surgical or Invasive Procedure:
[**4-24**] cerebral angiogram and re-coiling of basilar tip aneurysm
[**4-26**] Ventriculo-pleural shunt placed
History of Present Illness:
Patient is a 69 y/o female with CAD s/p PCI in [**2133**], h/o AAA
repair, brain aneurysm in [**2133**] s/p coiling who initially
presented with confusion to [**Hospital1 **] [**Location (un) 620**] on [**4-16**]. On the night of
[**4-15**], she apparently fell down while going to the bathroom
overnight, hit her head and neck, was fine, and went back to
sleep. In the morning, her husband noticed increased confusion
and that she was having visual hallucinations. She was afebrile
on arrival to the [**Hospital1 **] [**Location (un) 620**] ED. CT scan of the head showed no
change fromn prior or acute process. LP was performed, which
showed 4 RBCs, no whites, increased protein 139, and elevated
glucose. Cx with NGTD and HSV PCR pending. She was initially
started on Vanc/CTX. She was evaluated by both ID and neurology
and both recommended stopping the antibiotics. Due to increased
lethargy yesterday, MRI was performed. She was also having
increased ataxia and dysmetria. The imaging did not show any
temporal lobe involvement suggestive for HSV encephalitis but
the patient had change in her MRI since [**2133**] in the area of the
coiled aneurysm. There was a suspicion for some old or new
blood in GRE sequences on her MRI. Neurosurgery (Dr. [**First Name (STitle) **]
contact[**Name (NI) **] here - per discussion, this finding is not felt to be
the cause of her presentation, and that the presentation more
likely represented a septic meningitis. However, recommendation
was to bring patient to [**Hospital1 **] for close monitoring in case
intervention is needed. Upon transfer, patient was started on
acyclovir emperically.
.
On the floor, patient initially confused, but cleared quickly.
She is comfortable with no pain.
.
Telephone conversation with patient's husband: [**Name (NI) 4906**] states
that since patient's aneurysm in [**2133**], she has difficulty with
math and writing. She has had increasing lapses in short term
memory, and sometimes asks the same questions twice and can't
remember what she is doing. She has also had increasing
difficulties with walking and balance, stating she has an "odd"
gait. Her legs sometimes give out from under her and she slowly
falls to the ground. She does have a history of alcohol abuse
and continues to drink one glass of vodka and [**Location (un) 2452**] juice per
night. When asked about any odd behavoirs or personality
changes, he states that for the past year, she has collected
"every magazine she could get her hands on," does not read them,
but just stacks them in a pile. What made him concerned 3 days
ago was that she was hallucinating, stating her mother was in
the room with her when she was not.
She apparently had insight that she was hallucinating.
.
In talking with patient's PCP, [**Name10 (NameIs) **] has word-finding difficulties
at baseline.
Past Medical History:
- Brain anuerysm s/p coiling in [**2133**] - basilar artery aneurysm
with coiling sometime between [**2132**] and [**2135**], unclear where
- Anoxic encephalopathy following AAA rupture in [**2130**]
- h/o ruptured AAA. Course c/b the following:
- repair of AAA rupture on [**2131-7-13**]
- mesenteric ichemia resulting in exlap and ileocecotomy [**2131-7-14**]
- necrotizing pancreatitis d/t hypertriglyceridemia s/p multiple
debridements
- ileostomy and mucocutaneous fistula [**2131-7-16**]
- multiple abdominal washouts on [**8-10**], [**7-28**], [**8-3**], [**8-5**]
- skin graft to the lower [**1-24**] abdominal wall on [**8-8**]
- tracheostomy [**2131-8-2**]
- left eye vision loss, felt to be d/t cerebral artery aneurysm
(temporal artery biopsy negative)
# Ventral hernia with component separation requiring attempt at
colostomy closure and abdominal wall closure with marlex mesh on
[**2133-1-13**]
- [**2-26**]: split-thicknessskin graft to her abdominal wall defect
.
# Multiple hospitalizations for abdominal wound breakdown
requiring VAC; currently undergoing abdominal wall mesh
debridement and consideration of surgery with plastics, although
patient deferring at this time
# Type II DM
# PNA
# Hypertension
# A Fib - periop, on coumadin until [**5-28**] and then off for
unclear reasons
# Hypercholestermia
# STEMI: [**2-26**]: (inferior STEMI) - had total occlusion of RCA -
s/p BMS x2.
Social History:
Lives in single family home w/husband. Social history is
significant for the absence of current tobacco use. She drinks
one screwdriver a night.
Retired nurse
Family History:
Father died of an MI in his 60's, but no other family members
with CAD.
Physical Exam:
ADMISSION PE:
Vitals: 98 140/80 77 18 96% RA
General: Oriented x 1, confused, takes time to answer questions,
but clears after a few minutes
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No asterixis, Right eye ptosis, EOMs intact, , [**3-26**]
strength on right LE, [**3-26**] on left, [**3-26**] LE strength biltaerally,
downgoing toes bilaterally, Slow on heel to shin, mild dysmetria
on finger to nose, can spell world, forwards and backwards,
could not do serial 7s, has short-term memory deficit
EXAM UPON DISCHARGE:
alert to self, place and month (not year)
PERRL, EOMI
face symmetric, tongue midline
no pronator drift
MAE's with good strengths
incision staples intact (2 abdominal and head)
Pertinent Results:
ADMISSION LABS:
.
[**2137-4-19**] 06:20AM BLOOD WBC-4.9# RBC-3.32* Hgb-11.9* Hct-33.9*
MCV-102*# MCH-35.9* MCHC-35.1* RDW-12.9 Plt Ct-176
[**2137-4-19**] 06:20AM BLOOD Glucose-258* UreaN-31* Creat-1.4* Na-139
K-4.6 Cl-105 HCO3-24 AnGap-15
[**2137-4-19**] 06:20AM BLOOD Albumin-3.9 Calcium-9.6 Phos-3.4 Mg-2.0
[**4-20**] MRA Brain: IMPRESSION:
1. Markedly abnormal appearance to the previously-coiled basilar
artery tip aneurysm. There is now significant flow-related and
contrast enhancement, surrounding extensive thrombus involving a
large, apparently recanalized aneurysm sac, about the coil pack.
2. The recanalized, expanded aneurysm, measuring up to 2 cm (CC)
is
strategically located within the interpeduncular cistern and
anterior to the floor of the third ventricle, upon which it
exerts mass effect; it appears to be acting to produce
functional obstruction to lateral ventricular outflow at this
site, with marked lateral ventricular dilatation and evidence of
transependymal migration of CSF, new since the most recent [**Hospital1 18**]
NECT of [**2135-9-30**].
[**4-24**] Cerebral Angio: IMPRESSION:
[**Known firstname **] [**Known lastname **] [**Known lastname 1834**] cerebral angiography and recoiling of a
giant basilar aneurysm that was partially thrombosed. This was
uneventful.
[**4-26**] CT Chest: IMPRESSION:
1. The tip of the ventriculopleural shunt lies at the right
apex.
2. Incidental note of a lower descending thoracic aortic
aneurysm measuring 6 cm maximally, which has enlarged since a CT
dated [**2136-7-5**] when it measured 56 mm.
3. Bilateral small pleural effusions and moderately severe
bilateral
atelectasis.
[**4-26**] CT Head: IMPRESSION: Post VP shunt placement via a right
frontal approach, with no post-procedural hemorrhage or large
[**Month/Day (4) 1106**] territorial infarction. Multiple aneurysm coils obscure
neighboring structures.
[**4-29**] CT Abdomen: IMPRESSION:
1. No evidence for postsurgical fluid collection in the abdomen
or pelvis.
2. Fluid-filled vagina. This is a new finding, however, is of
uncertain
clinical significance. Correlation with clinical examination is
recommended.
3. Stable suprarenal aortic aneurysm.
4. Mild intrahepatic biliary ductal dilatation in the left
lateral segment is stable.
[**2137-4-30**] 09:20AM BLOOD %HbA1c-7.5* eAG-169*
Brief Hospital Course:
69 y/o female with CAD s/p PCI in [**2133**], h/o AAA repair, brain
aneurysm in [**2133**] s/p coiling who initially presented to [**Hospital1 **]
[**Location (un) 620**] on [**4-16**] with hallucinations, confusion, lethargy, now
being transferred for increasing leathrgy and neurosurgery
evaluation.
.
#. Confusion: Patient's initial presentation to [**Hospital1 **] [**Location (un) 620**]
consistent with acute delerium, with letahrgy, inattentiveness,
and hallucinations. On arrival, she no longer showed signs of
delirium. She was not delirious and maintained good attention,
denying any hallucinations. Her primary issue seems to be short
term memory and cerebellar signs with ataxic gait noted at OSH.
Per PCP, [**Name10 (NameIs) **] has a history of anoxic encephalopathy after AAA
rupture in [**2130**] and since had word-finding difficulties. Based
on CSF, lack of fever, no meninigeal signs, suspicion for
infection low. Acyclovir was discontinued when [**Hospital1 **] [**Location (un) 620**]
viral studies returned negative. Given her hx of etoh use, she
was also started on thiamine and folate. Neuro was consulted.
Neuro [**Doctor First Name **] was consulted and recommended angiogram and placement
of coil given MRA findings. She went to the angio suite on
[**2137-4-24**] for coiling of her basilar aneurysm. Procedure went
smoothly without complications. On [**4-26**] she [**Month/Day (4) 1834**] a VP shunt
along with the ACS service which included an incidental small
bowel enterotomy while attempting an initial
Ventriculoperitoneal shunt resulting in the conversion to the
Ventriculo-pleural shunt. She tolerated the procedure well and
was placed on ABX for the enterotomy.
#. Hypertension: Patient with labile blood pressure in SBPs
140s-180s on admission here. She was continued on home
metoprolol dose. Per neurosurgery recs, SBP maintained < 160
with aid of PRN hydralazine. Captopril was initiated on [**4-21**] for
BP control which worked well at 12.5mg TID. Medicine team
recommended transition to an equivalent dose of lisinopril at
time of discharge if she requires continued strict BP control
post-operatively.
#. Renal Failure: Patient has CKD with baseline Cr 1.2-1.6. Cr
1.4 on admission and remained stable throughout admission. Would
recommend renally dosing gabapentin prior to discharge pending
creatinine level at that time.
.
#. GERD: Continued on omeprazole.
.
#. Depression: Continued on sertraline 100 mg once a day. It was
confirmed w her PCP that she did not take celexa at home
(reported by OSH as a home medication).
In preparation for discharge she was evalauted by PT on [**4-27**] who
felt that she may require rehab and recommended OT consult as
well.
On [**4-29**] the patient complained of abdominal pain. General Surgery
was made aware and an abdominal CT was ordered. This was
negative for acute abnormality. On [**4-30**] it was noted that the
patient was having elevated glucose levels so a HgA1C was
ordered (7.5). She was changed to a diabetic diet. She continued
to have abdominal discomfort but it was stable and localized to
the incisional area.
On [**5-1**] the patient remained neurologically stable. On [**5-2**] she
was offered a bed at rehab and the patient was in agreement to
go.
Medications on Admission:
1. Sertraline 100 mg p.o. at bedtime.
2. Aspirin 325 daily.
3. Lorazepam 1 mg p.o. at bedtime.
4. Omeprazole 20 mg p.o. daily, delayed release.
5. Gabapentin 1200 mg p.o. t.i.d. (renally dosed)
6. pancrealipase
7. Vitamin D 50,000 units every week.
8. Toprol XL 150 mg p.o. daily.
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
2. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
8. insulin regular human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
12. captopril 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
13. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for pruritis.
15. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Recanalization of basilar aneurysm
hydrocephalus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital because of confusion and
hallucinations. You had a CT scan of your head and an MRI which
showed a new area of possible small bleed where your coil had
been previously placed. You were evaluated by the
neurosurgeons, who felt that you would benefit from angiogram
and surgery. You also had a test of your cerebrospinal fluid
called a lumbar puncture, which did not show any evidence of
infection.
.
We made the following changes to your medications:
ADDED Thiamine
ADDED Folate
ADDED Lisinopril for blood pressure control
You had a Chest CT on [**4-26**] which showed a thoracic aortic
aneurysm measuring 6 cm maximally,Please follow up with DR
[**Last Name (STitle) **], [**Last Name (STitle) **] surgery to discuss possible treatment of
this.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, do not
resume taking these unless cleared by your surgeon.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Department: [**Last Name (STitle) **] SURGERY
When: THURSDAY [**2137-7-11**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2137-7-11**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Follow-Up Appointment Instructions
??????Your staples/sutures can be removed on [**5-4**]. This can be done
at rehab. If there are any questions or problems, please call
[**Telephone/Fax (1) 1669**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks with a noncontrast head CT.
Completed by:[**2137-5-2**]
|
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|
[
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[]
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] |
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,155
| 184,685
|
54020
|
Discharge summary
|
report
|
Admission Date: [**2130-8-22**] Discharge Date: [**2130-8-30**]
Date of Birth: [**2062-8-9**] Sex: F
Service: SURGERY
Allergies:
Tetracycline Analogues / Streptomycin / Ciprofloxacin /
Penicillin V Potassium / Vicodin / Iodine / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / angiogram dye
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Cholelithiasis status post endoscopic retrograde
cholangiopancreatography for choledocholithiasis.
Major Surgical or Invasive Procedure:
Open cholecystectomy
History of Present Illness:
67 year old female with multiple medical co-morbidities who
recently underwent ERCP for choledocholithiasis. She started
having intermittent epigastric
pain 2 weeks ago, radiating to bilateral sides and back. The
pain was unrelated to food and had initially resolved after ERCP
(as had her LFTs) however some mild pain did restart. She was
tolerating a regular diet with no nausea or vomiting. She had
no prior episodes and no episodes of cholecystitis. She denied
fever/chills.
Past Medical History:
PMH:
- COPD, continues to smoke, not on home oxygen
- H/o pulmonary nodules followed for several years
- CAD s/p CABG (4 vessel in [**2116**], one vessel occluded on cath
[**2118**],
no stents)
- Perforated ulcer - [**2125**] ex-lap, was H pylori positive
- Uterine CA -s/p TAH BSO - 40 years ago
PSH:
- CABG ([**2116**])
- Appendectomy
- Tonsillectomy
- Bladder suspension procedure
- Eye surgery x 3
- TAH/BSO (40 years ago)
- Ex-lap for perforated ulcer repair ([**2125**])
Social History:
Retired claims adjustor, lives at home with spouse and current
1ppd smoker, 4-6 beers/day.
Family History:
Breast/ovarian cancer
Physical Exam:
Upon Discharge:
Vitals - 98.1 98.0 96 150/86 22 95%3L
Gen - AAOx3, NAD
CV - +S1/S2, no murmurs/rubs/gallops
Resp - distant breath sounds bilaterally, diffuse occasional
coarse breath sounds and crackles diffusely, no wheezes/rhonchi
Abd - soft, non-tender, non-distended, +BS, no
rebound/rigidity/guarding, no palpable masses
Inc - clean/dry/intact, no erythema/drainage/induration
Ext - no cyanosis/clubbing/edema
Pertinent Results:
OPERATIVE PATHOLOGY ([**2130-8-22**]): Gall bladder, cholecystectomy:
adenocarcinoma of the gallbladder with associated high-grade
dysplasia.
BILATERAL LOWER EXTREMITY ULTRASOUND ([**2130-8-25**]): No DVT in both
lower extremities.
CHEST X-RAY ([**2130-8-25**]): Enlargement of the peripheral
consolidative abnormality at the left lung base since [**8-24**] is consistent with increasing infection or infarction. These
diagnostic possibilities were discussed by Dr. [**Last Name (STitle) **] [**Last Name (STitle) 151**] the
physician caring for this patient at approximately 11:30 this
morning. Mild edema persists at the base of the right lung.
Heart size is normal.
V/Q SCAN ([**2130-8-25**]): Low likelihood ratio for recent pulmonary
embolism. Matched defects in both lung relate to COPD.
CHEST X-RAY ([**2130-8-28**]): Left lower lobe opacification with
associated pleural effusion, consistent with pneumonia in the
appropriate clinical setting.
LABS UPON DISCHARGE:
[**2130-8-30**] 04:33AM BLOOD WBC-8.6 RBC-3.03* Hgb-10.2* Hct-30.6*
MCV-101* MCH-33.8* MCHC-33.5 RDW-13.3 Plt Ct-293
[**2130-8-30**] 04:33AM BLOOD Plt Ct-293
[**2130-8-30**] 04:33AM BLOOD Glucose-103* UreaN-7 Creat-0.4 Na-134
K-4.0 Cl-100 HCO3-24 AnGap-14
[**2130-8-26**] 01:42AM BLOOD ALT-18 AST-22 AlkPhos-74 Amylase-18
TotBili-0.9
[**2130-8-30**] 04:33AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.9
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2130-8-22**], the patient underwent an
open cholecystectomy, which went well without complication
(reader referred to the Operative Note for details). The patient
was given an epidural for pain control, which controlled her
pain well. However, in the PACU, the patient required a
transient phenylephrine drip, 2 L fluid bolus, and one dose of
albumin due to a systolic blood pressure in the 70s, while
mentating well and being entirely asymptomatic. Of note, the
patient had taken her HTN medications that morning. With
adjustment of the epidural parameters, the patient was easily
weaned off the phenylephrine, with stable blood pressures in the
90-100s. Thereafter, she was trasnferred to the general surgical
floor with a foley catheter, NPO, on IVF, with a foley catheter
and JP drain. The patient was hemodynamically stable.
General Brief Hospital Course:
Neuro: The patient orgiginally received an epidural on POD1,
however, it did not control her pain, the epidural was split and
then discontinued on POD2 at which point the patient was
transistioned to oral pain medication with IV breakthrough.
When tolerating oral intake, the patient was successfully
transitioned to oral pain medications, and had good pain control
thereafter.
CV: The patient remained stable from a cardiovascular standpoint
after transfer from the PACU to the floor; vital signs were
routinely monitored. Of note an a-line was placed briefly while
the patient was in the ICU to monitor hemodynamics. a-line was
discontinued on POD4 as patients hemodynamics remained stable
throughout the rest of her hospital stay.
Pulmonary: On POD2 patient has an episode of desaturation to the
mid 70's which was transient and imporved with IS usage and O2
per nasal cannula. Patient experienced another episode of
desaturation to the 70's which also responded to supplemental
oxygen however, this episode was associated with a change in
mental status. Pateint was hemodynamicaly stable, O2 saturation
remained above 90 with supplemental oxygen and UOP was
sufficient. WBC was however elevated at 18 and the decision was
made to transfer the patient to the ICU for a further w/u of
altered mental status. Blood gases were followed closely and
the patient was continued on supplemental oxygen. ABGs remained
consistent with a picture of chronic COPD. While in the ICU
patient remaine stable from a cardiovascular standpoint,
however, she continued to have episoded of altered mental status
especially in the evening. Workup (please refer to Pertinent
Results section) proved negative for pulmonary embolism. Imaging
and clinical correlation was suggestive of pneumonia, and the
patient was treated accordingly (please refer to ID section
below).
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. Once
appropriate bowel function was seen to return, the patient was
transitioned to clear liquids, then full liquids, and finally a
regular diet. She tolerated all these steps well.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection throughout her stay. As
discussed above, the identification of pneumonia prompted
requesting the input of Infectious Disease specialists. Per
their recommendations, the patient was started on IV vancomycin,
cefepime, and flagyl. The vancomycin was discontinued after 2
days, while cefepime and flagyl were continued through till
discharge. Please note that per recommendations, the patient was
discharged with prescriptions, and clear instructions to take
THREE (3) DAYS of antibiotics after discharge as follows:
Cefpodoxime 400 mg PO q12H, and Flagyl 500 mg PO q8H.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Based upon the operative pathology, the Liver experts and
Hematology/Oncology team were consulted. They visited the
patient, and recommended further follow-up as outpatient to make
further plans. The patient and her family expressed strongly
their interest in completing her recovery at rehab, and pursuing
further once she felt more physically improved.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Atorvastatin 80 mg po daily
Fluticasone spray PRN
Isosorbide mononitrate ER 60 mg po daily
Metoprolol tartarate 100 mg 2 tabs [**Hospital1 **]
Nitroglycerin PRN
Olopatadine 0.2% eye drops 1 drop to both eyes daily
Prednisolone acetate 1% eye drop to both eyes 4x per day
Vitamin B-12
Omeprazole 20 mg po daily
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]:PRN PRN
3. Isosorbide Mononitrate 60 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. olopatadine *NF* 0.2 % OU daily
6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
7. Omeprazole 20 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN fever/pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
9. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*16 Tablet Refills:*0
10. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 4 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*12 Tablet Refills:*0
11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
12. Metoprolol Succinate XL 50 mg PO DAILY
Hold for SBP<100, P<60.
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H wheezing
Please perform Chest PT after each Neb
14. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-19**] tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 25112**] - [**Doctor Last Name **] Ponds
Discharge Diagnosis:
Cholelithiasis status post endoscopic retrograde
cholangiopancreatography for choledocholithiasis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for surgical
management of your cholelithiasis. You have done well in the
post operative period and are now safe to complete your recovery
at rehab with the following instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-27**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD
Phone:[**Telephone/Fax (1) 2723**]
Date/Time:[**2130-9-8**] 1:45
Provider: [**Name Initial (NameIs) 394**]/[**Name8 (MD) **] MD
Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2130-9-12**] 9:00
Completed by:[**2130-8-30**]
|
[
"518.52",
"574.20",
"156.0",
"496",
"V10.42",
"414.00",
"458.29",
"305.1",
"V45.77",
"V88.01",
"V45.81",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10458, 10543
|
4513, 8933
|
519, 542
|
10686, 10686
|
2158, 3122
|
13171, 13481
|
1679, 1703
|
9293, 10435
|
10564, 10665
|
8959, 9270
|
10837, 11664
|
11679, 13148
|
1718, 1718
|
380, 481
|
3139, 3533
|
570, 1053
|
10701, 10813
|
1075, 1554
|
1570, 1663
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,875
| 171,722
|
27171
|
Discharge summary
|
report
|
Admission Date: [**2104-4-10**] Discharge Date: [**2104-4-19**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
85 yo male being transferred on [**4-11**]/6 from OSH after he had
dizziness, syncope, and had fallen to the ground outside the
[**Hospital1 1474**] VA. A head CT showed subarachnoid blood. Patient was
transferred to [**Hospital1 18**] ED. He denies any HA, dizziness,
lightheadedness prior to syncope and states that he "just
dropped" and landed on his face. Wife witnessed this and states
there was no seizure activity. At the time of this event,
patient was on coumadin and plavix after having a coronary
artery stent placed at the VA on [**2104-3-7**].
Past Medical History:
CAD, stent placed at the VA [**2104-3-7**]
CHF
hx of right pleural effusion s/p thoracentesis
a fib,
DJD
hypercholesterol
anemia
dysphagia of solids and liquids for couple months
GI bleeding
Social History:
Patient gets all care at the VA system. He lives in a 2 story
home with wife, still drives
Family History:
NC
Physical Exam:
Vit: 95.3 75 105/73 15 98% SM with 4L NC
I/O: 24 hr 1750/2115, last 16 hr 2275/1515
Gen: elderly male, resting in bed, face mask in place
HEENT: Bilateral eye bruising, dried blood at nares, no icterus,
EOMI, PERRLA, neck supple, + jvd
CV: RRR, s1s2, [**1-14**] SM at LUSB
Pulm: Decreased breath sounds at bases, scattered wheezes and
few crackles in lower lung fields, right worse than left
ABD: + BS, soft, mild RUQ tenderness, no guarding
EXT: no peripheral edema, 2+ radial and DP pulses
NEURO: CN II-XII intact, alert and appropriate with
exam/questioning
Pertinent Results:
[**4-16**]: ECHO
Conclusions:
1. The left atrium is moderately dilated. The left atrium is
elongated. The right atrium is moderately dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. There is no
aorticvalve
stenosis. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
6.There is moderate pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
.
[**4-14**]: CXR: Moderate pulmonary edema and moderate right and small
left pleural effusion along with cardiomegaly and mediastinal
vascular engorgement have all worsened. Focal consolidation at
the apex of the left lung could be pneumonia, appearing since
[**4-10**].
.
[**4-12**] C-spine: Grade 1 anterolisthesis of C3 on C4 and grade 1
retrolisthesis of C5 on C6 are stable during flexion and
extension.
.
[**2104-4-10**]: trauma CT torso: No evidence of acute traumatic injury
or active extravasation. Large right pleural effusion with
associated atelectasis. 1.4 cm cystic-appearing lesion is seen
in the head of the pancreas. Followup imaging is recommended
when patient is stable
.
[**2104-4-10**] CT head:
1. Large subarachnoid hemorrhage in the basal cisterns and
suprasellar cisterns. While this may relate to subarachnoid
hemorrhage secondary to trauma and anticoagulation, a CT
angiogram would be necessary to exclude underlying aneurysm.
2. Third and lateral ventricular dilatation, raising
possibility of early obstructive hydrocephalus.
3. Chronic small vessel ischemic change and involutional
change, with old right cerebellar hemispheric infarct.
.
[**2104-4-11**] CTA: per report showed no aneurysm, official report
pending.
Brief Hospital Course:
# SAH - CT scan in the ED showed large subarachnoid hemorrhage
in the basal cisterns and suprasellar cisterns. On admission to
trauma surgery team with neurosurgery consulting patient's
anticoagulation was reversed. He was admitted to the trauma
SICU and started on dilantin. A CTA of the head showed no
evidence of aneurysm, bleed was likely due to trauma from fall
and anticoagulation. Patient's neurologic status was stable and
without deficit. He completed one week of dilantin without any
evidence of seizure activity. Patient will need to schedule a
follow up appt with Dr. [**Last Name (STitle) 23813**] in neurosurgery 6 week from
discharge.
.
# SOB - [**Hospital **] hospital course was complicated by shortness
of breath attributed to CHF and chronic pleural effusions. He
was ruled out for an MI, treated for possible aspiration
pneumonia with levofloxacin and flagyl, and had a
diagnostic/therapeutic right sided thoracentesis. ECHO showed
EF 60-65%. Pulmonary felt his symptoms were due to fluid
overload and the pleural fluid was consistent with a transudate
with lymphocytic predominance. The patient was diuresed with
Lasix with improvement in his symptoms. He will be transferred
to an acute rehab center for further diuresis and weaning from
oxygen. His daily fluid goal is [**Telephone/Fax (1) 1999**] cc/day and may be able
to reduce his lasix dose as he diuresed 1.5 L yesterday on 100
mg Lasix [**Hospital1 **]. Patient should follow up with his outpatient
pulmonologists at the VA for further monitoring and management
of his shortness of breath after discharge from rehab.
.
# CAD - Patient was s/p bare metal stent placement to left
circumflex on [**2104-3-7**] at the [**Hospital1 59561**]. Plavix and aspirin were held
initially due to concern for bleeding. Patient had episodes of
chest pain during this admission which were not correlated with
any evidence of ischemic injury concerning for clotting of the
stent. Both plavix and aspirin were restarted after approval by
neurosurgery. Patient had a troponin leak to 0.07 on [**2104-4-13**],
though his CKs remained normal. Cardiac medications were
titrated by consulting cardiologists and are as described in d/c
plan.
.
# Syncope - Pt had no further syncopal episodes while
hospitalized, but was noted to have up to 2 second pauses on
telemetry. He has been on a BB prior to admission and this may
have led to prolonged pause causing his syncopal episode. Pt's
BB was discontinued permanently per cardiology and pt should
avoid nodal blockers in the future as well. Pt may benefit from
a pacemaker in the future.
.
# Hypernatremia - Patient was hypernatremic initially, which
resolved with hydration of D5W and remained normal once his diet
was advanced and he was able to take PO liquids.
.
# AF - Patient was in NSR during this hospitalization. His
coumadin was held throughout. He can restart his coumadin on
[**2104-5-4**].
.
# Anemia - Hct remained stable, was 30.4 at discharge.
.
# Dysphagia - Pt has had dysphagia for the past few months. He
had a video swallow which showed mild to moderate oral, mild
pharyngeal dysphagia with aspiration of thin liquids which were
prevented by chin tuck maneuver. Patient was started on a thin
liquids/soft solids diet without further aspiration/coughing
episodes. Pt should have a repeat swallow study done at a later
date to assess for improvement in function.
.
Medications on Admission:
coumadin
isosorbide 120'
nitro prn
lasix 80'
KCL 20'
MVI
terazosin 3'
triamcinolone cream
lamisil
plavix 75'
omeprazole 40'
simvastatin 40'
atenolol 25'
lisinopril 20'
aspirin
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
3. Albuterol Sulfate 0.083 % Solution Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 days.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
17. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Subarachnoid hemorrhage
Congestive heart failure
Syncope
Anemia
Dysphagia
Discharge Condition:
Fair
Discharge Instructions:
If you develop chest pain, increasing shortness of breath,
fevers, chills, or dizziness/lightheadness call your primary
care doctor.
.
Your medications have been changed, take only the medications
listed in your discharge paperwork. NO MORE BETA BLOCKERS.
.
Follow up with your VA primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] pulmonologists
within one week of discharge from rehab.
.
You will need to call to schedule a neurosurgery follow up
appointment with Dr. [**Last Name (STitle) 739**] at [**Hospital1 18**] for 6 weeks from
discharge. Call [**Telephone/Fax (1) 66679**] to schedule this appointment.
Followup Instructions:
Follow up with your VA primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] pulmonologists
within one week of discharge from rehab.
.
You will need to call to schedule a neurosurgery follow up
appointment with Dr. [**Last Name (STitle) 739**] for 6 weeks from discharge.
Call [**Telephone/Fax (1) 66679**] to schedule this appointment.
Completed by:[**2104-4-19**]
|
[
"707.03",
"E888.9",
"780.2",
"427.31",
"414.00",
"852.01",
"486",
"276.0",
"V45.82",
"285.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
9071, 9143
|
3852, 7268
|
235, 251
|
9261, 9268
|
1789, 3285
|
9954, 10341
|
1182, 1186
|
7494, 9048
|
9164, 9240
|
7294, 7471
|
9292, 9931
|
1201, 1770
|
188, 197
|
279, 842
|
3294, 3829
|
864, 1057
|
1073, 1166
|
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