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28,150
| 117,699
|
33776
|
Discharge summary
|
report
|
Admission Date: [**2114-2-21**] Discharge Date: [**2114-3-5**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Falling Hct
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85yF with h/o CAD, CHF, COPD tx from [**Hospital 1474**] Hospital for low
Hct and evidence of peri-hepatic hematoma on CT scan. In brief,
she presented to OSH with abd pain, found to have free air on
CXR. Taken to OR and found to have large perforated gastric
ulcer as well as an ischemia perforation of the distal ileum.
She underwent a hemigastrectomy with Roux en Y as well as a SBR.
She developed multiple episodes of resp distress post-op and
had several extubations followed by emergent re-intubations. A
collection was found peri-hepatic. A CT guided drainage was
performed, which probably resulted in a liver injury. She
continued to have falling Hcts, and was resuscitated with PRBCs.
The collection itself grew out [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] and GNRs. She
also had gram positive cocci in her blood, likely from a line.
She was on linezolid, zosyn, and caspofungin on transfer. The
patient was transferred to our hospital for falling hematocrits
with evidence of a likely peri-hepatic hematoma.
Past Medical History:
PMH: CAD, MI [**2111**], prev EF 55%, HTN, COPD, descending thoracic
AA 4.2cm
PSH: hemigastrectomy with [**Last Name (un) **] and SBR
Physical Exam:
T93.9 HR50 BP135/50 RR24 Sat93%
Vent: AC 50%/450 x 24/ peep10
Intubated, sedated
Anasarca
Dobhoff and OGT in place
Bradycardiac, 1st degree AV block
Coarse breath sounds, rales
abdomen soft, distended, midline wound with some drainage
weeping of fluid from both arms
Pertinent Results:
Admission labs:
13.3
26.4 109
38.8
147 109 84 148
3.9 28 1.5
Ca 6.9, Mg 1.9, PO4 5.3
INR 1.1
AST 59, ALT 263, AP 274, Tb 2.8, Alb 1.8, [**Doctor First Name **] 101, Lip 13
ABG 7.35/50/88/29/0
Ca (ion) 0.93 lactate 1.2
CXR: pulmonary edema, b/l effusions, dobhoff in esophagus, CVL
in SVC
CT abd [**2114-2-22**]:
1. Large 15 x 10 cm heterogeneous subcapsular liver mass/high
attetuation
fluid collection. Given the relatively high attenuation of this
mass and the clinical history of recent biopsy, its appearance
is consistent with hematoma and would not be amenable to
drainage. A few foci of gas are noted within this collection,
likely due to recent procedure but underlying infection cannot
be excluded.
2. Status post Roux-en-Y procedure without evidence of
obstruction. Extensive peripancreatic inflammatory change likely
post-surgical.
3. Evidence of volume overload including large bilateral
pleural effusions, anasarca, and intra-abdominal fluid.
4. Right-sided aortic arch.
5. NGT in good position
FISTULOGRAM/SINOGRAM [**2-28**]: Enterocutaneous fistula with contrast
collecting within an amorphous extraintestinal space before
entering small bowel
CT GUIDANCE DRAINAGE [**2-28**]: Successful CT-guided pigtail catheter
placement into the patient's intraperitoneal fluid collection
RENAL U.S. [**2-27**]:Mild bilateral renal cortical thinning, without
evidence of hydronephrosis.
ECHO [**2-22**]:
left atrium is mildly dilated. mild symmetric LVH. LV systolic
function is hyperdynamic (EF 70-80%). No aortic valve stenosis.
No aortic regurgitation. MV leaflets are mildly thickened. No
MVP. TV leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
Neuro: The patient was off of sedation and became arousable
shortly after admission. She was kept off sedation other than
prn doses for comfort. Her neurological status deteriorated
late in her hospital course
Cardio: Echo at admission showed a hyperdynamic heart with an EF
of 70-80%. Initially she required no pressors, but as her
multi-organ failure progressed she required norepinephrine
and/or neosynephrine to maintain her blood pressure. Towards
the end of her hospital course the family decided not to
escalate her pressor requirements. Eventually, her BPs were
unable to be maintained and she expired on [**2114-3-5**].
Pulm: She was unable to wean from controlled ventilation. She
was attempted on pressure support multiple times but became very
tachypneic and demonstrated low tidal volumes during these
trials. Her CXR showed worsening pulmonary edema and pleural
effusions.
FEN: She was maintained on her TPN that she arrived with. Her
nutrition labs were checked weekly. Per renal, her diuresis was
limited due to her ARF. She was initially kept on LR, then
switched to MFs, and then KVO in order to maintain an even fluid
balance. The patient had significant anasarca. Her arms wept
almost a liter of fluid a day which was collected in drainage
bags.
GI: Her dobhoff was removed as it was non-functional in its
position. Tube feeds were resumed but down her OGT. She did
have some issues tolerating these with higher residuals and her
TFs were held appropriately at these times. She was continued
on Protonix for GI prophylaxis. She eventually was found to
have developed an EC fistula through one of her open wounds on
her abdomen. A pigtail was placed in this and allowed to drain.
GU: Her BUN/Cr were elevated at admission and continued to
slowly trend up. Renal was consulted. They recommended that we
try to maintain a even fluid balance, and avoid diuresis. They
recommended albumin for fluid if needed. They believed her ARF
was of multiple etiology including: sepsis, hypotension,
contrast etc. They did not believe dialysis was needed at this
time but continued to follow.
Heme: Her Hct was stable at admission but slowly trended down.
Her platelets and WBC also slowly trended down. It was believed
that this was secondary to her multi-organ failure.
ID: Her antibiotics were switched to Dapto, cipro, flagyl, and
caspofungin. These were continued through her hospital stay.
Her cultures grew out yeast and enterococcus from multiple
sources.
Endo: She was transferred with solumedrol on board. This was
stopped after transfer. Her blood sugars were relatively stable
throughout her hospital course and did not require an insulin
drip.
Eventually the patients family made her DNR. A few days later
they decided to not escalate care and she expired shortly after.
Medications on Admission:
[**Last Name (un) 1724**]: combivent, enalipril, imdur, asa
Admission meds: Linezolid, zosyn, caspofungin, solumedrol,
protonix, combivent
Discharge Disposition:
Expired
Discharge Diagnosis:
Perforated gastric ulcer s/p hemigastrectomy with Roux en Y and
SBR
Subcapsular liver hematoma
ARF
Respiratory failure
Enterocutaneous fistula
Anasarca
Discharge Condition:
Expired
|
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64,695
| 146,159
|
38842
|
Discharge summary
|
report
|
Admission Date: [**2146-4-11**] Discharge Date: [**2146-4-16**]
Service: NEUROLOGY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Confusion, slurred speech
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr [**Known lastname 86212**] is an 87 year old right handed man with a history
of type 2 diabetes mellitus (on insulin), prostate ca with
spinal
mets, Afib as per his [**Known lastname 802**], not on anticoagulation, who
presented to the OSH with slurred speech, confusion and
agitation
at the OSH. The history was obtained from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**], his HCP
and
[**Name2 (NI) 802**], as the patient is unable to recount a history. Yesterday
at 8:30 am, the patient called his [**Name2 (NI) 802**] stating that he was
feeling unwell; she got there by 9:45 am and his blood glucose
was 282. She stated that his blood pressure
which she had taken was fine (but did not remember the exact
numbers). He had apparently given himself 21 units of insulin,
and he told his [**Name2 (NI) 802**] that he had eaten. A couple of hours later
his blood glucose was 58. He only ate a yoghurt during the day.
At night, he was wandering around his home. By the morning, he
had become confused and agitated. When his [**Name2 (NI) 802**] suggested
taking
an ambulance to the hospital, he became combative. She was
concerned because the patient's speech sounded slurred. It was
not until he got to [**Hospital3 68**], that the staff pointed out
a left facial droop to her. In addition, she mentioned that he
did not appear to understand what she was talking about and was
agitated as a result of this. When I saw him in the ER, he
complained of a right retro-orbital headache, which he had when
he was at the OSH.
ROS: unobtainable from the patient, according to his [**Hospital3 802**], he
did not fall.
Past Medical History:
PMHx obtained from his [**Hospital3 802**]:
- Insulin dependent type 2 DM for over 20 years
- HTN
- prostate cancer with mets to spine (treated by Dr [**Last Name (STitle) 86213**]
[**Name (STitle) 86214**]
at [**Company 2860**]
- history of Afib (not on anticoag), he had a fall, and was
found
to have a HR in the 30s, thus a PPM was placed (sounds like
[**Last Name (un) **]-brady syndrome) *** as per PCP, [**Name10 (NameIs) **] known history of Afib,
pacemaker placed [**2-23**] for complete heart block
Social History:
His wife had [**Name (NI) 2481**] disease and died 2 weeks ago. His
daughter died with complications of MS and his son died of AIDS.
He is an ex-smoker, but had given up for a number of years. He
does not drink alcohol or use recreational drugs.
[**Name (NI) **] is [**Name (NI) **] [**Name (NI) 174**] who is also his HCP [**Telephone/Fax (1) 86215**]
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Family History:
Mother died of peritonitis in her 40s. His father died of
colorectal ca in his 60s.
Physical Exam:
T-98.3 HR-108 BP-161/91 RR-18 SpO2-98
Gen: Lying in bed, pulling at lines, looking very confused
HEENT: NC/AT, dry oral mucosa
Neck: No meningismus, no carotid or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Somnolent. Oriented to person, place, but not
date. Inattentive. His speech is slightly dysarthric.
Intermittently following one step commands.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Fundoscopy is normal. He blinks to threat. His
corneal reflexes are in tact bilaterally. He has a left facial
droop. His gag reflexes are in tact.
Motor:
Normal bulk bilaterally. Tone is increased in the left leg more
so than the arm.
Left pronator drift
He is antigravity in his arms and legs, but raises his left arm
and leg for less time.
Sensation: moves all 4 limbs away from noxious stimulus
Reflexes:
2 and symmetric throughout apart from absent Achilles jerks.
Right toe downgoing, left toe is up going
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: unable to assess
Pertinent Results:
[**2146-4-11**] 01:25PM URINE RBC-[**6-23**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0-2
[**2146-4-11**] 01:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2146-4-11**] 01:55PM PT-15.1* PTT-30.7 INR(PT)-1.3*
[**2146-4-11**] 01:55PM PLT COUNT-332
[**2146-4-11**] 01:55PM WBC-9.2 RBC-4.50* HGB-13.6* HCT-39.0* MCV-87
MCH-30.1 MCHC-34.7 RDW-12.2
[**2146-4-11**] 01:55PM GLUCOSE-168* UREA N-19 CREAT-1.1 SODIUM-134
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-26 ANION GAP-16
[**2146-4-11**] 07:04PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2146-4-11**] 07:04PM CK-MB-9 cTropnT-0.43*
[**2146-4-11**] 07:04PM CK(CPK)-424*
[**2146-4-12**] 03:07AM BLOOD ALT-16 AST-38 CK(CPK)-460* AlkPhos-88
[**2146-4-12**] 03:07AM BLOOD CK-MB-7 cTropnT-0.35*
[**2146-4-12**] 10:33AM BLOOD CK-MB-PND
[**2146-4-12**] 10:33AM BLOOD CK(CPK)-PND
[**2146-4-12**] 03:07AM BLOOD %HbA1c-8.6* eAG-200*
[**2146-4-15**] 09:45AM BLOOD WBC-9.1 RBC-3.89* Hgb-11.4* Hct-34.2*
MCV-88 MCH-29.3 MCHC-33.3 RDW-12.4 Plt Ct-246
[**2146-4-14**] 04:25AM BLOOD WBC-10.2 RBC-4.38* Hgb-12.6* Hct-37.5*
MCV-86 MCH-28.8 MCHC-33.6 RDW-12.3 Plt Ct-277
[**2146-4-13**] 01:32AM BLOOD WBC-10.5 RBC-3.52* Hgb-10.7* Hct-30.7*
MCV-87 MCH-30.2 MCHC-34.7 RDW-12.1 Plt Ct-277
[**2146-4-15**] 09:45AM BLOOD Neuts-82.0* Lymphs-13.8* Monos-3.2
Eos-0.7 Baso-0.2
[**2146-4-15**] 09:45AM BLOOD Plt Ct-246
[**2146-4-15**] 09:45AM BLOOD PT-15.3* PTT-28.8 INR(PT)-1.3*
[**2146-4-14**] 04:25AM BLOOD Plt Ct-277
[**2146-4-14**] 04:25AM BLOOD
[**2146-4-15**] 09:45AM BLOOD Glucose-213* UreaN-20 Creat-1.2 Na-132*
K-4.5 Cl-97 HCO3-19* AnGap-21*
[**2146-4-14**] 04:25AM BLOOD Glucose-101* UreaN-21* Creat-0.9 Na-131*
K-4.0 Cl-97 HCO3-21* AnGap-17
[**2146-4-13**] 01:32AM BLOOD Glucose-97 UreaN-22* Creat-1.0 Na-133
K-3.4 Cl-101 HCO3-22 AnGap-13
[**2146-4-15**] 09:45AM BLOOD ALT-19 AST-32 CK(CPK)-186 AlkPhos-85
TotBili-0.9
[**2146-4-15**] 09:45AM BLOOD CK-MB-5
[**2146-4-15**] 09:45AM BLOOD Albumin-3.0* Calcium-8.7 Phos-2.6* Mg-1.9
[**2146-4-14**] 04:25AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1
[**2146-4-13**] 01:32AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9
[**2146-4-12**] 03:07AM BLOOD %HbA1c-8.6* eAG-200*
[**2146-4-12**] 03:07AM BLOOD Triglyc-68 HDL-50 CHOL/HD-3.2 LDLcalc-96
[**2146-4-12**] 03:07AM BLOOD TSH-2.7
[**2146-4-11**] 07:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT head / CTA head [**2146-4-11**];
1. Large right MCA territory infarction with multiple patchy
areas of
hemorrhagic transformation.
2. CTA demonstrates a moderate, partially calcified, partially
noncalcified
plaque at the distal cervical internal carotid artery
bilaterally without
significant flow impairment.
3. The basal cisterns are normal without evidence of
subarachnoid hemorrhage.
CT head [**2146-4-12**];
Unchanged right MCA infarction with unchanged partial
hemorrhagic
transformation. No new infarct or hemorrhage compared to prior.
No significant mass effect.
CXR [**2146-4-11**]; No acute intrathoracic process.
TTE [**2146-4-14**]
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed (LVEF= 35
%) secondary to extensive severe apical hypokinesis with focal
apical dyskinesis. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. No intracardiac shunt.
Extensive apical left ventricular contractile dysfunction
consistent with myocardial infarct
Carotid ultrasound [**2146-4-12**];
Less than 40 percent on both sides (prelim read), final read is
pending
CT head [**2146-4-15**]
(prelim)- no change in size of bleed. final read is pending
Brief Hospital Course:
Mr. [**Known lastname 86212**] is an 87 yo with multiple vascular risk factors, poorly
controlled diabetes recently due to poor food intake. He had
appeared confused, disoriented, sleepy and slurred speech for
past 1-2 days by his neice. Imaging showed embolic appearing
stroke in right inf MCA with hemorrhagic transofrmation. He was
admitted to the neurological ICU for monitoring due to his
labile diabetic state.
.
Hospital course by problem;
.
Neurology; The patient was found to have a R MCA stroke with
hemorrhagic conversion. He was monitored in the neurological
ICU with q1h neurochecks and systolic blood pressure was allowed
to autoregulate to 160. A repeat CT head the following morning
showed a stable infarct with hemorrhagic transformation.
Antiplatelet agents were initially witheld upon admission, but
started on evening of HD#1 due to a troponin leak as discussed
below. While the patient's [**Known lastname 802**] reported a history of atrial
fibrillation, both the patient's PCP and his cardiologist have
no record of this and the patient has never been on coumadin.
EKG performed here showed paced rhythm. A TTE showed no
evidence of and carotid ultrasound showed less than 40 percent
stenosis on both sides (official read pending) The patient was
started on aspirin and a statin. His LDL was 96 and his HbA1c
was 8.6. The patient was transferred to the neurology floor on
HD#3. His agitation and inattention have been improving, and
his examination is notable for mild left nasolabial fold
flattening and possible left field cut. He was not cooperative
with exam , however the deficits seem to be improving gradually.
He however had agitation behaviour again and expressed ideas
about harmimg himself. Psychiatry was consulted who recommeded
mirtazepine QHS. On [**4-15**] am, he was given seroquel for agitation
and was drowsy and not waking up. He underwent repeat CT scan
which showed no change in bleed. His lab work was unremarkable.
He was observed, sedatives were held and they should be avoided
in future. Per psych, very small doses of haldol under close
supervision should be used for agitation.
Gradually over next few hours , he gained the alertness. The
most likely cause of drowsiness was thought to be medication
induced.
.
CV; The patient was found to have an initial troponin of 0.43
with CK of 420 and MB of 9. His EKG was paced. It was thought
this may have been related to demand ischemia vs. stroke vs.
subacute MI. He was followed by cardiology. His troponins
trended down to 0.35 and 0.33. A TTE showed no evidence of clot
or PFO. He was started on aspirin, statin, and a beta blocker.
His home [**Last Name (un) **] was resumed after allowing blood pressure to
autoregulate for stroke in the acute setting. His outpatient
cardiologist is Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 5217**] in [**Location (un) **] who placed a
St. [**Male First Name (un) 1525**] dual chamber pacemaker in [**2-23**] for complete heart
block.
.
Endocrine; The patient was noted to have labile fingersticks
over the past several days prior to admission. His fingersticks
were closely monitored and covered with regular insulin sliding
scale. A TSH was 2.7.
.
Hematology; The patient had a HCT drop from 39 to 34 on HD #2.
It was thought this may have been dilutional. No active source
of bleeding was identified. His HCT will continue to be
monitored daily.
.
Oncology; The patient has a history of prostate cancer,
metastatic to spine. He is followed for this at [**Hospital3 328**].
He is on casodex and lupron and as per his neice, his disease
has been stable.
.
Psychiatry; The patient continued to have episodes of agitation
and disorientation. He received haldol twice with good effect.
On HD#2 he received both haldol (5mg) and seroquel (25mg) in the
afternoon and became transiently hypotensive which responded to
fluid boluses and was somnolent for several hours. His
examination remained nonfocal but the patient did not return to
baseline until the next morning. Therefore it is recommended to
proceed with caution with use of any further antipsychotic
medications. Prior to transfer to the floor, the ICU team was
also concerned the patient was exhibiting signs of depression
(in the setting of his wife passing away two weeks ago). His
home remeron was resumed and his mood and affect will continue
to be assessed upon transfer to the floor. However due to
extreme sensitivity to sedatives, it was decided to stop
mirtazepine.
.
Abdomen/GI; The patient's diet was advanced to regular diet on
HD#2 and he has been tolerating this well.
.
Disp; The patient was followed by physical and occupational
therapy who recommended acute rehab.
.
Code; The patient is DNR but OK TO INTUBATE. His HCP is [**Name (NI) **]
[**Name (NI) 174**], [**Telephone/Fax (1) 86215**]
.
Medications on Admission:
Diovan 40 mg Tab Oral 1 Tablet(s) Once Daily
Casodex 50 mg Tab Oral 1 Tablet(s) Once Daily
Mirtazapine 7.5 mg Tab Oral 1 Tablet(s) Once Daily
Humulin N 100 unit/mL Susp, Sub-Q Inj Subcutaneous
15 Suspension(s) Once Daily evening
Humulin 70/30 100 unit/mL (70-30) Susp, Sub-Q Inj Subcutaneous
21 Suspension(s) Once Daily in morning
Lupron every 2 weeks
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. Insulin Lispro Subcutaneous
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Casodex 50 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lupron Depot (3 Month) 11.25 mg Kit Sig: Five (5) mg
Intramuscular once 3 months: As confirmed with his PCP [**Name Initial (PRE) 3726**].
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] ridge
Discharge Diagnosis:
Right MCA stroke with hemorrhagic conversion
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 for evaluation of stroke. You had CT scan of
brain which showed stroke on the right side of your brain.
You had cardiac ultrasound which did not show evidence of clot
but did show apical hypokinesia. You had ultrasound of carotids
which did not show evidence of significant stenosis on prelim
read (Final read is pending).
You were noted to be very sensitive to sedatives such as
seroquel, trazodone which should be avoided in future. We have
stopped your rameron as per psych inputs. That can be resumed
once your medical condition improves.
Followup Instructions:
Please call [**Last Name (LF) **],[**First Name8 (NamePattern2) 2191**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 32024**] (PCP) for scheduling
an appointment after DC from rehab.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2146-5-27**] 10:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"292.81",
"401.9",
"431",
"198.5",
"V45.01",
"434.91",
"427.31",
"414.01",
"E937.9",
"253.6",
"412",
"E849.7",
"V10.46",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14669, 14726
|
8536, 13395
|
245, 251
|
14815, 14815
|
4250, 8513
|
15584, 16029
|
2939, 3024
|
13798, 14646
|
14747, 14794
|
13421, 13775
|
14996, 15561
|
3039, 3345
|
180, 207
|
279, 1924
|
3548, 4231
|
14830, 14972
|
3369, 3369
|
1946, 2456
|
2472, 2923
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,312
| 112,593
|
50240+59235+59236
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2156-4-1**] Discharge Date: [**2156-4-28**]
Date of Birth: [**2088-4-12**] Sex: M
Service: NEUROLOGY
Allergies:
Codeine / Codeine Anhydrous / Ambien
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Code Stroke/Altered mental status
Major Surgical or Invasive Procedure:
MRI
EEG
History of Present Illness:
The pt is a 67 year-old gentleman who presented with
alteration in mental status.
The pt was unable to offer a history at the time of my
encounter.
Therefore, the following history is per the primary team, EMS
and
the medical record.
Per EMS, the pt was last seen well by his wife at 1am before
going to bed last night (i.e. 8 hours prior to presentation).
This morning at approximately 8am, his wife found him in bed not
responding to her and "thrashing around." She called EMS. On
their arrival, they found the pt to be unresponsive with eyes
deviated to the right and "pinpoint". Given history of diabetes
mellitus, fingersticks were performed and were 84 and 106. He
was
given 2mg of IV ativan without effect. He was subsequently
brought to the [**Hospital1 18**] ED for further evaluation.
At the time of my initial encounter, the pt was in the midst of
intubation. Therefore, a detailed NIHSS could not be performed
(see brief examination below). He was subsequently sedated and
paralyzed, unfortunately further obscuring the examination.
The pt was unable to offer a review of systems.
Past Medical History:
- Hypertension
- Diabetes mellitus, on insulin (insulin regimen NPH 40 q am +
SS) with HgA1C 5.[**2155-7-2**]
- Chronic renal failure (Baseline creatinine 1.7 - 3.1)
- Peripheral neuropathy
- Glaucoma
- Hepatitis B: SAg neg, SAb+, CAb+
- Hepatitis C: HCV VL 86K [**2155-7-21**], genotype IB
- Anemia - Baseline Hct 26-32
- H/O Chest pain, no CAD on angiography [**6-4**]
- Substance abuse (none since '[**42**])
- H/O Osteomyelitis
- H/O Back pain
- Legally blind
- H/O PPD conversion
- Erectile dysfunction
- H/O MVA with extensive injuries requiring skin graft
Social History:
Social history is significant for the absence of current tobacco
use (quit in [**2155-3-31**], 2 packs/week for ~50 yrs). There is no
H/O of alcohol abuse. No IVDU, although crack abuse till [**2138**]'s.
Patient is married with 3 children, lives with wife. Retired
[**Name2 (NI) **].
Family History:
No CAD in family; h/o cancer
Physical Exam:
Vitals: T: 98.5F P: 80 R: 16 BP: 253/140 SaO2: 98%
General: Lying in bed with eyes closed, intubated.
HEENT: NC/AT, MMM
Neck: No carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs with transmitted sounds bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes noted, multiple healed scars over abdomen and
legs.
Neurologic (initial examination just prior to intubation and
sedation):
-mental status: Does not open eyes to verbal or noxious stimuli.
No verbal output. Does not follow commands.
-cranial nerves: PERRL 1.5 to 1mm and briskly reactive. Eyes
were initially deviated to the right, on reexamination
approximately 10 minutes later, EOMI to oculocephalic maneuver.
Corneal reflex and nasal tickle present bilaterally. No overt
facial asymmetry. Gag reflex intact.
-motor: Normal bulk throughout. Could not assess tone. Was seen
to move all extremities antigravity in a semi-purposeful manner
during line placement before he was chemically paralyzed. No
overt adventitious movements were noted.
-sensory: Could not assess prior to intubation, sedation and
administration of paralytics.
-DTRs: Could not assess prior to intubation, sedation and
administration of paralytics.
Plantar response was mute bilaterally.
Pertinent Results:
[**2156-4-1**] 09:50AM WBC-7.4 RBC-3.29* HGB-10.3* HCT-32.9*
MCV-100* MCH-31.3 MCHC-31.3 RDW-14.8
[**2156-4-1**] 09:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2156-4-1**] 09:50AM cTropnT-<0.01
[**2156-4-1**] 09:50AM CK-MB-6
[**2156-4-1**] 09:50AM ALT(SGPT)-44* AST(SGOT)-76* CK(CPK)-134 ALK
PHOS-77 AMYLASE-156* TOT BILI-0.3
[**2156-4-1**] 11:57AM PHENYTOIN-15.6
Brief Hospital Course:
Neurologic: Patient was initially admitted to the
neuro-intensive care unit for close observation. Considerations
for patient's etiology of mental status change were multiple and
included seizure, hypertensive encephalopathy, metabolic,
infectious, toxic, medication/substance withdrawl, stroke. A
head CT scan did not demonstrate evidence of bleed or evolving
infarct. MRI was negative for infarct but showed extensive
small vessel disease presumably from poorly controlled
hypertension. As seizure was high on the differential patient
had bedside EEG monitoring which showed moderate enceohpalopathy
on [**3-31**] and [**4-6**]. On [**4-7**] a 15 second seizure was witnessed and
captured with EEG showing no epileptiform acitivity and
relatively normal background. In the emergency room he received
1.5 grams of IV phenytoin (in addition to total of 4mg IV
lorazepam) in ED, and was continued on Dilantin 100/100/130,
then increased to 100/100/230. LFTs were slightly elevated on
[**4-1**], but normal on [**4-2**] and again very mildly elevated [**4-8**].
Ammonia level was withing normal limits [**4-2**] and then repeated
for continued encephalopathy [**4-8**] but continued to be normal .
TSH was normal. CSF studies were sent to r/o CNS infection and
patient had normal results with no growth and negative HSV PCR.
A second set of MRI/CTs was obtained to make sure that patient
had not developed any interval neurological process that could
be affecting his mental status, and these studies were normal.
The pateint's delerium began to clear some after he was placed
in a windowside bed and forced into a more regular day/night
sleep schedule with daytime stimulation.
Cardiac wise he was followed on telemetry. No arythmia noted.
Hypertension was previously poorly controlled at home on
lisinopril, catapress, amlodipine and hydralazine. Lisinopril
was increased from 20 to 40, amlodipine continued at 10 daily,
hydralazine continued at 75 Q6hrs, catapress increased from 1 to
3. Lopressor was started and eventually titrated up to 150mg
TID. Cardiac enzymes were negative at admission.
Pulmonary: patient self-extubated [**4-2**] and tolerated well.
Endocrine: Patient's home doses of NPH insulin initially held as
he was intubated and not receiving nutrition. Was maintained on
a regular insulin sliding scale. When tube feeds started, he
had home dose of NPH (24 qAM, 20 qPM) restarted. NPH titrated
up as patient's blood sugars continued to be elevated. [**Last Name (un) **]
consult called [**4-23**] and patient was started on Lantus 15 with
Humalogue sliding scale.
Renal: Has history of chronic renal insufficiency. Creatinine
was 2.3 on admission and corrected to baseline level of 1.8
within 24 hours. The patient was found to be retaining urine
during the admission. He was catheterized. At discharge, he
was being treated for a UTI and Foley was discharged. He will
need a post-void residual checked after transfer to assure that
he is not retaining urine. Should he become aggitated or in
pain, urinary retention needs to be ruled out.
Inectious Disease: CXR was negative for pneumonia. UA was
negative but urine cultures grew beta strep. Was started on
Bactrim initially and then changed to clindamycin based on
sensitivities. Stool studies showed no Cdiff. CSF studies
also sent and negative cultures and HSV PCR. He had one UTI
treated with Ciprofolxacin and then a second UTI developed
before discharge. He was started on Cipro and Vanc to which the
organisms were sensitive.
GI: LFTs slightly elevated [**4-1**], then normal [**4-2**]. Again mildly
elevated [**4-8**] with AST less elevated than prior but Lipase again
similarly elevated with no clear reason. Patient's abnominal
exam at this time normal with no tenderness and normal bowel
sounds. Patient had normal bowel movements and no diarrhea or
tube feeding residuals, then passed swallow eval and started
diabetic diet.
FEN: was Hypernatremic so replenishing free water deficit of 3.4
L (plus insensible losses) with 100cc/hr of D51/2NS for total of
4 L
Prophyllactically received SC heparin, pneumoboots, PPI.
Medications on Admission:
(Per recent discharge summary):
1. Clonidine 0.2 mg/24 hr Weekly
2. Aspirin 81 mg PO DAILY
3. Omeprazole 20 mg PO once a day.
4. Lisinopril 20 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Insulin: NPH insulin 24 units in the morning, 20 units qhs
7. Atorvastatin 10 mg PO DAILY
8. Oxycodone-Acetaminophen 5-325 mg PO Q6H as needed.
9. Pilocarpine HCl 4% Drops One Drop Ophthalmic Q8H
10. Dorzolamide-Timolol 2-0.5 % One Drop Ophthalmic DAILY
11. Latanoprost 0.005 % Drops One Drop Ophthalmic HS
12. Hydralazine 75 mg PO Q6H
13. Isosorbide Dinitrate 20 mg PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Hypertensive encephalopathy.
Discharge Condition:
Good. Patient becoming more oriented daily.
Discharge Instructions:
FOllow up as below. Do not drink or use drugs. Take
medications as directed.
REHAB: Please note that the patient has history of urinary
retention. Please check a post-void residual tonight to assure
that the patient is not retaining. If in the future, there is
aggitation or pain, please consider that he may be retaining
urine.
Please also place the patient in a window-adjacent bed. His
delerium seems to improve significantly if he is forced into a
regular wake/sleep schedule by daytime stimulation.
Followup Instructions:
AFter discharge from rehabiliation, please call your [**Location (un) 3390**]: [**Name Initial (NameIs) 3390**]:
[**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 250**] to arrange
Neurologist: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2156-5-25**] 11:30. [**Hospital1 18**] [**Hospital Ward Name 516**], [**Location (un) **] of
[**Hospital Ward Name 23**] Building.
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2156-6-10**] 2:30
Name: [**Known lastname 17013**],[**Known firstname 33**] L Unit No: [**Numeric Identifier 17014**]
Admission Date: [**2156-4-1**] Discharge Date: [**2156-4-28**]
Date of Birth: [**2088-4-12**] Sex: M
Service: NEUROLOGY
Allergies:
Codeine / Codeine Anhydrous / Ambien
Attending:[**First Name3 (LF) 11296**]
Addendum:
Added Pyridium 100mg TID for 4 days for bladder pain from UTI.
Pertinent Results:
[**2156-4-1**] 09:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-4-1**] 09:50AM ALT(SGPT)-44* AST(SGOT)-76* CK(CPK)-134 ALK
PHOS-77 AMYLASE-156* TOT BILI-0.3
[**2156-4-1**] 10:05AM GLUCOSE-89 LACTATE-0.9 NA+-143 K+-4.9
CL--117* TCO2-17*
[**2156-4-1**] 11:57AM WBC-10.3 RBC-3.24* HGB-9.9* HCT-32.3*
MCV-100* MCH-30.7 MCHC-30.8* RDW-14.7
WBC, CSF 1 #/uL
PERFORMED AT WEST STAT LAB
RBC, CSF 29* #/uL 0 - 0
CLEAR AND COLORLESS
PERFORMED AT WEST STAT LAB
Polys 25 %
20 CELL DIFFERENTIAL
PERFORMED AT WEST STAT LAB
Lymphs 40 %
Monocytes 35 %
HSV PCR Negative.
RPR negative.
MRI Brain: : Many of the images are degraded by patient motion.
Within this limitation, there appears to be redemonstration of
the high T2 signal largely within the periventricular white
matter of both cerebral hemispheres, as well as within the pons.
These abnormalities have been previously characterized as
chronic small vessel infarcts. There does not appear to be any
new major vascular territorial infarct identified, including no
abnormal signal on the diffusion-weighted scans. The
high-resolution imaging of the hippocampal regions, does not
demonstrate overt hippocampal asymmetry or abnormal signal in
this locale. Within the limits of the motion degraded contrast
enhanced scans, no definite pathological enhancement in the
brain is appreciated.
EEG: This 24 hour EEG telemetry captured one pushbutton
activation for unclear symptoms. There was no electrographic
change on
EEG seen in association with this activation. No electrographic
seizures or interictal epileptiform discharges were seen.
Although much
of the recording was contaminated by electrode artifact, the
background
did reach a normal alpha frequency maximum.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11297**] MD [**MD Number(2) 11298**]
Completed by:[**2156-4-23**] Name: [**Known lastname 17013**],[**Known firstname 33**] L Unit No: [**Numeric Identifier 17014**]
Admission Date: [**2156-4-1**] Discharge Date: [**2156-4-28**]
Date of Birth: [**2088-4-12**] Sex: M
Service: NEUROLOGY
Allergies:
Codeine / Codeine Anhydrous / Ambien
Attending:[**First Name3 (LF) 11296**]
Addendum:
See portions below.
Chief Complaint:
aggitation, hypertensive to SBP 167 in setting of hypertension,
refusal to take PO.
Major Surgical or Invasive Procedure:
No new surgical/invasive procedure. See attatched D/C summary
for invasive procedures of initial admission.
History of Present Illness:
The patient is a 68yo man DM, HTN, extensive small vessel
disease, blind, CRI, neuropathy, who is sent back from rehab to
which he was discharged earlier today. Reason was that he seemed
confused and punched staff, as well as for SBP of 167.
Upon his prior admission, he was found in bed thrashing around.
He was brought to the ED where ativan did not resolve his
symptoms, and was loaded on PHT. Considerations for patient's
etiology of mental status change were multiple and included
seizure (Sec generalized), hypertensive encephalopathy,
metabolic, infectious, toxic, medication/substance withdrawl,
stroke. A head CT scan did not demonstrate evidence of bleed or
evolving infarct. MRIx2 was negative for infarct but showed
extensive small vessel disease presumably from poorly controlled
hypertension; there were no interval changes. Bedside EEG
monitoring showed moderate enceohpalopathy on [**3-31**] and [**4-6**],
whereas on [**4-7**] a 15 second seizure was witnessed and captured
with EEG showing no epileptiform acitivity and relatively normal
background. LFTs were slightly elevated, ammonia level was
within
normal limits; TSH was normal. CSF profile was normal with no
growth and negative HSV PCR.
The patient's delerium began to clear some after he was placed
in a windowside bed and forced into a more regular day/night
sleep schedule with daytime stimulation. He was somewhat
agitated
after his Foley was d/c-ed prior to d/c but calmed down later.
After transfer to rehab, he apparently was confused and
combatative. Tried to punch staff and apparently seeing things
in
his room. Rehab staff though one picc in one arm would not be
sufficient for access, especially as he refused to take meds.
Their note says that they will accept pt with better BP control
(SPB was 167 while agitated).
After return back to the floor (the pt was directed to [**Hospital Ward Name **] 5
without permission from ED attending, sent up via ED triage
nurses, without notification of the team.
On the floor, the first thing the pt mentions is that he is
"terrified".
ROS:
denies pain; detailed ROS not possible
Past Medical History:
- Hypertension
- Diabetes mellitus, on insulin (insulin regimen NPH 40 q am +
SS) with HgA1C 5.[**2155-7-2**]
- Chronic renal failure (Baseline creatinine 1.7 - 3.1)
- Peripheral neuropathy
- Glaucoma
- Hepatitis B: SAg neg, SAb+, CAb+
- Hepatitis C: HCV VL 86K [**2155-7-21**], genotype IB
- Anemia - Baseline Hct 26-32
- H/O Chest pain, no CAD on angiography [**6-4**]
- Substance abuse (none since '[**42**])
- H/O Osteomyelitis
- H/O Back pain
- Legally blind
- H/O PPD conversion
- Erectile dysfunction
- H/O MVA with extensive injuries requiring skin graft
Social History:
Discharge Summary Social History Signed [**Last Name (LF) **],[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] [**4-23**],[**2155**] 4:19 PM
Social history is significant for the absence of current tobacco
use (quit in [**2155-3-31**], 2 packs/week for ~50 yrs). There is no
H/O of alcohol abuse. No IVDU, although crack abuse till [**2138**]'s.
Patient is married with 3 children, lives with wife. Retired
[**Name2 (NI) 17015**].
Family History:
No CAD in family; h/o cancer
Physical Exam:
VITALS: T97.3 HR68 BP170/82 RR18 sO2 99% RA
GEN: NAD
HEENT: mmm
NECK: no LAD; no carotid bruits; limited ROM, no Brudz
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2ABDOMEN: normal
bowel sounds, soft, nontender, nondistended
EXTREMITIES: multiple skin scars from grafts
MENTAL STATUS:
Awake and alert, able to say name, age 24. Does not know where
he
is. Able to follow simple midline and appendicular commands.
CRANIAL NERVES:
II: Poor vision. Pupils pinpoint.
III, IV, VI: Extraocular movements intact when asking him to
move
to R and L. No ptosis.
V: Facial sensation intact to light touch.
VII: Facial movement symmetrical
VIII: Hearing intact to voice
IX: Palate elevates in midline.
XII: Tongue protrudes in midline
[**Doctor First Name 2237**]: Sternocleidomastoid and trapezius normal bilaterally.
MOTOR SYSTEM: Normal bulk; rigidity in both UE; tone increased
in
both LE. Mild tremor in UE
Able to hold arms and legs antigravity, rather symmetrically.
REFLEXES:
B T Br Pa Pl
Right 3 3 3 1 -
Left 3 3 3 1 -
Toes: mute bilaterally.
SENSORY SYSTEM: intact to LT in all 4's.
COORDINATION: No dysmetria per observation.
GAIT: deferred
Pertinent Results:
[**2156-4-23**] 08:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2156-4-23**] 08:20PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2156-4-23**] 08:20PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2156-4-28**] 05:37AM BLOOD WBC-7.9 RBC-2.78* Hgb-8.7* Hct-26.8*
MCV-97 MCH-31.3 MCHC-32.4 RDW-14.5 Plt Ct-214
[**2156-4-28**] 05:37AM BLOOD Plt Ct-214
[**2156-4-28**] 05:37AM BLOOD Glucose-126* UreaN-20 Creat-1.6* Na-143
K-3.8 Cl-112* HCO3-21* AnGap-14
[**2156-4-28**] 05:37AM BLOOD Calcium-9.0 Phos-4.5 Mg-1.6
[**2156-4-20**] 12:04 pm URINE Source: Catheter.
**FINAL REPORT [**2156-4-23**]**
URINE CULTURE (Final [**2156-4-23**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 5260**] [**Last Name (NamePattern1) **].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- <=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM------------- <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ <=1 S
[**2156-4-23**] 8:20 pm URINE Source: Catheter.
**FINAL REPORT [**2156-4-25**]**
URINE CULTURE (Final [**2156-4-25**]): NO GROWTH.
Brief Hospital Course:
Addendum to patient's return from Rehab [**2156-4-23**]. See attatched
D/C summary for course from [**Date range (1) 17016**].
Neuro:
The patient returned from rehab within several hours of
discharge with report that he had been aggitated and combative,
hypertensive to SBP 167, and refusing to take PO medications.
On arrival, he reported that he was "terrified" and thought that
he was going to die there. He had a non-focal neurological exam
that continued to show some delerium but no acute changes from
discharge. He was able to be re-oriented and was soon
normotensive and again agreeing to take PO. He did not at any
time during this re-admission require sedation, restraints or
bed-side sitter. He has continued to show some mild to moderate
encephalopathy with a waxing/[**Doctor Last Name 2364**] pattern, but this continues
to clear slowly. His sleep pattern continues to be very
disrupted despite great efforts to normalize him by getting him
out of bed every morning and trying to stimulate him.
Currently, he is oriented to "hospital" and "2075" but continues
to be confused and perseverative otherwise. This is an
improvement from re-admission at which time he was more
disoriented to the extent that he did not know where he was.
For further work up, he had an ABG which was relatively normal,
CRP which was 1.0 and ESR which is pending. A serum tox screen
was negative. He also had a repeat UA on readmission which
showed continued UTI. The UTI is being treated and the urine
culture was negative. As he has not had any events strongly
suggestive for seizure, and has had multiple EEGs without any
epileptiform activity, his Keppra was discontinued completely
(had previously been tapering down and was down to 500 [**Hospital1 **]).
CVS:
Mr [**Name13 (STitle) 17017**] reported some chest pain on sunday [**4-25**]. He was
unable to give a clear description an was answering "yes" to
pain in all other areas of his body as well. He was unsure if
he had any symptomatic SOB or chest pressure, but his vital
signs were stable. A stat EKG was unchanged from 2 recent EKGs
and serial ck/troponins were negative x 3. He did not
experience any further chest pain this admission. His
hypertension was mostly well controlled with one SBP of 167 on
[**4-27**]. On Monday [**4-26**] his hydralazine was changed from IV to PO
equivalenr of 75 PO Q6hrs and on [**4-27**] his Losartan was increased
from 50 to 100 daily.
Resp:
No respiratory issues this admission.
GI:
No GI issues this admission. Mr [**Name13 (STitle) 17017**] has been taking adequate
POs this admission but does require assistance with meals as he
is legally blind. He has been taking all medications PO and has
not required any NG at any time this re-admission. His
previously elevated LFTs and amylase/lipase have normalized and
he has been continued on lantoprazole for GI prophylaxis.
ID:
Mr [**Name13 (STitle) 17018**] was transferred on Vancomycin and Ciprofloxacin for
enterobacter and E-coli growing in a urine culture. On
re-admission, his UA was positive, but the urine culture has not
grown anything to date. Based on the previous positive urine
culture, he was switched from Vanc/Cipro to ampicillin 1gm IV
Q12 to which the Enterobacter and Ecoli were sensitive. He will
finish his last day of ampicillin on [**4-29**] in PM which will
complete a seven day course for the UTI. Mr [**Name13 (STitle) 17018**] has been
afebrile and has a normal white count. There are no other ID
issues.
Endo:
Mr [**Name13 (STitle) 17019**] has DM and was re-admitted on Lantus 15 units QHS
along with insulin sliding scale. This was modified on [**4-26**] by
the [**Last Name (un) 616**] Diabetes Consult service who increased is suppertime
insulin coverage on the sliding scale. On [**4-27**] he had a low AM
sugar of 50 and his lantus was decreased from 15 to 7 based on
[**Last Name (un) 616**] recs. This may require further titration as his diet and
PO intake vary.
Renal: Mr [**Name13 (STitle) 17017**] suffers from chronic renal insufficiency and
it is unclear what his prior baseline creatinine was. His
initial admission creatinine was 2.3 and he has corrected to a
current creatinine of 1.6. He has had no other renal issues
this admission.
Urology: The patient had urinary retention on [**4-23**] in the
setting of a UTI that was mid-treatment. He currently has a
foley in place which should be disctontinued tomorrow evening
when he has completed his 7 day course of ampicillin.
Heme: Mr [**Name13 (STitle) 17017**] has had some anemia this admission with a Hct
ranging 25-30. His Hct was within this same range on an
admission last year. Guiacs were performed and were negative.
Iron studies did not show iron defficiency anemia but his MCV
was borderline elevated which could be secondary to his history
of ETOH abuse.
PPX: Mr [**Name13 (STitle) 17017**] received Ativan per CIWA for prophylaxis against
ETOH withdrawl during the first week of admission ([**4-1**]) but he
did not require any ativan after that. He has received
lantoprazole for GI prophylaxis. He is also on heparin SC for
DVT prophylaxis. He received a coures of Dilantin and then
Keppra for seizure prophylaxis, but this was discontinued after
serial negative EEGs and no events.
Medications on Admission:
Acetaminophen 650 mg PR Q4-6H:PRN pain
Insulin SC (per Insulin Flowsheet)
Amlodipine 10 mg PO/NG DAILY
hold for SBP < 120, Hr<60
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Aspirin 325 mg PO/NG DAILY
Lansoprazole Oral Disintegrating Tab 30 mg PO/NG [**Hospital1 **]
Bisacodyl 10 mg PO/PR [**Hospital1 **]:PRN until stools
Levetiracetam 500 mg PO/NG [**Hospital1 **]
Ciprofloxacin HCl 250 mg PO Q12H
Lisinopril 40 mg PO/NG DAILY hold for SBP < 120
Clonidine TTS 3 Patch 1 PTCH TD QSAT
Losartan Potassium 50 mg PO DAILY hold for SBP < 110
Cyanocobalamin 1000 mcg PO DAILY
Magnesium Sulfate 2 gm / 50 ml SW IV PRN value < 1.8
Dextrose 50% 25 gm IV PRN blood sugar<50
Metoprolol 150 mg PO/NG TID Hold for sBP<120, HR<60
Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES DAILY
Nystatin Oral Suspension 5 ml PO QID:PRN thrush
Enalaprilat 1.25 mg IV Q6 HOURS PRN SBP > 140
Phenazopyridine HCl 100 mg PO TID Duration: 4 Days
FoLIC Acid 1 mg PO DAILY
Pilocarpine 4% 1 DROP BOTH EYES Q8H
Heparin 5000 UNIT SC TID
Thiamine HCl 100 mg PO/NG DAILY
HydrALAzine 20 mg IV Q6H hold for sbp < 120
Vancomycin 1000 mg IV Q 12H
Discharge Medications:
1. Latanoprost 0.005 % Drops [**Hospital1 1649**]: One (1) Drop Ophthalmic HS (at
bedtime).
2. Clonidine 0.3 mg/24 hr Patch Weekly [**Hospital1 1649**]: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
3. Dorzolamide-Timolol 2-0.5 % Drops [**Hospital1 1649**]: One (1) Drop
Ophthalmic DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 1649**]: One (1)
Injection TID (3 times a day).
5. Pilocarpine HCl 4 % Drops [**Hospital1 1649**]: One (1) Drop Ophthalmic Q8H
(every 8 hours).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 1649**]: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
7. Acetaminophen 650 mg Suppository [**Hospital1 1649**]: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for pain.
8. Folic Acid 1 mg Tablet [**Hospital1 1649**]: One (1) Tablet PO DAILY (Daily).
9. Aspirin 325 mg Tablet [**Hospital1 1649**]: One (1) Tablet PO DAILY (Daily).
10. Thiamine HCl 100 mg Tablet [**Hospital1 1649**]: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 50 mg Tablet [**Hospital1 1649**]: Three (3) Tablet PO
TID (3 times a day).
12. Lisinopril 20 mg Tablet [**Hospital1 1649**]: Two (2) Tablet PO DAILY
(Daily).
13. Amlodipine 5 mg Tablet [**Hospital1 1649**]: Two (2) Tablet PO DAILY (Daily).
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
15. Losartan 50 mg Tablet [**Last Name (STitle) 1649**]: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 120.
Disp:*60 Tablet(s)* Refills:*2*
16. Cyanocobalamin 500 mcg Tablet [**Last Name (STitle) 1649**]: Two (2) Tablet PO DAILY
(Daily).
17. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) 1649**]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
18. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) 1649**]: Seven (7) units
Subcutaneous at bedtime: To be titrated based on his daily
sugars.
19. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) 1649**]: One (1)
units per sliding scale Injection four times a day: per insulin
sliding scare with QID accuchecks.
20. Enalaprilat 1.25 mg/mL Injectable [**Last Name (STitle) 1649**]: One (1) Intravenous
Q6 HOURS PRN () as needed for SBP > 140.
21. Dextrose 50% in Water (D50W) Syringe [**Last Name (STitle) 1649**]: One (1)
Intravenous PRN (as needed) as needed for blood sugar<50.
22. Hydralazine 25 mg Tablet [**Last Name (STitle) 1649**]: Three (3) Tablet PO every six
(6) hours: hold for SBP<120.
23. Ampicillin Sodium 1 g Piggyback [**Last Name (STitle) 1649**]: One (1) Intravenous
every twelve (12) hours for 2 days: last dose to be [**4-29**] PM, to
complete 7 day antibiotic course for Ecoli and Enterobacter in
urine. (Both Amp sensitive).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Diagnosis:
Hypertensive encephalopathy.
Discharge Condition:
Good. Patient becoming more oriented daily.
Discharge Instructions:
FOllow up as below. Do not drink or use drugs. Take
medications as directed.
FOR [**Hospital3 **]: Please note that the patient is legally
blind and can get disoriented when moved. He may require
re-orienting and reassurance multiple times. His delerium and
level of alertness waxes and wanes. He is most often very
somnolent in the early morning and he is typically more
aggitated or confused in the afternoons. In the last 10 days
here, he has not required any sedation, restraint or sitter. He
is usually easily comforted and re-oriented . He has also
transiently refused PO intake for short periods (1 hr) but is
usually amenable to taking PO later if re-approached gently.
Please note that the patient has history of urinary retention.
If in the future, there is aggitation or non-specific pain,
please consider that he may be retaining urine, and check a
post-void residual.
Please also place the patient in a window-adjacent bed. His
delerium seems to improve significantly if he is forced into a
regular wake/sleep schedule by daytime stimulation. He has a
disordered wake/sleep schedule at baseline per wife, and
maintaining a normal sleep wake cycle in house has been
difficult, but has led to sifnigicant improvement.
Followup Instructions:
AFter discharge from rehabiliation, please call your PCP:
[**Name10 (NameIs) 11**],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 23**] to arrange follow up. He is
aware of your hospital course to date.
Neurologist: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 190**]
Date/Time:[**2156-5-25**] 11:30. [**Hospital1 8**] [**Hospital Ward Name 600**], [**Location (un) 601**] of
[**Hospital Ward Name **] Building.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1147**], M.D. Phone:[**Telephone/Fax (1) 1936**]
Date/Time:[**2156-6-10**] 2:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11297**] MD [**MD Number(2) 11298**]
Completed by:[**2156-4-28**]
|
[
"437.2",
"070.54",
"585.9",
"780.39",
"599.0",
"369.4",
"070.32",
"276.2",
"403.90",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
29570, 29640
|
20303, 25588
|
13423, 13533
|
29713, 29760
|
18007, 20280
|
31051, 31837
|
16749, 16779
|
26757, 29547
|
29661, 29692
|
25614, 26734
|
29784, 31028
|
3072, 3788
|
16794, 17109
|
13300, 13385
|
13561, 15681
|
17268, 17988
|
17124, 17252
|
15703, 16267
|
16283, 16733
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,087
| 179,588
|
50288
|
Discharge summary
|
report
|
Admission Date: [**2131-10-2**] Discharge Date: [**2131-10-12**]
Date of Birth: [**2074-8-16**] Sex: M
Service: SURGERY
Allergies:
Cellcept
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Trauma- MVC
Major Surgical or Invasive Procedure:
1. Intubation
2. Open reduction internal fixation right distal radius
History of Present Illness:
PI: The patient is a 57 yo male s/p renal transplant, HTN, IDDM
who was airlifted from OSH following MVA. History mainly
obtained
from records as patient was intubated.
Earlier tonight patient had MVA car versus tree accident with
moderate damage. He was unrestrained, airbag worked. According
to
the notes, he was able to ambulate at the scene and it is not
clear whether the patient lost consiousness. FSBS at scene was
52, for which he received an amp of D50.
He was brought to OSH. He had laceraration to his head and
periorbital ecchymoses. A CT head showed small SAH (R-frontal
and
temporal) and focal, punctate hemorrhage in R basal ganglia as
well as small vessel disease.
He was transferred to [**Hospital1 18**], where he was intubated in the OR
with fiberoptics as he had a raspy voice (according to his
daughter this is his baseline). Injuries include L-rib fractures
([**2-17**]), C1 fracture (minimally displaced), widened mediastinum. A
head CT was repeated.
Past Medical History:
1. Insulin dependent diabetes mellitus
2. Cerebral vascular event
3. Hypertension
4. Laproscopic cholecystectomy
5. Renal transplant x 2
Social History:
n/a
Family History:
n/a
Physical Exam:
A&Ox2
PERRLA left 2-->1mm
Right periorbital hematoma and multiple lacerations
CTA bilaterally
RRR
Abd soft, ntnd, foley in place
Rectal nml tone, heme negative
C spine ttp, no step off
Pertinent Results:
[**2131-10-2**] 10:47PM BLOOD WBC-16.9* RBC-4.09* Hgb-13.3* Hct-37.9*
MCV-93 MCH-32.5* MCHC-35.1* RDW-14.1 Plt Ct-147*
[**2131-10-3**] 02:50AM BLOOD WBC-11.1* RBC-3.44* Hgb-10.9* Hct-31.7*
MCV-92 MCH-31.7 MCHC-34.5 RDW-14.1 Plt Ct-136*
[**2131-10-3**] 04:13PM BLOOD WBC-14.2* RBC-3.16* Hgb-10.4* Hct-29.6*
MCV-94 MCH-33.0* MCHC-35.2* RDW-14.2 Plt Ct-127*
[**2131-10-4**] 01:53AM BLOOD WBC-13.4* RBC-3.03* Hgb-9.7* Hct-28.7*
MCV-95 MCH-31.8 MCHC-33.6 RDW-14.3 Plt Ct-137*
[**2131-10-5**] 02:09AM BLOOD WBC-10.4 RBC-2.77* Hgb-8.8* Hct-25.5*
MCV-92 MCH-31.9 MCHC-34.7 RDW-14.0 Plt Ct-120*
[**2131-10-5**] 11:10AM BLOOD WBC-11.5* RBC-2.82* Hgb-9.1* Hct-26.1*
MCV-93 MCH-32.4* MCHC-34.9 RDW-14.0 Plt Ct-121*
[**2131-10-6**] 02:46AM BLOOD WBC-11.5* RBC-2.91* Hgb-9.1* Hct-26.7*
MCV-92 MCH-31.3 MCHC-34.1 RDW-13.8 Plt Ct-173
[**2131-10-7**] 03:09AM BLOOD WBC-7.9 RBC-2.68* Hgb-8.6* Hct-24.2*
MCV-90 MCH-32.1* MCHC-35.7* RDW-13.8 Plt Ct-170
[**2131-10-11**] 04:55AM BLOOD WBC-7.6 RBC-3.28* Hgb-10.2* Hct-29.9*
MCV-91 MCH-31.2 MCHC-34.2 RDW-14.0 Plt Ct-530*
[**2131-10-2**] 10:47PM BLOOD PT-13.6* PTT-20.8* INR(PT)-1.2
[**2131-10-2**] 10:47PM BLOOD Plt Ct-147*
[**2131-10-3**] 02:50AM BLOOD PT-13.8* PTT-23.6 INR(PT)-1.3
[**2131-10-3**] 02:50AM BLOOD Plt Ct-136*
[**2131-10-3**] 04:13PM BLOOD Plt Ct-127*
[**2131-10-5**] 02:09AM BLOOD Plt Ct-120*
[**2131-10-5**] 11:10AM BLOOD Plt Ct-121*
[**2131-10-6**] 02:46AM BLOOD Plt Ct-173
[**2131-10-10**] 01:52AM BLOOD Plt Ct-423#
[**2131-10-11**] 04:55AM BLOOD Plt Ct-530*
[**2131-10-2**] 10:47PM BLOOD Fibrino-369
[**2131-10-6**] 10:50AM BLOOD Parst S-NEGATIVE
[**2131-10-3**] 02:50AM BLOOD Glucose-230* UreaN-17 Creat-0.8 Na-138
K-4.4 Cl-105 HCO3-26 AnGap-11
[**2131-10-3**] 04:13PM BLOOD Glucose-142* UreaN-16 Creat-0.8 Na-137
K-4.4 Cl-104 HCO3-26 AnGap-11
[**2131-10-4**] 01:53AM BLOOD Glucose-210* UreaN-15 Creat-0.8 Na-138
K-4.5 Cl-106 HCO3-24 AnGap-13
[**2131-10-5**] 02:09AM BLOOD Glucose-68* UreaN-11 Creat-0.8 Na-141
K-3.9 Cl-108 HCO3-26 AnGap-11
[**2131-10-5**] 11:10AM BLOOD Glucose-181* UreaN-15 Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-24 AnGap-14
[**2131-10-7**] 03:09AM BLOOD Glucose-141* UreaN-19 Creat-0.8 Na-136
K-4.3 Cl-103 HCO3-25 AnGap-12
[**2131-10-8**] 01:52AM BLOOD Glucose-229* UreaN-21* Creat-0.8 Na-137
K-4.4 Cl-104 HCO3-25 AnGap-12
[**2131-10-11**] 04:55AM BLOOD Glucose-51* UreaN-16 Creat-0.9 Na-136
K-5.0 Cl-103 HCO3-21* AnGap-17
[**2131-10-2**] 10:47PM BLOOD Amylase-71
[**2131-10-3**] 02:50AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.5*
[**2131-10-11**] 04:55AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
[**2131-10-7**] 08:57AM BLOOD Vanco-6.7*
[**2131-10-4**] 01:53AM BLOOD Phenyto-9.0*
[**2131-10-5**] 02:09AM BLOOD Phenyto-7.0*
[**2131-10-2**] 10:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-10-5**] 12:14PM BLOOD FK506-LESS THAN
[**2131-10-6**] 02:46AM BLOOD FK506-7.8
[**2131-10-11**] 10:03AM BLOOD FK506-PND
[**2131-10-3**] 12:16AM BLOOD Type-ART pO2-166* pCO2-42 pH-7.41
calHCO3-28 Base XS-2
[**2131-10-7**] 07:21PM BLOOD Type-ART Temp-36.7 O2 Flow-4 pO2-129*
pCO2-38 pH-7.46* calHCO3-28 Base XS-3
Brief Hospital Course:
Admitted to trauma service T-SICU. Intubated and sedated. Seen
by orthopedics for radius fracture and unltimately ORIF ([**10-5**])
of radius without complication. Evaluated by Orthopedic spine
service- recommended continued hard cervical collar. Transplant
nephrology followed throughout his hopsitalization. Patient was
febrile through his stay in the SICU and treated with Vancomycin
and Zosyn empirically.
Video swallow study on HD6 revealed mild oral and mild to
moderate pharyngeal dysphagia [**1-17**] tongue weakness. This
resulted in recommendation for ground consistency diet with thin
liquids
Patient extubated on HD 4 ([**10-4**])
HD 11: Patient with continued waxing and [**Doctor Last Name 688**] baseline
confusion (oriented to person and intermittently to time).
Repeat Head CT revealed decreased intracranial bleed. CT Sinus
revealed nondisplaced posterior wall fracture of the maxillary
sinus with fluid ni the left maxillary and bilateral ethmoid
sinuses. CT cervical spine revealed know right C1 lateral mass
fracture. Continued on immunosuppressive therapy for
transplant.
Medications on Admission:
See admission H & P
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
Disp:*30 Tablet(s)* Refills:*0*
3. Albuterol Sulfate 0.083 % Solution Sig: [**12-17**] Inhalation Q6H
(every 6 hours) as needed.
Disp:*1 1* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Prednisone 5 mg Tablet Sig: 1.5 tabs Tablets PO at bedtime:
TOTAL DOSE 7.5 mg PO QD.
Disp:*60 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Azathioprine 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*20 * Refills:*2*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
1. Right subarachnoid hemorrhage
2. Thalamic contusion
3. 1st cervical vertebrae lateral mass fracture
4. Right distal radius fracture
5. Left sided rib fractures (Rib 1, [**2-20**])
6. Pulmonary contusion
Discharge Condition:
Stable
Discharge Instructions:
1. Wear cervical collar at ALL TIMES
2. Physical therapy, occupational therapy, speech therapy
3. Neuro rehab per protocols of accepting facility
4. Follow daily tacrolimus (FK05) levels
Followup Instructions:
1. Trauma clinic in 2 weeks [**Telephone/Fax (1) 24689**]
2. [**Hospital **] clinic [**Telephone/Fax (1) 9769**]
3. Orthopedic spine clinic in 6 weeks. Call [**Telephone/Fax (1) 54028**]
4. Follow up with your transplant doctor within 1-2 weeks
|
[
"401.9",
"801.20",
"787.2",
"873.42",
"813.41",
"861.21",
"998.89",
"921.0",
"921.2",
"V58.67",
"V42.0",
"E816.0",
"V12.59",
"805.01",
"250.00",
"780.6",
"807.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.32",
"96.6",
"99.07",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7209, 7256
|
4896, 6003
|
280, 352
|
7506, 7515
|
1781, 4873
|
7754, 8008
|
1556, 1561
|
6073, 7186
|
7277, 7485
|
6029, 6050
|
7539, 7731
|
1576, 1762
|
229, 242
|
380, 1358
|
1380, 1519
|
1535, 1540
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,278
| 100,130
|
47158
|
Discharge summary
|
report
|
Admission Date: [**2109-7-21**] Discharge Date: [**2109-8-13**]
Date of Birth: [**2053-6-5**] Sex: F
Service: [**Doctor Last Name 1181**] MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 56-year-old white
female with a history of right frontal craniotomy on [**2109-7-1**], for a dysembryoplastic angioneural epithelial lesion
with features of an oligodendroglioma who was started on
Dilantin postoperatively for seizure prophylaxis and was
subsequently developed eye discharge and was seen by an
optometrist who treated it with sulfate ophthalmic drops.
The patient then developed oral sores and rash in the chest
the night before admission which rapidly spread to the face,
trunk, and upper extremities within the last 24 hours. The
patient was unable to eat secondary to mouth pain. She had
fevers, weakness, and diarrhea. There were no genital
the morning of [**7-20**].
PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Benign
right frontal cystic tumor status post right frontal
craniotomy on [**2109-7-1**].
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: Lipitor, Tylenol with Codeine, Dilantin,
previously on Decadron q.i.d. tapered over one week and
discontinued a week ago.
SOCIAL HISTORY: The patient lives with her husband,
daughter, and son. [**Name (NI) **] smoking or ethanol use history.
PHYSICAL EXAMINATION: Vital signs: T-max 104.3??????, currently
100.8??????, heart rate 107-110, blood pressure 110/27,
respirations 15-20, oxygen saturation 98% on room air.
General: The patient was an alert, ill-appearing woman with
postsurgical occiput. Head and neck: Injected conjunctivae,
greenish ocular discharge, ulcerative oral lesions.
Cardiovascular: Regular rhythm. Rapid rate. No murmurs.
Pulmonary: Clear to auscultation bilaterally. Abdomen:
Normoactive bowel sounds. Soft, nontender, nondistended.
Extremities: No edema. Skin: Diffuse erythema and pustules
on the face. Patulous pustules on the chest, back, and
proximal upper extremities. GU: No genital lesions.
LABORATORY DATA: Hematocrit 34.1, WBC 10.3, platelet count
291,000, differential of 87 neutrophils, 0 bands; sodium 133,
potassium 3.8, chloride 93, CO2 21, BUN 17, creatinine 0.9,
glucose 121; ALT 39, AST 42, LDH 434, amylase 63, albumin
3.4, total bilirubin 0.3; urinalysis with positive ketones,
negative nitrites; urine culture pending; blood cultures
times two pending; conjunctival culture pending.
HOSPITAL COURSE: Given the patient's severe exfoliative skin
involvement with rapid progression and extensive involvement
of the body, she was admitted to the Medical Intensive Care
Unit for close monitoring. She was started on prophylactic
Oxacillin to cover skin flora, and Dermatology was consulted
along with Neurology and Ophthalmology for the ophthalmic
involvement.
The patient's course in the Intensive Care Unit was
uneventful, and she was discharged to the floor with very
close monitoring which included q.1 hour Pred Forte
application to the eye and close consultation with
Ophthalmology. With regard to her skin lesions, they
continued exfoliate over the next couple of days, and her
skin care included frequent Vaseline hydrated petroleum
application to decrease insensible losses. The patient's
intake and output were closely monitored and replaced
appropriately; however, the intensive nursing care
requirement made it difficult for the patient to receive
adequate on the floor, and therefore, she was transferred to
the Medical Intensive Care Unit again for frequent ophthalmic
applications and skin care.
While in the MICU, the patient continued to have meticulous
skin care and eye care. The skin lesions continued to
desquamate and exfoliate which is the natural
progression of this disease. She began to have involvement
of the genital area with continued desquamation of the
exfoliative lesions. Her course in the Intensive Care Unit
within the next 8-10 days was a slow but gradual improvement
from a dermatologic and ophthalmologic standpoint.
From a cardiovascular standpoint, she was in sinus
tachycardia which was felt to be secondary to her
[**Doctor Last Name **]-[**Location (un) **] syndrome leading to dehydration and
insensible fluid losses.
While in the Intensive Care Unit, she was also found to be
mildly hypoxic which is likely secondary to atelectasis
because of the patient's immobility. Lower extremity
Dopplers were also done, and no deep venous thromboses were
found.
From and Infectious Disease standpoint, the patient was
started on intravenous Oxacillin empirically. Blood cultures
on the 5th was with no growth times two; however, one bottle
from her PICC line grew out gram-positive cocci on [**7-27**].
She was started on a course of Vancomycin. Subsequently the
organism was found to be CNS with Corynebacterium, and
Vancomycin was discontinued prior to transfer to the floor on
[**8-5**].
The patient's course on the floor was uncomplicated with
continued improvement.
Dermatology: The patient, as indicated, improved
dramatically from her presentation to the time of discharge.
Her exfoliative lesions healed over the course of this
admission. Her skin care requirements decreased to Petroleum
jelly twice a day at the time of discharge. She was able to
take in oral foot without problems.
Ophthalmology: The patient's eye care requirement improved
markedly. She was able to open her eyes and use her vision
without significant problems at the time of discharge. Her
Pred Forte was discontinued on the day of discharge, and she
is to have follow-up with Ophthalmology a couple of days
after discharge.
Fluid, electrolytes, and nutrition: On admission the patient
was begun on TPN for nutritional support. As the patient
improved from a medical perspective, her TPN was weaned, and
at the time of discharge, the patient was taking adequate
p.o. with supplementation of Boost.
Infectious Disease: At the time of admission, she was
started on empiric antibiotics and placed on contact
precautions secondary to her extensive skin lesions; however,
as the patient improved throughout the course of this
admission, contact precautions were discontinued, and the
patient was discharged home with services.
Cardiology/Pulmonology: The patient was tachycardiac
throughout this admission which was attributed to her fluid
losses secondary to [**Doctor Last Name **]-[**Location (un) **] syndrome; however, given
the patient's immobility throughout the course of this
admission, a CT angiogram was performed to evaluate for
possible pulmonary embolism, and none were found.
Neurology: The patient has a history of cystic tumor status
post resection in [**Month (only) 205**] of this year and was started on
prophylactic Dilantin leading to presumed [**Doctor Last Name **]-[**Location (un) **]
syndrome. At the time of this admission, the patient's
Dilantin was discontinued, and no other anticonvulsants were
started, given the patient's risk of seizures several weeks
after her surgery was unlikely. This decision was made with
the support of her neurosurgeon, Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1338**].
Five days before discharge, the patient did have a syncopal
event while in the bathroom showering with the help of a
nursing aide. The likely etiology of this is orthostatic
hypotension from her fluid losses; however, given the
patient's neurologic history, Neurology was consulted to
evaluate for possible seizure. Neurology's recommendations
were to obtain a repeat CT scan which was unchanged from
previous showing a right frontal lobe extra-axial hypodensity
which was stable. They also recommended repeat MR imaging
which was again unremarkable except for a stable extra-axial
lesion noted on CT scan. Neurology therefore agrees with the
primary team that the syncopal event was likely secondary to
a vasovagal reaction. A follow-up MR scan would be
recommended with gadolinium to evaluate for the presence of
residual tumor. This can be done as an outpatient with Dr.
[**Last Name (STitle) 1338**].
Rehabilitation: The patient throughout this admission worked
with our physical therapy people and continued to improve
with regard to range of motion and strength in the upper and
lower extremities, and by the time of discharge, she was
ambulating throughout the [**Doctor Last Name **] and around the hospital
without problems. She was therefore discharged home without
need for Physical Therapy Services.
At the time of discharge, the patient has markedly improved
from her initial presentation and is to be discharged home
with nursing assistance.
DISCHARGE STATUS: Markedly improved.
DISCHARGE DIAGNOSIS:
1. [**Doctor Last Name **]-[**Location (un) **] syndrome secondary to Dilantin.
2. Status post craniotomy on [**2109-7-1**], for a cystic
cranial lesion, likely dysembryoplastic angioneural
epithelial lesion with features consistent with an
oligodendroglioma.
DISCHARGE MEDICATIONS: Polysporin ophthalmology O.U. q.i.d.,
hydrated Petroleum as needed, Lipitor 10 mg p.o. q.d.,
Nystatin, Boost t.i.d.
FOLLOW-UP: 1. Ophthalmology [**2109-8-20**], at 12:45
p.m. 2. Primary care physician in two weeks. 3.
Dermatology as needed.
DISCHARGE NOTE: PLEASE NOTE THAT THE PATIENT IS ALLERGIC TO
DILANTIN AND TEGRETOL GIVEN HER [**Doctor Last Name **]-[**Location (un) **] SECONDARY TO
DILANTIN. The patient is recommended to wear an alert
bracelet which indicates this reaction.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern4) 40425**]
MEDQUIST36
D: [**2109-9-3**] 12:59
T: [**2109-9-3**] 12:58
JOB#: [**Job Number 99931**]
[**Name6 (MD) **] [**Name8 (MD) **], M.D.(cclist)
|
[
"E936.1",
"263.9",
"272.0",
"276.5",
"311",
"695.1",
"427.89",
"787.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
8966, 9781
|
8679, 8942
|
2464, 8658
|
1363, 2446
|
195, 897
|
920, 1217
|
1234, 1340
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,254
| 107,341
|
17964
|
Discharge summary
|
report
|
Admission Date: [**2153-8-30**] Discharge Date: [**2153-9-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
Angiogram.
History of Present Illness:
81 M c CAD c hx remote MI, CABG in [**2130**] c SVG to [**Last Name (LF) **], [**First Name3 (LF) **] and
SVG to RCA; recent cath in [**11-11**] demonstrating patent SVG to
[**Date Range **]/OM with OM supplying collaterals to RCA/LAD. SVG to RCA
graft occluded proximally. Severe native vessel disease: LMCA
70% diffuse, LAD 80% diffuse, LCX occluded prox, RCA occluded
prox. Also has history of CHF c EF 20% 3/05 c 3+ MR, 3+TR,
moderate pulmonary HTN, and a history of atrial flutter s/p
cardioversion to NSR in [**2-11**] followed by [**Hospital1 **]-V ICD placement.
.
Presented to ED complaining of 1 day history of sharp, RUQ and
epigastric pain, nausea c 1 episode of vomiting. He reported
missing his medications on [**8-28**] and taking them on [**8-29**] on an
empty stomach. No other GI complaints; normal BM last on [**8-29**],
no BRBPR, melena, diarrhea. CT abdomen done showing known
distal abdominal aneurysm 3.9*3.5 cm extending into both
proximal common iliac arteries, cholelithiasis, and no acute
abdominal pathology. Labs notable for 2 negative cardiac
enzymes. ETT-MIBI done; exercised 5.75 min on modified [**Doctor Last Name 4001**]
protocol; test stopped [**1-11**] hypotension and 2 six beat runs of
NSVT c exertion. Imaging showed a new partially reversible
inferior wall defect, stable fixed defect in the distal anterior
wall/apex, and stable moderate partially reversible
antero/infero-septal defect. After return to [**Name (NI) **], pt. had 2
episodes of sustained polymorphic VT for which he received 2 ICD
shocks. Received amiodarone and started on heparin gtt and sent
to cath lab; since pt. stable in cath lab c native v-paced
rhythm and no complaints, decision made to defer cath to AM and
pt. transfered to CCU for monitoring.
Past Medical History:
CAD: CABG in [**2130**] (SVG->RCA and SVG-> OM); [**11-11**] Cath: severe
3-vessel disease, occluded RCA graft, patent OM graft
CHF (ischemic, global hypokinesis, EF=20-30%)
Severe MR
[**First Name (Titles) 650**] [**Last Name (Titles) **]
Severe pulmonary hypertension
NSTEMI [**2-11**]
h/o Afib ([**2-11**])-> converted
[**Hospital1 **]-V ICD pacemaker placed [**2-11**]
CRI
Eczema
History of hematuria
anemia
Hypothyroid
Social History:
Former smoker (quit in [**2116**]'s, 30 pk yr hx), 7oz wine/day,
former high school science teacher. Lives with wife, second
marriage, a daughter in
[**Name (NI) **], one son and daughter from first marriage
Family History:
NC
Physical Exam:
VS: 98.7 116/51, P 60 VPaced, R 14, 100% 2LNC,
GEN: Comfortable at 45 degrees, pleasant
HEENT: MMM. EOMI.
NECK: JVP to ear when patient laying at 20 degrees.
CV: RRR. S1,S2, gallop (?S4). Soft systolic murmurs at tricusip
and mitral areas. No rub.
PULM: Decreased movement of air throughout. Crackles at bases.
Occasional scattered expiratory wheezes.
ABD: Softly distended, shifting dullness, nontender, +BS
EXT: No edema. 2+ DP/PT pulses BL. Changes of Venous stasis L>R.
Onchychomycosis. Warm/well perfused.
Pertinent Results:
[**2153-8-30**] 03:45PM GLUCOSE-192* UREA N-28* CREAT-2.0* SODIUM-138
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17
[**2153-8-30**] 03:45PM CK(CPK)-111
[**2153-8-30**] 03:45PM CK-MB-4 cTropnT-0.04*
[**2153-8-30**] 03:45PM CALCIUM-9.9 PHOSPHATE-3.6 MAGNESIUM-2.1
[**2153-8-30**] 03:45PM PT-12.8 PTT-24.5 INR(PT)-1.1
[**2153-8-30**] 06:30AM CK(CPK)-88
[**2153-8-30**] 06:30AM CK-MB-NotDone cTropnT-<0.01
[**2153-8-30**] 12:40AM GLUCOSE-165* UREA N-31* CREAT-2.2* SODIUM-138
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
[**2153-8-30**] 12:40AM ALT(SGPT)-12 AST(SGOT)-25 CK(CPK)-111 ALK
PHOS-61 AMYLASE-92 TOT BILI-0.9
[**2153-8-30**] 12:40AM LIPASE-49
[**2153-8-30**] 12:40AM cTropnT-<0.01
[**2153-8-30**] 12:40AM CK-MB-3
[**2153-8-30**] 12:40AM CALCIUM-11.2* PHOSPHATE-3.4 MAGNESIUM-2.3
[**2153-8-30**] 12:40AM WBC-8.4 RBC-4.97 HGB-10.5* HCT-31.3* MCV-63*
MCH-21.1* MCHC-33.5# RDW-15.9*
[**2153-8-30**] 12:40AM NEUTS-90.3* LYMPHS-7.6* MONOS-1.8* EOS-0.2
BASOS-0.1
[**2153-8-30**] 12:40AM HYPOCHROM-2+ POIKILOCY-1+ MICROCYT-3+
[**2153-8-30**] 12:40AM PLT COUNT-171#
.
ETT: 81 yo man (s/p CABG and h/o ischemic cardiomyopathy
with LVEF ~ 30%) was referred to evaluate his shortness of
breath and an
atypical chest discomfort. The patient completed 5.75 minutes of
a
[**Doctor Last Name 4001**] protocol representing a limited functional exercise
tolerance.
Although the patient was near fatigue secondary to shortness of
breath,
the exercise test was stopped secondary to a hypotensive blood
pressure
response accompanied by ventricular irritability. No chest,
back, neck
or arm discomforts were reported during the procedure. The ECG
changes
are uninterpretable in the presence of ventricular pacing.
Atrial and
ventricular pacing was noted at baseline. Sinus with rhythm with
occasional VPDs were noted in exercise and post-exercise. Toward
peak
exercise, two 6-beat runs of nonsustained VT were noted. As
noted, a
hypotensive blood pressusre response to exercise was noted.
MIBI: 1. Transient cavitary dilitation. 2. New, moderate,
partially reversible defect in the inferior wall. Stable,
moderate, predominantly fixed defect in the distal anterior wall
and apex. Stable , moderate, partially reversible antero- and
inferoseptal defect. 3. Global hypokinesis, with best
preserved motion in the anterior and lateral walls. LVEF 31%.
Cath: [**8-31**]: 1. Selective coronary angiography of this right
dominant system
revealed severe native three vessel disease. The LMCA is
heavily
calcfied and diffusely diseased. The LAD is proximally occluded
after a
small diagnonal. The LCx is proximally occluded. The RCA is
known to
be proximally occluded and not engaged (compared to angiography
in
[**11-11**], the LAD is now completely occluded).
2. Graft angiography showed that the SVG to D1 to OM graft is
patent
with 50% lesion at the anastamosis with D1 and distal 50%
discrete
stenosis.
3. Hemodyanmic measurements shows elevated right and left sided
filling
pressure, severe pulmonary hypertension, as well as reduced
cardiac
output (see table above).
4. Left ventriculogram was not performed due to concerns about
the
patient's renal insufficiency. In addition, non-invasive
assessment of
the patient's left ventricular systolic function is available.
Brief Hospital Course:
A/P: 81 yo male w/ CAD s/p CABG, CHF, [**Hospital1 **]-V ICD presents with
epigastric pain, developed V-fib post ETT-MIBI.
1.) Cardiovascular: a) Ischemia: Patient with known severe 3
vessel disease, s/p CABG with subsequent occlusion of RCA graft,
now presents with atypical chest pain and new reversible defect
on MIBI suggesting unstable angina. The episode of Vfib after
ETT was likely [**1-11**] ischemia; however, we cannot anatomically
localize polymorphic VT, therefore must also consider
medications and electrolyte abnormalities are also on the
differential although much less likely. The patient was treated
with 24 hours of heparin and underwent cardiac cath, and was
found to have severe disease however, no lesions were amenable
to cath. He was continued on aspirin, plavix, statin,
betablocker and ace-inhibitor. b) Pump- Mr [**Known lastname **] has severe
ischemic CHF, with an EF of ~30%. He will be discharged on a low
Na diet, and instructed to perform daily weights. c) Rhythm: BiV
ICD in place, paced rhythm currently. S/p VF in ED with ICD
firing x2. As above, this is likely secondary to ischemia,
however there were no treatable lesions found with cath. His
metoprolol was increased and he was loaded with Amiodarone in an
attempt to maintain normal rhythm. He will follow up with
cardiology.
.
2.) Leukocytosis- This is most likely secondary to his [**1-11**] ICD
firing, however, he did have a small area of erythema on his arm
due to phlebitis. He was treated with a 2 week course of
cefazolin.
.
3.) CKD: Baseline Cr appears to be 1.5-1.8, however, may be
higher as no recent values are available in his records. His
Creatinine is currently 2.0, which may represent a mild prerenal
state. Likely not obstructive as no hydronephrosis observed on
CT. He was given gentle hydration and Mucomyst prior to cath
(although hydration limited by severe CHF), and nephrotoxic meds
were avoided as much as possible. Kidney function remained
stable throughout admission.
.
4) Endocrine- Hypothyroid- The patient was continued on his home
dose levoxyl.
.
FULL CODE
Medications on Admission:
(pt unclear re: exact meds, doses)
Furosemide
Lisinopril
Levoxyl 50
Toprol XL 100 mg qday
Aspirin 81 mg qday
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 200 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*
6. Toprol XL 50 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*
7. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for
14 days.
Disp:*28 Capsule(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*48 Tablet(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO as directed:
take 2 tabs (400mg) three times per day for 6 days, then 2 tabs
(400mg) once per day for 2 weeks, then 1 tab (200mg) once per
day thereafter.
Disp:*80 Tablet(s)* Refills:*1*
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Vfib.
Secondary: CAD. CHF. CRI
Discharge Condition:
Good- stabilized on new medication regimen, no events on tele,
asymptomatic. Patient has a cephalic vein thrombosis and
resultant phlebitis for which he is taking antibiotics for two
weeks.
Discharge Instructions:
During this admission you have been treated for ventricular
tachycardia. Your medications have been changed. Please
continue to take all medications as prescribed. Please call
your doctor immediately if your ICD fires again. Please seek
immediate medical care if you develop chest pain, palpatations,
shortness of breath, or any other symptom that is concerning to
you.
If you begin to notice increasing swelling in your arm, please
call your PCP right away.
Followup Instructions:
You have the following appointments:
1. DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2153-9-10**] 9:30
2. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2153-9-10**]
10:00
3. Ultrasound, [**Hospital Ward Name 517**], [**Location (un) 470**] Phone number [**Telephone/Fax (1) 49745**],
[**2153-9-18**] at 9AM.
|
[
"414.01",
"413.9",
"427.41",
"412",
"416.8",
"451.84",
"424.0",
"V45.81",
"585.9",
"397.0",
"244.9",
"288.8",
"441.4",
"398.91",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"88.56",
"37.23",
"89.49"
] |
icd9pcs
|
[
[
[]
]
] |
10584, 10590
|
6683, 8782
|
277, 290
|
10675, 10868
|
3337, 6660
|
11380, 11814
|
2784, 2788
|
8941, 10561
|
10611, 10654
|
8808, 8918
|
10892, 11357
|
2803, 3318
|
222, 239
|
318, 2094
|
2116, 2543
|
2559, 2768
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,676
| 115,207
|
31845
|
Discharge summary
|
report
|
Admission Date: [**2157-10-13**] Discharge Date: [**2157-10-21**]
Date of Birth: [**2102-1-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Phenobarbital / Percocet / Percodan / Demerol / Nsaids
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest discomfort, dyspnea
Major Surgical or Invasive Procedure:
[**2157-10-14**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending, vein
grafts to obtuse marginal and right coronary artery.
History of Present Illness:
Mrs. [**Known lastname 18252**] presented to outside hospital with seven day history
of exertional chest pain associated with dyspnea. On the morning
of admission, she awoke with chest pain. EKG on admission showed
new lateral T wave abnormalities. She ruled for myocardial
infarction with positive troponin. Stress MIBI revealed anterior
apical defect consistent with ischemic heart disease. Subsequent
cardiac catheterization showed severe three vessel coronary
artery disease including an 80% ostial left main lesion. Given
her critical coronary anatomy, she was transferred to the [**Hospital1 18**]
for surgical intervention.
Past Medical History:
Coronary Artery Disease
Hypertension
Hypercholesterolemia
Diabetes Mellitus Type II
History of Herpes Zoster
Osteoarthritis
Gout
Gastroesophogeal Reflux Disease
History of Asthma(Cold-induced)
s/p Laminectomy
s/p Bilateral Total Knee Replacements
s/p Bilateral Shoulder Surgery
s/p Cholecystectomy
s/p Cervical Fusion
s/p Lasery Eye Surgery
s/p Carpal Tunnel Surgery
Social History:
Works as [**Name8 (MD) **] RN, lives alone. Denies tobacco and ETOH.
Family History:
Father has history of MI. Sister underwent PTCA at age 60.
Physical Exam:
Vitals: T 98.0, BP 139/77, HR 72, RR 16, SAT 96% 2L
General: WDWN femaile in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, no murmur or rub
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 1+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2157-10-20**] 04:45PM BLOOD WBC-11.3*# RBC-4.24 Hgb-12.6 Hct-35.4*
MCV-84 MCH-29.7 MCHC-35.6* RDW-13.6 Plt Ct-520*
[**2157-10-13**] 10:59AM BLOOD WBC-7.8 RBC-4.27 Hgb-12.9 Hct-36.1 MCV-85
MCH-30.2 MCHC-35.7* RDW-13.4 Plt Ct-342
[**2157-10-20**] 04:45PM BLOOD Plt Ct-520*
[**2157-10-14**] 12:31PM BLOOD PT-13.5* PTT-34.3 INR(PT)-1.2*
[**2157-10-13**] 10:59AM BLOOD Plt Ct-342
[**2157-10-13**] 10:59AM BLOOD PT-12.8 PTT-57.6* INR(PT)-1.1
[**2157-10-14**] 11:13AM BLOOD Fibrino-122*
[**2157-10-20**] 04:45PM BLOOD Glucose-159* UreaN-17 Creat-1.0 Na-137
K-4.1 Cl-94* HCO3-31 AnGap-16
[**2157-10-13**] 10:59AM BLOOD Glucose-218* UreaN-24* Creat-1.0 Na-140
K-4.0 Cl-103 HCO3-27 AnGap-14
[**2157-10-20**] 04:45PM BLOOD ALT-89* AST-58* LD(LDH)-243 AlkPhos-105
Amylase-49 TotBili-0.4
[**2157-10-20**] 04:45PM BLOOD Lipase-52
[**2157-10-13**] 10:59AM BLOOD cTropnT-0.01
[**2157-10-20**] 04:45PM BLOOD Albumin-3.7 Calcium-10.0 Phos-4.7* Mg-1.6
[**2157-10-13**] 10:59AM BLOOD %HbA1c-6.5*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2157-10-18**] 3:45 PM
CHEST (PA & LAT)
Reason: eval ptx s/p CT d/c
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
eval ptx s/p CT d/c
REASON FOR EXAM: S/P CABG, chest tube removed.
PA AND LATERAL VIEWS OF THE CHEST, THREE RADIOGRAPHS: Patient is
post median sternotomy and CABG. Cardiac size is normal. Left
lower lobe atelectasis has improved, almost completely resolved.
Otherwise, the lungs are clear. There is a questionable small
apical left pneumothorax.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: WED [**2157-10-19**] 9:37 AM
Cardiology Report ECG Study Date of [**2157-10-15**] 2:07:26 PM
Sinus rhythm. Findings are as previously described on the
tracing of [**2157-10-14**]
and are probably without change, although baseline artifact
makes comparison
difficult.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
95 118 94 326/387 11 23 67
Cardiology Report ECHO Study Date of [**2157-10-14**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG procedure
Height: (in) 66
Weight (lb): 193
BSA (m2): 1.97 m2
BP (mm Hg): 156/78
HR (bpm): 67
Status: Inpatient
Date/Time: [**2157-10-14**] at 10:32
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.0 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.88
TR Gradient (+ RA = PASP): >= 19 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient appears to be in sinus rhythm.
Results were
Conclusions:
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is
not present. No aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
Post Bypass
1. Biventricular systolic function is unchanged.
2. Mild mitral regurgitation persists.
3. Aorta intact post decannulation
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2157-10-14**] 11:54.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mrs. [**Known lastname 18252**] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. She remained pain
free on intraveous therapy. Workup was unremarkable and she was
cleared for surgery. On [**10-14**], she underwent coronary
artery bypass grafting by Dr. [**Last Name (STitle) 914**]. For surgical details,
please see seperate dicatated operative note. Following the
operation, she was brought to the the CSRU for invasive
monitoring. Within 24 hours, she awoke neurologically intact and
was extubated without incident. Due to hypertension, she
initially required Nitro drip. Over several days, medical
therapy was titrated accordingly and she transferred to the SDU
for further care and recovery. Chest tubes and pacing wires were
removed without complication. She had several episodes of
agitation and confusion after receiving dilaudid and IV ativan,
the confusion resolved after discontinuing the medications.
However On POD # 5 was seen by psychiatry for disorientation and
agitation after receing ambien for sleep. She was given Haldol
and she improved over a few hours. She was pleasant and
cooperative in the afternoon and interacting with visitors. She
was ready for discharge to rehab on POD 7.
Medications on Admission:
IV Heparin, Aspirin 81 qd, Lasix 40 qd, Glyburide 2.5 [**Hospital1 **],
Lopressor 50 [**Hospital1 **], Cytotec 200 [**Hospital1 **], Relafen, Protonix 40 qd,
Crestor 10 qd, Effexor XL 150 qd, Calan 240 qd, Citracal
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Misoprostol 200 mcg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous once a day.
14. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38640**] [**Doctor Last Name **]
Discharge Diagnosis:
Coronary Artery Disease. Acute MI - s/p CABG
Hypertension
Hypercholesterolemia
Diabetes Mellitus Type II
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
[**Telephone/Fax (1) 170**].
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) 914**] in [**5-19**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**] in [**3-19**] weeks, call for appt
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-19**] weeks, call for appt [**Telephone/Fax (1) 74697**]
Completed by:[**2157-10-21**]
|
[
"V43.65",
"250.00",
"E939.4",
"E935.2",
"401.9",
"292.81",
"414.01",
"410.11",
"530.81",
"493.90",
"272.0",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9678, 9754
|
6970, 8219
|
348, 535
|
9903, 9910
|
2186, 3285
|
10274, 10687
|
1688, 1748
|
8484, 9655
|
3322, 3349
|
9775, 9882
|
8245, 8461
|
9934, 10251
|
4414, 6909
|
1763, 2167
|
283, 310
|
3378, 4388
|
563, 1195
|
6947, 6947
|
1217, 1586
|
1602, 1672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,866
| 196,100
|
10145
|
Discharge summary
|
report
|
Admission Date: [**2184-5-14**] Discharge Date: [**2184-5-22**]
Date of Birth: [**2138-10-6**] Sex: M
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 33882**] is a 45-year-old
gentlemen who presented on annual follow-up of his
percutaneous transluminal coronary angioplasty and was found
to have a stent occluded. He was noted to have an old acute
myocardial infarction on routine physical, positive stress
test. Catheter showed three vessel disease. Angioplasty
second look was restenosed. He denies any anginal symptoms.
PAST MEDICAL HISTORY: Significant for diabetes,
claudication, and hepatitis C.
MEDICATIONS ON ADMISSION: Lipitor 10 q.d., aspirin 325 q.d.,
Glucovance 500 t.i.d., Epivir 300 q.d., folic acid 400 mg po
q.d.
ALLERGIES: No known drug allergies.
EXAM ON ADMISSION: Significant for clear lungs. Regular S1,
S2 without murmur. Soft, nontender, nondistended abdomen.
Pulse exam was full with 1+ pulses in the feet bilaterally.
Chest x-ray was clear.
HOSPITAL COURSE: The patient was admitted to the hospital
where he underwent a five vessel coronary artery bypass graft
using left internal mammary artery and saphenous vein
grafting. He tolerated the procedure and was taken to the
Cardiothoracic Intensive Care Unit in stable condition. He
was extubated on the night of surgery. Nitroglycerin was
continued given his radial artery. This was changed to Imdur
on postoperative day one. He was kept in the unit. On
postoperative day number one, he received 20 units of packed
red cells for low saturation and marginal urine output. He
was then transferred to the floor. On the floor, he
progressed slowly, complaining often of nausea and fatigue.
He was on an insulin drip initially and then [**Last Name (un) **] Service
was consulted and glucose management was started. He
progressed slowly through the stages of Physical [**Hospital **]
Rehabilitation. He was noted to have minimal serous drainage
on his sternum. Cultures were obtained which eventually grew
methicillin sensitive staph aureus. He was started on
levofloxacin for his drainage as well as question of right
middle lobe infiltrate on chest x-ray. He remained afebrile,
however, his white count did jump to 16 at one point, but by
the time of discharge this was down to 10. He denied
coughing and had no further drainage from his chest wound.
His right thigh saphenectomy site had a small hematoma. This
did not appear to be infected nor cause any erythema of his
skin.
The patient continued to improve slowly and was discharged to
home on postoperative day number eight. He is to complete
another ten days of levofloxacin for a two week course.
While he was in house, the Diabetes Teaching Service showed
him how to use a glucometer and introduced the concept that
he may need insulin somewhere down the road to help control
his diabetes. He was discharged home with services for
glucose monitoring and wound checks.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 75 mg po b.i.d.
2. Lasix 20 mg po q.d. times seven.
3. KCL 20 mEq po q.d. times seven.
4. Levofloxacin 500 mg po q.d. times ten.
5. Glucophage 500 mg po b.i.d.
6. Glyburide 5 mg po b.i.d.
7. Aspirin 81 mg po q.d.
8. Ibuprofen 600 mg po q. 6 hours.
9. Epivir 300 mg po q.d.
10. Iron 325 po t.i.d. with meals.
11. Percocet 1-2 tabs po q. 4-6 hours prn.
12. Colace 100 mg po b.i.d.
FOLLOW-UP: He is to follow-up with Dr. [**First Name (STitle) **], his primary
care physician in one to two weeks, and Dr. [**Last Name (STitle) **] in three
to four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 22884**]
MEDQUIST36
D: [**2184-5-23**] 20:22
T: [**2184-5-23**] 20:22
JOB#: [**Job Number 33883**]
|
[
"414.01",
"996.74",
"412",
"250.00",
"V02.61",
"V45.82",
"411.1",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"42.23",
"36.14",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3000, 3856
|
676, 821
|
1040, 2974
|
168, 568
|
836, 1022
|
591, 649
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,204
| 142,586
|
44327
|
Discharge summary
|
report
|
Admission Date: [**2176-7-8**] Discharge Date: [**2176-7-13**]
Date of Birth: [**2137-10-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
[**2176-7-9**] TIPS procedure:
Placement of 10 mm x 7 cm x 2 cm Viatorr TIPS shunt dilated to
10 mm.
Embolization of two gastric varices. Reduction of porta systemic
gradient from 15 mmHg to 10 mmHg.
History of Present Illness:
Mr. [**Known lastname 77244**] is a 38 year-old man with a history of alcoholic
cirrhosis, grade 1 esophogeal varices, duodenal ulcer, and
[**Doctor First Name **]-[**Doctor Last Name **] tear who presents with melena and
light-headedness. He is a patient of Dr.[**Name (NI) 37497**] and was
seen in clinic as recently as [**2176-7-3**]. At that time, he
presented for a routine visit and admitted to continued alcohol
consumption, and he was advised to abstain. He continued
consuming, however, and had his last drink on [**2176-7-7**], having "a
few beers" that evening. He presented to the ED today after his
partner noticed [**Name2 (NI) **] black stools. He has had two bowel
movements over this interval but denied nausea, vomiting, or
abdominal pain.
.
Of note, he has a history of multiple prior GI bleeds, with a
perforated duodenal ulcer bleed that led to a Billroth 1
procedure. In [**2174**], he had an upper GIB that was secondary to a
[**Doctor First Name **]-[**Last Name (un) **] tear. In [**2175-11-8**], he presented to [**Hospital1 18**] with
hematemesis and was found to have grade 1 esophogeal varices and
gastric varices on EGD. His last EGD was performed in [**Month (only) 404**]
[**2176**] and demonstrated three cords of grade 1 varices in the
esophagus and gastric varices measuing 2 cm and 0.5 cm, none of
which were bleeding.
.
On presentation, VS in the ED were 98 106/62 96 16 100%nrb. His
hct on presentation was He had bloody emesis (500cc) and was
bolused with pantoprazole and started on octreotide gtt. He
also received zofran, versed, and was intubated for airway
protection. An OG tube was placed and had drainage of 40-50 cc
partially clotted blood. Two 18 guage and one 20 guage PIV were
placed. He was transfused 1 u PRBC. Hepatology was consulted
and he was admitted to the MICU.
.
On arrival, VS were HR 100 BP 90s/60. Central venous access was
attained with placement of a right IJ sepsis line ([**Location (un) 109**]). He was
emergently scoped (EGD) by hepatology and was found to have
three cords of nonbleeding grade 1 esopheal varices, nonbleeding
gastric varices, and clotted blood in the fundus. He was
transfused an additional unit of blood and FFP.
.
Review of systems: unable to obtain
.
Past Medical History:
Cirrhosis
Gastric varices
h/o alcohol abuse
Duodenal ulcer, status post Billroth I performed in DR [**Last Name (STitle) **] [**2170**]
Social History:
Lives with girlfriend. [**Name (NI) 1403**] as a stone [**Doctor Last Name 3456**]. He has a prior
history of heavy ETOH use, usually beer, stopped briefly after
duodenal ulcer/surgery in [**Country 13622**] Republic in [**2170**] but
continued to struggle with ETOH-ism. Currently, he reports
occasional beer ([**4-10**] /week) or wine with dinner, but consumed 8
beers at a football game the week prior to admission. No history
of DTs, hallucinations or seizures. Attended AA for a period of
but last meeting about 6 months ago. Patient admits to
intermittent intranasal cocaine use. Denies IVDU. He has never
used tobacco.
Family History:
Noncontributory. Denies any known ETOH-ism in other siblings or
close family members. [**Name (NI) **] known liver or GI diseases in family
per patient.
Physical Exam:
On Presentation to MICU:
Vitals: T: 98.4 BP: 90/55 P: 109 R: 18 O2: 100%
General: intubated
HEENT: ETT in place, sclera anicteric, MMM, oropharynx with OGT
and bloody secretions from OGT and around mouth
Neck: supple, no JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, distended, bowel sounds present, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
[**2176-7-8**] 07:15PM WBC-8.6# RBC-3.04*# HGB-9.7*# HCT-28.7*#
MCV-95 MCH-31.8 MCHC-33.6 RDW-16.6*
[**2176-7-8**] 07:15PM NEUTS-77.2* LYMPHS-17.4* MONOS-4.7 EOS-0.3
BASOS-0.4
[**2176-7-8**] 07:15PM PLT COUNT-141*#
.
[**2176-7-8**] 07:15PM PT-16.9* PTT-26.8 INR(PT)-1.5*
.
[**2176-7-8**] 07:15PM GLUCOSE-233* UREA N-36* CREAT-0.9 SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
[**2176-7-8**] 07:15PM ALT(SGPT)-58* AST(SGOT)-86* ALK PHOS-102
AMYLASE-41 TOT BILI-1.4
.
HCt trend:
[**2176-7-8**] 07:15PM BLOOD Hct-28.7*#
[**2176-7-8**] 10:34PM BLOOD Hct-26.2*
[**2176-7-9**] 04:45AM BLOOD Hct-27.8*
[**2176-7-9**] 10:16AM BLOOD Hct-25.6*
[**2176-7-9**] 07:25PM BLOOD Hct-26.6*
[**2176-7-10**] 01:15AM BLOOD Hct-24.6*
[**2176-7-10**] 06:12AM BLOOD Hct-27.1*
[**2176-7-10**] 11:20AM BLOOD Hct-25.8*
[**2176-7-10**] 05:01PM BLOOD Hct-26.2*
[**2176-7-10**] 11:29PM BLOOD Hct-24.4*
[**2176-7-11**] 04:23AM BLOOD Hct-25.9*
[**2176-7-11**] 09:48AM BLOOD Hct-26.3*
.
CXR (my read): ETT in place ~5 cm above [**Female First Name (un) 5309**], no infiltrate
.
EGD [**2176-7-8**]: three cords of nonbleeding grade 1 esopheal
varices, nonbleeding gastric varices, and clotted blood in the
fundus
.
EGD [**2-16**]: three cords of grade I varices, varices at the
fundus, otherwise normal EGD to second part of the duodenum
.
Colonoscopy [**12-15**]: Diverticulosis of the sigmoid colon.
Otherwise normal colonoscopy to cecum
.
EKG: NSR, nl axis, old 1 mm qwaves in III, avf
Brief Hospital Course:
# GI bleed: Patient presented with Hct of 29, down from a
baseline of 49 with h/o prior GI bleeds secondary to multiple
etiologies, including perforated duodenal ulcer and
[**Doctor First Name **]-[**Doctor Last Name **] tear. This episode likely secondary to gastric
variceal bleed as clots and blood in fundus on EGD though no
active bleeding seen. He required 4 units of PRBCs 2 U of
platelets initially and an additional 2 U on day 2 and 3 of
hospital stay. He was taken for TIPS procedure with Hct
remaining in 25-27 range and was transitioned off ppi drip and
octreotide drip. His respiratory status improved and he was
extubated without problems. His hematocrit remained stable and
he did not require further transfusions during admission. The
patient was discharged with pantoprazole po daily.
.
# Alcoholic cirrhosis: Has portal hypertension with varices on
EGD. On nadolol as outpatient. Also with good synthetic
function overall with albumin of 4 and INR of 1.4 at baseline.
Now status post TIPS procedure which the patient tolerated well.
He was continued on lactulose, PPI, and ciprofloxacin for
prophylaxis.
.
# Alcoholism: Known to be currently drinking 4-6 beers three
days per week per his girlfriend. [**Name (NI) 60563**] with valium was started
in setting of alcoholic cirrhosis but patient required no doses
during his stay. Thiamine, multivitamin, folic acid was started.
Social work consult was called for abuse issues and coping.
.
# Respiratory failure: Intubated for airway protection in
setting of massive upper GIB. No history of lung disease at
baseline. The patient was extubated successfully without further
complications.
.
# Follow-up: the patient has a scheduled US one week post-TIPS
for evaluation. He has appointments scheduled with his PCP and
hepatology clinic.
Medications on Admission:
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
NADOLOL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
MULTIVITAMIN - 1 Tablet(s) by mouth once a day
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth qam
THIAMINE HCL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
.
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol abuse
Alcoholic cirrhosis
Variceal bleeding
Discharge Condition:
hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to the hospital with dark stools and bloody
vomiting, concerning for GI bleeding. This was likely caused by
alcohol use. You were admitted to the Intensive Care Unit and
treated for low blood counts (anemia). You will need to continue
taking your medications and abstain from alcohol in order to
avoid further bleeding and damage to your liver.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take lactulose 15-30 mL three times a day (can titrate
to [**3-12**] bowel movements per day)
Please make sure to keep your scheduled appointments with your
doctor.
If you experience nausea, vomiting, dark stools,
lightheadedness/dizziness, fevers, or any other concerning
symptoms please call your doctor or return to the emergency
room.
If you experience bright red blood while vomiting or black,
[**Month/Day (3) **] stools call 911 or go to your nearest emergency room.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7869**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2176-7-31**]
4:00
Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2176-7-17**] 2:15. This is for your liver ultrasound.
The appointment is located in the [**Hospital Unit Name **] ([**Hospital Ward Name **]) on
the [**Location (un) 470**]. You cannot eat or drink for six hours prior this
appointment.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2176-7-31**] 3:10
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Discharge summary
|
report
|
Admission Date: [**2170-5-25**] Discharge Date: [**2170-5-29**]
Date of Birth: [**2138-4-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Upper endoscopy - [**2170-5-28**]
History of Present Illness:
Ms. [**Known lastname 85911**] is a 32 yo F w/ h/o SLE, PUD s/p H pylori
eradication, chronic anemia (?[**2-13**] iron deficiency with ferritin
4), GERD who presents with near syncope at Heme/onc clinic and
hematemesis. Of note, she was admitted to [**Hospital1 18**] from [**Date range (1) 61076**]
for n/v, vomitus with blood streaks and pyelonephritis. During
this admission, she had an EGD notable only for chemical
gastritis. Her nausea and pain at that admission were managed
with PO tylenol, morphine, compazine and IVF. TTG-IGA was
negative as was H pylori. Of note, CT at that admission showed
non-specific dilation of the pancreatic ducts which was at the
upper limit of normal on rpt MRCP. For this reason, GI thought
she should be seen in f/u for possible chronic pancreatitis w/
w/u incl abd u/s. Of note, GI is also considering further
studies to w/u her iron-deficiency anemia.
.
The pt was seen twice by rheumatology in [**Month (only) 547**] for f/u where she
was increased in her azathioprine and put on a prednisone taper.
.
Today, the pt went to heme onc for an initial visit for anemia
workup. Blood was drawn and the pt became presyncopal after
which she reportedly had 8 oz of bloody emesis. She was referred
to the ED where she had no more emesis. There, she also reported
decreased energy over the past couple of weeks and diffuse abd
pain. Hct in the ED was rechecked with a 4 pt drop prior to IVF
being given. NG lavage of 1L showed blood-streaked fluid which
cleared. She then had 8oz of bloody vomit again.
.
GI was consulted in the ED and recommended PPI and octreotide
gtt which were started. They did not want to do EGD tonight.
They did want the pt to recieve 2u PRBCs and her home carafate.
Also in the [**Name (NI) **], pt had 1 18 gauge IV and 2 20 gauge IV's placed.
CXR was done which is not yet read officially. The pt also
recieved 4mg then 8mg of ondansetron and 4mg IV morphien x2 in
the ED. Vitals prior to transfer from ED were: T98 HR 71 BP
134/91 R 21 100% on RA. She was reportedly never tachycardic in
the ED.
.
On arrival to the ICU, pt c/o diffuse abd pain and nausea with
clear emesis. She c/o all over headache.
.
Past Medical History:
Medical Hx:
SLE: hair loss/malar rash/arthritis/oral ulcers/transient [**Doctor First Name **],
anti-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 9374**]/raynaud's/sicca sx.
Anemia: since age 7, lowest to HCT 12, multiple transfusions in
[**Location (un) **]. Interval baseline HCT stable 35. Thought to be iron
deficiency vs autoimmune vs gyn losses, on Fe Supplements.
Menorrhagia with clots: pelvic U/S [**1-20**] showed pelvic
congestion, small hemorrhagic follicle. repeat in [**4-20**] was
normal with multiple follicles. Improved with OCPs.
Epistaxis - self limited, episodes lasting 2-3min, 2-3x/wk.
UTI: renal U/S wnl in [**2169**]
PUD: s/p h.pylori tx
GERD
Hiatal Hernia
Fibromyalgia
Depression: on Celexa
Surgical Hx:
s/p C-section x3
bilateral tubal ligation
Followed by Dr. [**Last Name (STitle) 85912**] [**Name (STitle) **] at [**Location **]
Center. [**Telephone/Fax (1) 6951**]
Social History:
No history of ETOH, tobacco, or illicit drug use.
Migrated from [**Location (un) **] in [**2166**]. Lives with her husband and 3
children.
Family History:
Father with history of ulcer died of perforation at young age.
Mother: HTN
Aunt: uterine cancer
Aunt: easy bruising
Physical Exam:
Tmax: 36.3 ??????C (97.3 ??????F)
Tcurrent: 36.3 ??????C (97.3 ??????F)
HR: 51 (51 - 64) bpm
BP: 105/64(74) {105/61(70) - 115/76(85)} mmHg
RR: 8 (8 - 16) insp/min
SpO2: 100%
Heart rhythm: SB (Sinus Bradycardia)
General Appearance: Well nourished, Anxious
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Bowel sounds present, No(t) Distended, Tender:
diffusely but esp RLQ and epigastric
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, No(t)
Sedated, Tone: Normal
Pertinent Results:
Admission Labs:
[**2170-5-25**] 03:20PM BLOOD WBC-4.9 RBC-3.32* Hgb-8.0* Hct-26.2*
MCV-79* MCH-24.0* MCHC-30.4* RDW-14.7 Plt Ct-262
[**2170-5-25**] 03:20PM BLOOD Neuts-55.6 Lymphs-39.5 Monos-3.6 Eos-1.2
Baso-0.2
[**2170-5-25**] 03:20PM BLOOD Ret Aut-1.7
[**2170-5-25**] 06:30PM BLOOD Glucose-108* UreaN-16 Creat-0.4 Na-141
K-3.0* Cl-110* HCO3-23 AnGap-11
[**2170-5-25**] 03:20PM BLOOD LD(LDH)-148 TotBili-0.6
[**2170-5-25**] 03:20PM BLOOD calTIBC-394 VitB12-524 Folate-19.2
Hapto-98 Ferritn-3.8* TRF-303
Discharge Labs:
[**2170-5-29**] 06:18AM BLOOD WBC-3.4* RBC-3.23* Hgb-8.1* Hct-25.8*
MCV-80* MCH-25.2* MCHC-31.6 RDW-16.1* Plt Ct-287
[**2170-5-28**] 05:16AM BLOOD ESR-7
[**2170-5-29**] 06:18AM BLOOD Glucose-89 UreaN-10 Creat-0.5 Na-142
K-3.6 Cl-107 HCO3-24 AnGap-15
[**2170-5-29**] 06:18AM BLOOD ALT-11 AST-18 LD(LDH)-139 AlkPhos-41
TotBili-1.1
[**2170-5-29**] 06:18AM BLOOD Calcium-8.3* Phos-4.8*# Mg-1.9
CT Torso:
1. No evidence of PE.
2. No evidence of renal tract calculi.
RUQ Ultrasound:
1. Gallbladder sludge. Mildly prominent extrahepatic common bile
duct, with no evidence of intrahepatic biliary dilatation.
EDG [**2170-5-28**]:
Erythema in the antrum compatible with gastritis (biopsy)
Petechiae in the cardia compatible with ? gastritis or
?vaculitis
(biopsy, biopsy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Ms. [**Known lastname 85911**] is a 32 yo F w/ h/o SLE, PUD s/p H pylori
eradication, chronic anemia (?[**2-13**] iron deficiency with ferritin
4), GERD who presents with epigastric pain and hematemesis x3d
with near syncope at Heme/onc clinic FTH BRB in emesis and 4
point hct drop on arrival to the ED.
# Hematemesis- Story sounded similar to prior admission 2 mo ago
where EGD showed only chemical gastropathy although known h/o
PUD. 4pt HCT drop in ED was concerning but repeat hcts on
arrival to ICU and the following morning after transfusion of 1U
PRBCs were stable. The patient was given PPI and octreotide
gtts overnight, then transitioned to IV PPI daily in the
morning. Patient was called out to the medicine floor. GI
continued to follow her and performed EGD on [**2170-5-28**] which
showed erythema in the antrum compatible with gastritis (biopsy)
and petechiae in the cardia compatible with gastritis or
possible vaculitis. Biopsies were taken and pending on
discharge. GI follow-up was arranged for the patient.
# Abdominal pain- Patient complaining diffuse abdominal pain.
Unclear if this is acute exacerbation of her chronic abdominal
pain or a new process. Initially favored chronic pancreatitis
flare vs. PUD vs. severe gastritis given pts history. Lipase
was negative and LFTs were normal aside from slightly elevated
Tbili. On the floor patient complained of pleuritic right flank
pain. Given her UA from 1-2 days ago were clean, it was very
unlikely that it was pyelonephritis. Patient went for CTA for
chest given pleuritic nature of the pain which showed no PE. CT
Torso showed no evidence of renal calculi. Repeat UA's
continued to have too many epithelial cells, and given afebrile
and no leukocytosis, she was not placed on antibiotics for WBC
of 6 on UA. On discharge, pain was much improved and she was
tolerating PO. Patient has an appointment with GI for
follow-up.
# SLE- continued home azathioprine, hydroxychloroquine,
prednisone
# Anemia: Unclear etiology at this point but has been a chronic
problem for the last at least 2 years. PAtient reports supposed
to be getting IV Iron at [**Hospital1 2177**] but never did. Now s/p pRBCs in ED
so no need for acute IV iron now. Likely needs further workup
and did have outpatient heme/onc set up but with pre-syncopal
episode did not undergo the full evaluation yesterday and will
need as outpatient again. Patient is to follow-up with
outpatient hematologist as previously arranged.
Medications on Admission:
AZATHIOPRINE - 150 mg daily
HYDROXYCHLOROQUINE 200mg daily
NYSTATIN - 100,000 unit/mL susp 3 times daily
OMEPRAZOLE - 40 mg daily
PREDNISONE - 10 mg daily
SUCRALFATE - 1 gram daily
FERROUS SULFATE 325 daily
HYDROCORTISONE ACETATE [ANTI-ITCH] - 0.5 %-0.5 % Lotion four
times daily PRN
metamucil [**Hospital1 **]
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
2. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
6. Nystatin 100,000 unit/mL Suspension Sig: [**1-13**] mL PO three
times a day as needed for thrush.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for Pain.
Disp:*20 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*3*
11. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
12. Hydrocortisone Acetate 0.5 % Cream Sig: One (1) Topical
four times a day as needed for itching: as previously
prescribed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Gastritis, abdominal pain
Secondary Diagnosis: SLE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
vomiting blood and abdominal pain. You were transfused 2 units
of blood for your blood loss. The GI doctors [**Name5 (PTitle) 6349**] [**Name5 (PTitle) **]
during this admission. They performed an upper endoscopy which
showed a small amount of blood in your stomach which was felt
secondary to your repeated nausea and vomitting. You were
continued on your medications.
Your outpatient Lupus physician was [**Name (NI) 653**] while you were in
the hospital and she would like you to take your prednisone at
20 mg a day and to start Bactrim to prevent any lung infections
due to your long-term use of steroids. A follow-up appointment
has been arranged for you to see her in the next 2-3 weeks.
It is also important that you arrange your iron infusions as
previously discussed with your hematologist prior to admission.
Please call the office at the number given to you at that
appointment to arrange your treatments.
The following changes were made to your medications:
- increase: prednisone 20 mg daily
- start: bactrim DS 1 tab daily
- start: protonix 40 mg twice a day
- start: ondansteron 4 mg every 8 hours as needed for nausea
- start: tylenol 650 mg every 6 hours as needed for pain
- start: oxycodone 5 mg every 6 hours as needed for pain
The rest of your medications have not changed. Please continue
to take them as originally prescribed
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name3 (LF) **]
Location: [**Location **] CENTER
Address: [**Last Name (un) 6949**], [**Location (un) **],[**Numeric Identifier 25248**]
Phone: [**Telephone/Fax (1) 79351**]
Appointment: [**2170-5-31**] 10:15am
This is a follow up appointment to your hospitalization. You
will be reconnected with your primary care physician after this
visit.
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2170-6-8**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2170-6-13**] at 1:30 PM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: RHEUMATOLOGY
When: WEDNESDAY [**2170-7-11**] at 12:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Unit Name **] [**Location (un) 861**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
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"710.0",
"535.51",
"311",
"599.70",
"285.1",
"729.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
10286, 10292
|
6106, 8590
|
283, 319
|
10407, 10407
|
4742, 4742
|
11985, 13361
|
3620, 3737
|
8953, 10263
|
10313, 10313
|
8616, 8930
|
10558, 11962
|
5265, 6083
|
3752, 4723
|
232, 245
|
347, 2518
|
10380, 10386
|
4759, 5248
|
10332, 10359
|
10422, 10534
|
2540, 3447
|
3463, 3604
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,867
| 139,049
|
7643
|
Discharge summary
|
report
|
Admission Date: [**2149-1-1**] Discharge Date: [**2149-1-7**]
Date of Birth: [**2108-5-27**] Sex: F
Service: MEDICINE
Allergies:
Hydroxychloroquine Sulfate / Oxaprozin
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
gi bleed
Major Surgical or Invasive Procedure:
EGD with argon laser therapy
History of Present Illness:
40 yo F with scleroderma complicated by gastric antral vascular
ectasia (GAVE) and recurrent GI bleeding admitted with [**Last Name (un) **],
likely from GAVE, hemodynamically stable for argon-photo
coagulation today.
Past Medical History:
# Scleroderma: The patient presented for the first time with
skin changes on [**7-/2148**] with sclerodactyly and Raynaud's
phenomenon. The patient initiated treatment with methotrexate
on
[**2148-7-8**]. However, her skin disease has progressed rapidly.
The patient is under evaluation in the [**Hospital6 **] to
be included in a therapeutic protocol. Methotrexate has been
discontinued for the patient to have a wash out before
initiating
immunosuppressive treatment.
# Gastric vascular ectasia (GAVE) s/p multiple rounds of argon
plasma coagulator
#Chronic anemia secondary to gastric vascular ectasia
#Arthritis: Presenting in [**3-/2148**] with polyarticular and
symmetric joint pain and swelling involving PIP joints.
Serology
is positive for [**Doctor First Name **] 1:160 with a speckled pattern, but all other
antibodies were negative. The patient was treated briefly with
Plaquenil, which was discontinued due to the discoloration of
lips
Social History:
Denies EtOH, tobacco or drugs. Originally from [**Country 3396**] (in US
for 16 years). Lives with husband. [**Name (NI) **] one daughter.
Family History:
Mother with hypertension. Father without medical problems.
Physical Exam:
98.7, 94/58, 91, 22, 100%/RA
GEN: pleasant, comfortable, NAD
HEENT: pale conjunctiva, 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, warm, good pulses
SKIN: thickening of skin on arms and legs from scleroderma
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
RECTAL: Guaiac positive stools
Pertinent Results:
Admit labs:
[**2149-1-1**] 07:45PM BLOOD WBC-9.5 RBC-2.63* Hgb-7.0* Hct-23.6*
MCV-90 MCH-26.5* MCHC-29.5* RDW-17.7* Plt Ct-590*
[**2149-1-1**] 07:45PM BLOOD Glucose-95 UreaN-10 Creat-0.4 Na-135
K-6.3* Cl-101 HCO3-26 AnGap-14
[**2149-1-1**] 07:45PM BLOOD Calcium-9.0 Phos-4.5 Mg-2.3
====================================================
Discharge labs:
[**2149-1-7**] 06:12AM BLOOD WBC-11.1* RBC-3.31* Hgb-9.1* Hct-29.6*
MCV-90 MCH-27.5 MCHC-30.7* RDW-15.9* Plt Ct-335
[**2149-1-7**] 06:12AM BLOOD Plt Ct-335
[**2149-1-6**] 04:05AM BLOOD Glucose-98 UreaN-5* Creat-0.2* Na-140
K-3.5 Cl-108 HCO3-25 AnGap-11
=================================
CT CHEST W/O CONTRAST [**2149-1-4**] 1:48 PM
CT CHEST W/O CONTRAST
Reason: SCLERODERMA, INTERSTITIAL LUNG DISEASE
[**Hospital 93**] MEDICAL CONDITION:
40 year old woman with scleroderma (here with GI bleeding
secondary to GAVE), persistent tachycardia
REASON FOR THIS EXAMINATION:
?pulm hypertension, interstitial lung disease--HIGH
RESOLUTION--please page if ?
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 40-year-old female with scleroderma presenting with
gastrointestinal bleeding, persistent tachycardia, to rule out
interstitial lung disease.
TECHNIQUE: CT of the chest was performed without intravenous
contrast at end- inspiration and during dynamic expiration.
Prone HRCT images were also obtained.
COMPARISON: With CT chest of [**2148-9-13**].
FINDINGS:
CT CHEST WITHOUT INTRAVENOUS CONTRAST:
There is a right-sided central venous line with the tip in the
right atrium. There are multifocal scattered nodular opacities
with a tree-in-[**Male First Name (un) 239**] and peribronchovascular distribution
predominantly in the right lower lobe. Appearances are
suggestive of infectious or inflammatory etiology, most likely
related to aspiration. There is a 4-mm subpleural ground-glass
opacity in the left lower lobe, again likely infectious or
inflammatory.
There are several scattered mediastinal lymph nodes with the
largest measuring 10 x 8 mm in a pretracheal location. There is
no pericardial or pleural effusion. The esophagus is slightly
dilated in-keeping with the known diagnosis of scleroderma.
The unenhanced upper abdominal viscera appear unremarkable.
MUSCULOSKELETAL: There are no worrisome bone lesions.
CONCLUSION:
1. Multifocal ground-glass opacities predominantly in the right
lower lobe in a tree-in-[**Male First Name (un) 239**] pattern of distribution are
suggestive of infectious or inflammatory etiology related to
aspiration.
2. There is no definite evidence of interstitial lung disease.
Brief Hospital Course:
40 yo F with scleroderma complicated by gastric antral vascular
ectasia (GAVE) and recurrent GI bleeding admitted with [**Last Name (un) **],
likely from GAVE, hemodynamically stable for argon-photo
coagulation today.
.
# GIB: from GAVE (h/o recurrent bleed s/p argon-photo
coagulation, last on [**2148-12-12**])
- Transfused 2 units
- Argon laser therapy and crit followed after, stable.
.
# Tachycardia: from GIB + Dehydration; resolved after IV
Hydration and transfusion. Patient states baseline in 90s.
.
# Scleroderma: Followed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] from rheum as
outpt. Currently off of all immunosupressives. CT chest obtained
at their request. Will follow up as outpatient.
.
# Left Knee Pain: chronic [**7-14**] pain in left knee from joint
effusion [**3-8**] scleroderma
- continued ultram, tylenol prn pain
.
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Scleroderma
2. Gastric antral vascular ectasia (GAVE)
3. Iron deficiency anemia
4. Acute blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Please contact your primary care physician if you develop
lightheadedness, vomit blood, have bloody diarrhea, or develop
chest pain.
Stop taking ferrous sulfate and start taking Niferex (iron
polysaccharide complex) twice a day instead for your iron
supplement.
Also, take carafate for the next 7 days--this is to help with
the bleeding.
Follow up as below. Make sure you have your blood count checked
(CBC) when you see the doctors next week. I have given you a
prescription for this.
Followup Instructions:
You have the following appointments:
1.With the scleroderma clinic at [**Hospital6 **] on
[**2149-1-13**]
2.Gastroenteroogy:Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2149-1-14**] 9:00
3.Provider: [**Name (NI) 1039**] HARRIER, PT Date/Time:[**2149-1-17**] 1:10
4.Rheumatology Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2149-1-22**] 1:00
Also be sure to follow up with your primary care doctor. Her
number is [**Telephone/Fax (1) 26145**].
|
[
"710.1",
"537.83",
"285.1",
"276.51",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
6960, 6966
|
5052, 5921
|
306, 336
|
7119, 7127
|
2445, 2781
|
7665, 8283
|
1735, 1795
|
5944, 6937
|
3239, 3340
|
6987, 7098
|
7151, 7642
|
2797, 3202
|
1810, 2426
|
258, 268
|
3369, 5029
|
364, 583
|
605, 1562
|
1578, 1719
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,631
| 136,715
|
45021
|
Discharge summary
|
report
|
Admission Date: [**2199-1-3**] Discharge Date: [**2199-1-9**]
Date of Birth: [**2126-7-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Elavil
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
complete heart block
Major Surgical or Invasive Procedure:
temporary pacer
intubation
History of Present Illness:
Pt is a 72 yo woman with a history of CAD (s/p PCI [**2198-12-6**]),
diastolic dysfunction, ESRD on HD, DM and a pancreatic mass who
originally presented to [**Hospital3 3583**] ([**2199-1-2**]) s/p a fall
c/o lightheadedness of several days duration. On the day of
admission, Pt describes feeling dizzy and then falling to the
ground without LOC or head trauma but with a right humeral head
fracture. At [**Hospital3 **], ROS was negative for CP/SOB,
F/C/S, dysarthria/visual changes, N/V/D. Pt reports no recent
medication changes and has taken all as prescribed. Upon
arrival to [**Hospital3 3583**], ECG was significant for a reported
2' AV block-Mobitz II, however; most likely was actually a 2' AV
block-Mobitz I (Wenckebach). Subsequently external pcaer pads
placed and nodal agents held. Pt hemodynamically stable. Exact
course unclear, but a temporary pacer wire was placed last
evening. This AM, Pt reportedly found to be in CHB with pacer
not capturing. SBP subsequently decreased to 80's with
bradycardia to the 20's. Atropine given and external pacers
replaced. For airway protection, Pt was electively intubated.
Lastly pacer wire was repositioned until it was sucessful in
capturing. Pt transfered to [**Hospital1 18**] for further management and
evaluation for permanent pacemaker.
Of note, CXR at OSH was significant for LLL PNA along with left
shirft leukocystosis for which Pt receieved one dose of Zosyn.
Past Medical History:
chronic renal failure - has HD every Mon/Wed/Friday
CHF
CAD, s/p PCI to LAD/RCA ([**2198-12-5**])
DM2
hypothyroidism s/p thyroidectomy
neuropathy
pancreatic lesion with planned distal pancreatectomy in [**Month (only) **].
cholecystectomy
legally blind
Social History:
Lives w/ Husband and has 10 children. No tobacco, EtOH, drug
abuse.
Family History:
Sister with CAD. Father deceased [**3-12**] MI. Extensive DM FHx.
Physical Exam:
VS: 99.0, 133/46, 80 V-paced
Vent: PSV 15/5, 0.50, rr 14, VT 320, 99%
PE: Minimally sedated but respnsive, intubated
NC/AT, anicteric, conjuctiva wnl, WTT
neck suple, RIJ, JVP not appreciated
course BS through out with rales at left base
RRR, nl S1/S2, [**4-14**] SM RUSB
Abd soft, NT, ND, NABS
1+ LLE edema, right arm immobilized without deformity
A&O
Pertinent Results:
[**2199-1-3**] 07:10PM BLOOD WBC-11.9* RBC-3.33* Hgb-10.6* Hct-32.2*
MCV-97 MCH-31.9 MCHC-33.0 RDW-16.6* Plt Ct-297
[**2199-1-4**] 03:52AM BLOOD WBC-12.1* RBC-3.12* Hgb-9.8* Hct-30.9*
MCV-99* MCH-31.6 MCHC-31.8 RDW-17.1* Plt Ct-274
[**2199-1-5**] 07:20AM BLOOD WBC-12.4* RBC-3.34* Hgb-11.0* Hct-33.7*
MCV-101* MCH-32.9* MCHC-32.7 RDW-17.0* Plt Ct-272
[**2199-1-6**] 06:30AM BLOOD WBC-9.1 RBC-3.07* Hgb-9.9* Hct-30.6*
MCV-100* MCH-32.1* MCHC-32.2 RDW-17.0* Plt Ct-256
[**2199-1-3**] 07:10PM BLOOD Neuts-86.4* Bands-0 Lymphs-8.1* Monos-4.9
Eos-0.3 Baso-0.2
[**2199-1-3**] 07:10PM BLOOD PT-14.2* PTT-29.9 INR(PT)-1.3
[**2199-1-3**] 07:10PM BLOOD Plt Ct-297
[**2199-1-4**] 03:52AM BLOOD Plt Ct-274
[**2199-1-5**] 07:20AM BLOOD Plt Ct-272
[**2199-1-6**] 06:30AM BLOOD Plt Ct-256
[**2199-1-3**] 07:10PM BLOOD Glucose-119* UreaN-31* Creat-5.1* Na-139
K-5.2* Cl-98 HCO3-29 AnGap-17
[**2199-1-4**] 03:52AM BLOOD Glucose-108* UreaN-34* Creat-5.4* Na-135
K-5.0 Cl-97 HCO3-28 AnGap-15
[**2199-1-5**] 07:20AM BLOOD Glucose-122* UreaN-20 Creat-3.8*# Na-136
K-4.4 Cl-94* HCO3-30* AnGap-16
[**2199-1-6**] 06:30AM BLOOD Glucose-94 UreaN-31* Creat-4.5* Na-133
K-4.5 Cl-94* HCO3-29 AnGap-15
[**2199-1-3**] 07:10PM BLOOD CK(CPK)-43
[**2199-1-3**] 07:10PM BLOOD CK-MB-NotDone cTropnT-0.19*
[**2199-1-4**] 03:52AM BLOOD CK(CPK)-66
[**2199-1-4**] 03:52AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2199-1-3**] 07:10PM BLOOD Calcium-8.5 Phos-6.0*# Mg-1.9
[**2199-1-4**] 03:52AM BLOOD Calcium-8.4 Phos-6.6* Mg-1.9 Cholest-168
[**2199-1-5**] 07:20AM BLOOD Calcium-9.0 Phos-4.4# Mg-1.8
[**2199-1-6**] 06:30AM BLOOD Calcium-8.6 Phos-5.5* Mg-1.9
[**2199-1-4**] 03:52AM BLOOD Triglyc-126 HDL-52 CHOL/HD-3.2 LDLcalc-91
[**2199-1-4**] 03:52AM BLOOD TSH-9.8*
[**2199-1-4**] 03:42AM BLOOD Lactate-1.4
[**2199-1-3**] 10:02PM BLOOD Type-ART PEEP-5 pO2-134* pCO2-47* pH-7.40
calHCO3-30 Base XS-3 -ASSIST/CON Intubat-INTUBATED
[**2199-1-4**] 03:42AM BLOOD Type-ART pO2-47* pCO2-55* pH-7.38
calHCO3-34* Base XS-5
CXR:
IMPRESSION: CHF with possible pneumonia involving the left lower
lobe. Superimposed pneumonia in the left lower lobe.
XR:
IMPRESSION:
1. Anterior dislocation of the humerus.
2. Humeral head and neck fracture.
3-View
IMPRESSION:
Comminuted subcapital fracture of the right humerus.
ECHO:
The left atrium is moderately dilated. The right atrium is
markedly dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF 60-70%). No masses or thrombi are seen in the left
ventricle. There is
no ventricular septal defect. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated. Right
ventricular
systolic function appears depressed. There is abnormal septal
motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
There is no mitral valve prolapse. Moderate (2+) mitral
regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+]
tricuspid regurgitation is seen. There is at least moderate
pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Brief Hospital Course:
72 yo female with history CAD s/p PCI, CHF, DM, ESRD on HD who
presents to [**Hospital1 18**] from OSH with CHB requiring pacing.
1) Rhythm: Pt with an initial 2'- AV block (most likely Mobitz
I) on ECG followed by reported CHB. The OSH hospital reported
Mobitz II however at [**Hospital1 18**] patient was persistently in Mobitz I
and conversion from Mobitz II to Mobitz I not common because
area of conduction block are two totally different locations.
Pt stable upon transfer with temporary pacer placed. Pt
ventricular paced at 80; HD stable. Upon close evaluation of
ECG it appears as though block as at the AV node most likely
secondary to medications. By the AM, pacer was turned down and
her native rhythm became obvious; with a HR 70-80's with a
prolonged PR and occasional Wenckebach. During stay, BB were
held. Given pt's lack of symptoms and current infection and
humerus fracture, felt it was best to delay a formal EPS until
stable. The patient continued to have Wenckebach rhythm with
occasional pauses however these were totally asymptomatic. EP
consulted and felt that pt did not warrant immediate pacemaker
placement. Pt would require right sided pacemaker placement in
light of AV fistula in left arm. Since she has right shoulder
fracture, right subclavian line in place, and is being treated
for a pneumonia it was deemed that these issues should be
settled and she would then be evaluated as an outpatient. She
was discharged to rehab with [**Doctor Last Name **] of hearts monitor for ant
continued symptoms she experienced post hospitalization. Pt is
to follow up with Dr [**Last Name (STitle) 96254**] in clinic in the next month at
[**Telephone/Fax (1) 5518**]; to discus the possibility of a permanent
pacemaker.
2) CAD: Pt with known 2VD s/p recent PCI. Pt without obvious
cardiac complaint. ECG at OSH without acute ischemic changes
and initial cardiac enzymes negative. Pt continued on ACEi,
ASA, Plavix, [**Last Name (un) **]. Pt with history of CAD by diagnostic cath but
without a MI, so BB not essential in her medical treatment.
Therefore, on discharge Pt to resume her ACEi, [**Last Name (un) **], ASA and
Plavix while stopping her BB.
3) Pump: Echo in [**2196**] with EF 50% and global hypokinesis. Pt
in mild CHF on presentation, but saturating well post
extubation. Pt was maintained on her ACEi, [**Last Name (un) **] and clonidine;
with BB held as per above. Pt remained normotensive during stay
and will be discharged home on her usual dosing of ACEi, [**Last Name (un) **] and
clonidine.
4) Renal: Pt with ESRD who gets HD three times a week. Pt seem
by the renal service and underwent hemodialysis as per her
outpatient regimen of q Mon/Wed/[**Doctor First Name **].
5) ID: Pt with LLL consolidate on CXR. Started on Ceftriaxone
and Azithromycin for presumed community acquired PNA. Sputum
gram stain with gram + cocci and gram - rods without and growth
by culture. Blood cultures remained without growth. Pt to be
discharged home to complete a total 10 day course of
antibiotics.
6) Resp: Pt electively intubated at OSH for airway protection.
Upon arrival to [**Hospital1 18**], Pt stable on SIMV. Pt quickly weaned to
PSV which she tolerated well. Pt extubated that evening without
difficulty and for the remaining hospitalization was stable.
7) Ortho: Pt with right humeral head fracture without
dislocation by CT. Ortho consulted who recommended sling for
immobilization and follow-up in two weeks as out-patient with Dr
[**First Name (STitle) 4223**] [**Telephone/Fax (1) 96255**]).
Medications on Admission:
ASA 325
Plavix 75
renagel 1600 TID
Clonidine 0.1 qAM
Accupril 40 qAM
Diovan 160 qAM
Synthroid 150 mcg
Phos-lo 667 [**Hospital1 **]
Ativan 0.5 TID
Zoloft 50
NPH 10 qAM, 5 qHS
Discharge Medications:
1. medication
Regular Insulin Sliding Scale
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
5. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Valsartan 160 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
11. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 5 days: last dose 12/3.
15. Psyllium 58.6 % Packet Sig: One (1) Packet PO TID (3 times a
day) as needed.
16. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
17. Quinapril HCl 40 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
18. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
19. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
QHD (each hemodialysis) for 10 days: Please give last dose on
[**1-13**] and then stop.
Discharge Disposition:
Extended Care
Facility:
Life Care Center - [**Location (un) 3320**]
Discharge Diagnosis:
secondary heart block
right humerus fracture
CAD
community acquired pnuemonia
HTN
Discharge Condition:
good
Discharge Instructions:
Please call your physician if you experience chest pain,
tingling in arms or jaw, heart palpiations, shortness of breath,
fever, shaking chills, confusion.
Followup Instructions:
please follow up with cardiologist Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5518**])
in two to four weeks in regards to possible pacemaker.
please follow up with orthopaedic surgeon Dr [**First Name (STitle) 4223**]
([**Telephone/Fax (1) 1228**]) in two weeks in regards to your right humerus
fracture.
please follow up with your PCP Dr [**Last Name (STitle) 18998**] ([**Telephone/Fax (1) 20264**]) in the
next month.
|
[
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
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icd9pcs
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[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,327
| 124,017
|
53754
|
Discharge summary
|
report
|
Admission Date: [**2126-1-16**] Discharge Date: [**2126-1-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
fever, hypotension.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo male with a h/o colon cancer s/p colectomy [**2115**], melanoma
s/p excision [**2117**], CAD s/p MI w/PCI to LAD [**2114**], HTN presented
to the ED following syncopal episode. The patient remembers
"falling" but says it happened so fast that he is not sure what
happened. Per his son over the last three days he has become
progressively more weak and last night was unable to dress
himself or walk. Per the patient and his son he has had no
fever, cough, nausea, vomiting, diarrhea, dysuria, rash,
headache, chest pain or palpitations. Also deny recent weight
loss, constipation, blood in stool or melena. Son said he had
some 'sneezing' 3 days ago. He last took his BP med (ACE)
yesterday morning. No sick contacts.
.
In the ED, initial VS were: 97 84 142/96 14 99 on RA. The
patients labs were remarkable for leukocytosis, negative cardiac
enzymes. UA was negative for infection. CXR was unremarkable.
EKG showed NSR with [**Last Name (un) **] ST depressions in II, v6, ?v4,v5. He
received a 1L of NS and was awaiting a bed on the regular
medicine floor, however prior to transfer to the floor, the
patient sustained a fall from bed. Did not lose consciousness.
Head and C spine CT showed no acute process. He then spiked a
temp to 103. Blood cultures were sent and the patient was given
tylenol, Vanco, oseltamivir, ceftriaxone, levofloxacin. Repeat
WBC was down from 13 to 12 but had a new bandemia, creatinine
was stable at 1.3, lactate was 3.2 and second set of cardiac
enzymes was negative. DFA for flu were sent-flu negative, blood
cultures pending. Repeat CXR showed no change. His SBP dropped
to the 90s and he received 2L fluid. According to ED records his
BP ranged 90/55 to 105/57 (on transfer to the floor), HR though
per verbal report he did have one [**Location (un) 1131**] of systolic in the
80s. Has 2 peripheral IVs. Coming to ICU for ?hypotension.
.
On the floor, the patient reports feeling well, continues to
deny any symptoms.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Hypertension.
- Coronary artery disease with MI on [**2115-10-5**], s/p
stent to distal LAD
- Colon cancer s/p right colectomy [**11/2115**]
- Melanoma on bac s/p wide excision [**3-/2118**]
Social History:
The patient was born in [**Country **], then moved to [**Country 12930**] and came to
the US in the 50s. He [**Last Name (un) **] retired engineer. He lives with his
son and reports being independent in ADLs but having memory
problems. Denies ever tobacco, ETOH, drug use.
.
Family History:
non-contributory
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS ON ADMISSION:
[**2126-1-16**] 06:45PM BLOOD WBC-13.9*# RBC-4.49* Hgb-13.9*# Hct-41.2#
MCV-92 MCH-31.0 MCHC-33.8 RDW-14.1 Plt Ct-221#
[**2126-1-16**] 06:45PM BLOOD Neuts-88.1* Lymphs-6.9* Monos-4.7 Eos-0.1
Baso-0.2
[**2126-1-16**] 06:45PM BLOOD PT-12.1 PTT-23.2 INR(PT)-1.0
[**2126-1-16**] 06:45PM BLOOD Glucose-145* UreaN-21* Creat-1.3* Na-139
K-4.1 Cl-104 HCO3-23 AnGap-16
[**2126-1-16**] 06:45PM BLOOD ALT-14 AST-20 CK(CPK)-56 TotBili-0.7
[**2126-1-16**] 06:45PM BLOOD cTropnT-<0.01
[**2126-1-16**] 06:45PM BLOOD Albumin-3.8 Calcium-9.1
[**2126-1-17**] 02:20PM BLOOD Albumin-3.2* Calcium-7.8* Phos-2.5*
Mg-1.8
[**2126-1-17**] 04:58PM BLOOD Type-ART pO2-39* pCO2-62* pH-7.15*
calTCO2-23 Base XS--9 Comment-GREEN TOP
[**2126-1-17**] 06:35AM BLOOD Lactate-3.2*
LABS ON TRANSFER FROM THE ICU:
[**2126-1-18**] 04:47AM BLOOD WBC-22.6* RBC-3.71* Hgb-11.9* Hct-35.1*
MCV-95 MCH-32.2* MCHC-34.1 RDW-14.5 Plt Ct-151
[**2126-1-17**] 02:20PM BLOOD Neuts-90.3* Lymphs-6.7* Monos-2.6 Eos-0.2
Baso-0.2
[**2126-1-17**] 06:30AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2126-1-18**] 04:47AM BLOOD Plt Ct-151
[**2126-1-18**] 04:47AM BLOOD Glucose-104* UreaN-23* Creat-1.4* Na-135
K-4.5 Cl-105 HCO3-22 AnGap-13
[**2126-1-18**] 04:47AM BLOOD ALT-PND AST-PND LD(LDH)-PND CK(CPK)-207
AlkPhos-PND TotBili-PND
[**2126-1-17**] 11:26PM BLOOD CK(CPK)-239
[**2126-1-18**] 04:47AM BLOOD CK-MB-6 cTropnT-0.07*
[**2126-1-18**] 04:47AM BLOOD Albumin-PND Calcium-7.7* Phos-3.0 Mg-1.7
[**2126-1-17**] 08:59PM BLOOD Type-ART pO2-75* pCO2-38 pH-7.39
calTCO2-24 Base XS--1
[**2126-1-17**] 08:59PM BLOOD Lactate-2.2*
[**2126-1-17**] 5:00 am BLOOD CULTURE VENIPUNCTURE #2.
**FINAL REPORT [**2126-1-23**]**
Blood Culture, Routine (Final [**2126-1-23**]):
FUSOBACTERIUM NUCLEATUM.
Anaerobic Bottle Gram Stain (Final [**2126-1-20**]):
GRAM NEGATIVE ROD(S).
IMAGING:
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2126-1-17**] 5:56 PM
Final Report
INDICATION: [**Age over 90 **]-year-old man with fever and hypotension. History
of colon
cancer. COMPARISON: [**2115-12-12**].
TECHNIQUE: Pre- and post-contrast axial images were obtained
through the
chest. Post-contrast images were obtained through the abdomen
and pelvis.
Multiplanar reformatted images were generated.
CT CHEST WITHOUT AND WITH IV CONTRAST: The pulmonary arterial
tree is well
opacified, and there is no pulmonary embolus. The thoracic aorta
is normal in caliber without dissection, pseudoaneurysm, or
acute abnormality. Mild
atherosclerotic calcifications are noted at the aortic arch and
coronary
vessels. The left common carotid artery and the right
brachiocephalic artery arise from a common trunk off the aortic
arch. Small lymph nodes in the mediastinum and hila do not meet
size criteria for pathologic enlargement. A precarinal node
measures 9 mm in short axis. A right hilar lymph node measures 8
mm in short axis. The heart size is normal without pericardial
effusion. There are calcified right hilar and sub-carinal nodes
consistent with granulomatous disease. The coronary arteries are
heavily calcified.
In the lungs, mild dependent atelectasis is noted bilaterally,
without
consolidation or pleural effusion. The tracheobronchial tree is
patent to
subsegmental levels There is posterior indentation of the
proximal trachea, suggestive of teacheal-malacia..
CT ABDOMEN WITH IV CONTRAST: In the caudate lobe of the liver, a
3.5 x 2.5 cm hypodense lesion abuts the IVC, and there is loss
of the fat plane between the liver and IVC, concerning for
vascular invasion. The lesion is predominantly hypodense, with
no peripheral enhancement, demonstrating somewhat irregular
margins. Additionally, there are tiny hypodense lesions in the
upper left lobe and anterior right lobe, too small to
characterize. No other liver lesions are identified. There is no
intra- or extra-hepatic biliary ductal dilatation. The
gallbladder is unremarkable. The pancreas demonstrates fatty
replacement. The spleen, adrenal glands, stomach, and duodenum
are unremarkable. The kidneys enhance and excrete contrast
symmetrically without hydronephrosis, stones or worrisome renal
masses. The infrarenal abdominal aorta demonstrates a 3.0 x 3.2
cm fusiform dilatation. There is mild atherosclerotic
calcification. Major branches are patent. There is no free air
or free fluid in the abdomen. There is no retroperitoneal or
mesenteric lymphadenopathy by size criteria.
CT PELVIS WITH IV CONTRAST: The patient has undergone prior
right colectomy. There is moderate diverticulosis involving the
descending and sigmoid colon, without diverticulitis. The
remaining loops of small and large bowel are unremarkable. The
urinary bladder contains a Foley catheter and a small amount of
air consistent with instrumentation. There is no free fluid in
the pelvis. The prostate gland is unremarkable. There is no
pelvic or inguinal lymphadenopathy by size criteria.
OSSEOUS STRUCTURES: There is no fracture or worrisome bony
lesion.
Degenerative changes are present in the spine.
IMPRESSION:
1. No pulmonary embolus or acute aortic abnormality. Clear lungs
aside from mild atelectasis.
2. 3.5 cm irregular, hypodense lesion in the caudate lobe of the
liver,
concerning for metastasis. This closely abuts and may invade the
adjacent
IVC. Abscess is considered less likely, given the absence of gas
within the lesion and the absence of peripheral enhancement.
3. No acute bowel abnormality, or intraperitoneal collection to
suggest other source of infection.
4. Diverticulosis without diverticulitis.
5. case was enetered into critical results reporting.
CT C-SPINE W/O CONTRAST Study Date of [**2126-1-17**] 12:06 AM
Final Report
INDICATION: [**Age over 90 **]-year-old male status post fall.
COMPARISON: No prior study available for comparison.
TECHNIQUE: Contiguous axial images were obtained through the
cervical spine. No contrast was administered. Coronal and
sagittal reformats were displayed.
FINDINGS: C1 through C7 are visualized. There is no acute
fracture. There
is no prevertebral soft tissue swelling. There is grade 1
anterolisthesis of C5 on C6, age indeterminate without prior
study available for comparison.
CT is not able to provide intrathecal detail comparable to MRI.
There is
extensive multilevel degenerative change with an endplate
osteophyte formation and facet arthropathy.
At C2-C3, there is small disc-osteophyte complex without canal
narrowing or deformity of the thecal sac.
At C4, there is heterotopic bone along the inner surface of the
right lamina, which abuts the cord. At C4-C5, there is mild
central disc bulge without narrowing of the canal. At C5, there
is heterotopic bone along the right lamina, which narrows the
canal but does not abut the cord.
At C6-C7, there is disc-osteophyte complex with mild narrowing
of the canal but no compression of the thecal sac.
IMPRESSION:
1. No acute fracture.
2. Grade 1 anterolisthesis of C5 on C6, age indeterminate
without prior study available for comparison.
3. Multilevel degenerative change as above may predispose the
patient to cord injury in the setting of trauma. If there is
clinical concern and no
contraindication, MRI may be obtained for further evaluation.
ECHOCARDIOGRAM:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with inferior and
infero-lateral hypokinesis. 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 root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened. 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 [**2115-10-7**], no definite change.
MRI abdomen:
FINDINGS: There is a 4.9 x 3.2 cm mass within the caudate lobe
which is
hypointense on T1-weighted images and slightly hyperintense on
T2-weighted
images. This lesion demonstrates heterogeneous enhancement on
post-contrast
images, with central nonenhancing regions, likely representing
necrosis. There appears to be a small vessel running through
this lesion (image 22 of series 8). There are no other focal
liver lesions, and there is no intra- or extra-hepatic biliary
dilatation. The portal veins and hepatic veins are patent.
There are no pathologically enlarged lymph nodes by size
criteria. The gallbladder is decompressed and contains a stone.
The adrenal glands, spleen, and pancreas are normal. There are
bilateral renal parapelvic cysts. The visualized portions of the
gastrointestinal tract are unremarkable, and there is no
concerning bone marrow abnormality.
Multiplanar 2D and 3D reformations and subtraction images
provided multiple
perspectives for the dynamic series.
IMPRESSION:
1. Enhancing mass within the caudate lobe, highly suspicious for
malignancy. Imaging features do not suggest abscess.
2. Cholelithiasis.
Brief Hospital Course:
[**Age over 90 **] year old man with history of CAD, colectomy for colon CA in
[**2115**], melanoma, HTN who presents with fever and relative
hypotension.
# Sepsis: Patient admitted initially to MICU with fever and
relative hypotension. Regarding infectious workup: CXRx2 no
evidence of PNA, DFA for flu was negative, U/A negative.
Cardiac etiology of hypotension less likely as patient ruled out
for MI, and no signs of CHF, however at age [**Age over 90 **] could have AS and
vasodilation in the setting of fever/pain could cause
hypotension so echocardiogram was done (no AS, see above).
Initially, patient was treated with broad spectrum antibiotics-
flagyl/cefepime/vancomycin. He remained afebrile with resolving
leukocytosis on this regimen. His blood cultures eventually
revealed fusobacterium, and suspected source was necrosis within
liver mass. ID team was consulted and followed throughout his
hospital course. Transplant surgery (Dr. [**Last Name (STitle) **] followed the
patient as well, and discussed surgical options with the patient
and his family. It was their wish to decline surgery at this
time given the patient's age, comorbidities, and multiple risks
of the surgery. He will complete a 14 day course of antibiotics
(received IV flagyl/cefepime inhouse, to receive PO augmentin to
complete course).
# Syncope: By history appears to have been vasovagal or
micturition syncope, but more likely poor cerebral perfusion due
to hypotension as it occurred after taking his BP meds in the
setting of likely sepsis. No acute intracranial process. No
acute fracture on spine. Infectious workup was completed as
above. The patient was orthostatic intermittently throughout
hospital course, but this was responsive to fluids. He was seen
by physical therapy.
# Liver Lesions: Identified on CT scan and confirmed on MRI,
concerning for metestatic disease. Tumor markers revealed normal
AFP and CEA. No biopsy or surgical intervention was performed
given treatment goals of patient.
# AVNRT: During his stay in the MICU, the patient had new AVNRT.
He was started on diltiazem with good effect and no further
episodes of AVNRT on the general medical floor over the course
of a week.
# Acute on chronic Renal Failure: Cr elevated to 1.3 on
admission, and trended down to 0.9 with IVF hydration. Likely
prerenal in the setting of poor PO intake/dehydration prior to
hospitalization.
# CAD: Continued aspirin. Lipid panel was drawn and LDL was at
goal so statin not started.
# Hypertension: Lisinopril uptitrated from 10mg to 20mg in the
setting of persistent BP's of 150's-160's systolic and 100's
diastolic. This should be further titrated as an outpatient.
Medications on Admission:
1. Zestril 10mg PO daily
2. ASA 81mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Diltiazem HCl 90 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO once a day.
3. Zestril 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days: take through [**2126-2-2**].
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Bacteremia, Sepsis
2. Liver mass
3. AVNRT
4. Syncope
SECONDARY DIAGNOSIS:
1. Hypertension
2. Coronary artery disease
3. s/p Colon cancer
4. s/p Melanoma
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2126-1-16**] with low blood pressures and fevers. We did blood
cultures, which showed a bloodstream infection. You will need to
take antibiotics when you leave the hospital for this infection,
until [**2126-1-30**].
We also did imaging and found a mass in your liver. We strongly
suspect that this is a malignant tumor, as we discussed with you
and your family. Per your wishes, we did not pursue any surgical
options. Dr. [**Last Name (STitle) **] discussed this with you and your family.
The following changes have been made to your medications:
1. Start taking augmentin through [**2126-2-2**] (this is an
antibiotic)
2. Start taking diltiazem (for your fast heart rate)
3. Increase lisinopril to 20mg (for your blood pressure)
Followup Instructions:
When: Monday, [**2-4**], 1:30
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
|
[
"V10.05",
"562.10",
"584.9",
"E942.4",
"199.1",
"V45.89",
"197.7",
"V10.82",
"276.51",
"414.01",
"V45.82",
"403.90",
"E942.6",
"041.84",
"412",
"427.89",
"790.7",
"276.2",
"780.2",
"574.20",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16470, 16555
|
13281, 15958
|
282, 288
|
16775, 16775
|
3832, 3837
|
17760, 18015
|
3285, 3303
|
16055, 16447
|
16576, 16576
|
15984, 16032
|
16957, 17737
|
3318, 3813
|
2311, 2759
|
223, 244
|
316, 2292
|
16673, 16754
|
16595, 16652
|
3851, 13258
|
16790, 16933
|
2781, 2976
|
2992, 3269
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,158
| 155,719
|
19290+57039
|
Discharge summary
|
report+addendum
|
Admission Date: [**2135-12-22**] Discharge Date: [**2135-12-28**]
Date of Birth: [**2058-9-21**] Sex: F
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: Patient is a 77-year-old female
who is complaining of back pain for several days and was
experiencing back pain radiating to the chest. At some point
the patient had a syncopal episode and fell onto her face.
The patient reports a positive loss of consciousness. The
patient was found down, bleeding significantly from her face
and was brought immediately to the Emergency Department for
further evaluation. Patient was normotensive in the 70s and
receiving intravenous fluids when she arrived at the
Emergency Department. She was intubated in the Emergency
Department using Vecuronium and succinylcholine and was then
evaluated using many radiographic modalities which showed
multiple facial fractures. The patient was then transferred
to the Trauma Surgical Intensive Care Unit for further
evaluation.
PAST MEDICAL HISTORY:
1. Osteoporosis.
2. Compression fractures.
PAST SURGICAL HISTORY: None.
MEDICATIONS:
1. Fosamax.
2. Aspirin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On arrival her temperature is 100.8,
pulse of 74, blood pressure 146/68, 14, 100%. The initial
settings for the respirator are IMV at a tidal volume 500,
rate of 14, FIO2 60%, and peak of 5. In general, intubated,
sedated, paralyzed. HEENT: Traumatic facial fractures with
skull depression. Bilateral tympanic membranes without
blood. Pupils pinpoint, sluggish to light. Neck: In collar
without LAD or jugular venous distention. Carotids 2+.
Rectal: Guaiac negative, decreased tone. Lungs: Clear to
auscultation bilaterally. Heart is regular rate and rhythm;
normal S1 and S2. Abdomen: Soft, nontender, nondistended;
no hepatosplenomegaly. Extremities: Upper extremity full
range of passive; left lower extremity full range of movement
in passive motion; 1+ pitting edema bilateral knees.
Vasculature: Right and left carotids, radial femorals, and
dorsalis pedis all 2+.
LABORATORY DATA: Initial lab results showed a white count of
15, hematocrit of 30, and platelet count of 206. CK was 119,
troponin was less than 0.01. Urinalysis was negative.
Urinary electrolytes were unremarkable.
SUMMARY OF HOSPITAL COURSE: The patient was transported to
the Trauma SICU, where she was evaluated by Ear, Nose, and
Throat as well as Plastics for the facial fractures and
epistaxis. The ENT service at this point used balloons to
tamponade the bleeding from the patient's nose. Multiple
adjustments were made during the Trauma SICU time in order to
control the bleeding. The initial evaluation by Plastic
Surgery was that the patient would require in-house surgical
repair of the multiple fractures.
After a short stay in the Trauma SICU the patient was then
evaluated by Cardiology, who determined that the patient
either had sick sinus syndrome or another intermittent
arteriovenous block or block below the AV node which
resulted in four- to five-second pauses on telemetry
monitoring. The Cardiology service felt the best course of
action was to place a pacemaker for the patient. This
procedure was done without complication. The patient was
extubated and after a short period of time was sent to the
Trauma Floor for further evaluation and possible surgical
repair of facial fractures.
After a short time on the floor patient was reevaluated by
the Plastic Surgery service, who felt that at this point her
facial fractures were non-operative. The ENT service also
felt that the epistaxis was under control and that no other
intervention was necessary. The patient was evaluated by
Speech and Swallow and Physical Therapy, and it was
determined that the patient would leave the hospital to go to
rehab prior to going home to ensure the patient's safety. At
time of discharge the patient had improving pain symptoms and
was improving overall clinically.
DISCHARGE CONDITION: Good.
DISPOSITION: To rehab.
DISCHARGE DIAGNOSES:
1. Syncope.
2. Pacemaker placement.
3. Multiple facial fractures.
4. Likely repaired intermittent arteriovenous block or block
below the arteriovenous node.
DISCHARGE MEDICATIONS:
1. Percocet 325.
2. Colace 100 b.i.d.
3. Erythromycin ointment, one to two drops ophthalmic q.i.d.
4. Famotidine q. 12 hours.
5. Bisacodyl 10 mg suppository q. h.s.
DISCHARGE INSTRUCTIONS:
1. Follow up with the Trauma Clinic in one to two weeks.
2. Follow up with the [**Hospital 3595**] Clinic in one to two weeks.
3. The patient may also follow up with her outpatient
plastic surgeon, Dr. [**First Name (STitle) **], for possible repair of the
fractures in the future.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. 2923
Dictated By:[**Last Name (NamePattern1) 7170**]
MEDQUIST36
D: [**2135-12-27**] 10:52
T: [**2135-12-27**] 12:59
JOB#: [**Job Number 52548**]
Name: [**Known lastname 9778**], [**Known firstname 194**] Unit No: [**Numeric Identifier 9779**]
Admission Date: [**2135-12-22**] Discharge Date: [**2108-2-20**]
Date of Birth: [**2058-9-21**] Sex: F
Service:
ADDENDUM: After reconsideration by the Plastic Surgery
Service, the patient was finally sent to the operating room
for repair of her facial fractures. The surgery was
uneventful (see the Operative Report), and the patient was
returned to the floor in good condition.
Over the next two days, the patient was evaluated by Physical
Therapy and Occupational Therapy. The patient's clinical
condition improved with a reduction in facial swelling each
day that she was on the floor.
DISCHARGE DISPOSITION: Ultimately, the patient was screened
by Physical Therapy and okayed for discharge to home with
home physical therapy and home cardiorespiratory nursing
evaluation.
CONDITION AT DISCHARGE: The patient was discharged in good
condition with her family to her house.
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern4) 3342**], M.D. [**MD Number(1) 3343**]
Dictated By:[**Last Name (NamePattern1) 2961**]
MEDQUIST36
D: [**2135-12-31**] 09:35
T: [**2135-12-31**] 09:36
JOB#: [**Job Number 9780**]
|
[
"733.13",
"E884.9",
"E849.0",
"428.31",
"427.31",
"427.81",
"802.4",
"428.0",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04",
"96.04",
"37.78",
"37.72",
"21.09",
"76.74",
"96.71",
"89.64",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
5680, 5855
|
3979, 4011
|
4032, 4194
|
4217, 4388
|
4412, 5656
|
1068, 1153
|
2313, 3957
|
1176, 2284
|
5870, 6229
|
166, 976
|
998, 1044
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
841
| 140,374
|
24485
|
Discharge summary
|
report
|
Admission Date: [**2153-12-2**] Discharge Date: [**2153-12-7**]
Date of Birth: [**2110-6-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
History of stroke
Major Surgical or Invasive Procedure:
[**2153-12-3**] Minimally Invasive PFO Closure
History of Present Illness:
Ms. [**Known lastname 61896**] is a 43 year old female who suffered a stroke in [**Month (only) 116**]
[**2152**]. Workup at that time revealed patent foramen ovale/atrial
septal defect. She was subsequently placed on Warfarin. A recent
echocardiogram from [**2153-8-11**] showed an atrial septal defect
with left to right flow. Her LVEF was estimated at 60%. She now
presents for surgical intervention. Of note, Warfarin was
discontinued five days prior to admission. In addition, she had
been on antibiotics for mildly productive cough.
Past Medical History:
Atrial Septal Defect/Patent Foramen Ovale, History of Stroke in
[**2152-6-11**], Ulcerative Colitis, Raynauds Disease, History of
Thrombophlebitis, s/p Ex-lap for Ovarian Torsion [**2151**]
Social History:
Denies tobacco. Admits to only rare ETOH. She works with
computers. She is married.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: BP 100/64, HR 72, RR 20, SAT 98% on room air
General: well developed, well appearing female in no acute
distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2153-12-2**] 04:59PM BLOOD WBC-7.3 RBC-3.86* Hgb-10.7* Hct-31.1*
MCV-81* MCH-27.6 MCHC-34.3 RDW-14.7 Plt Ct-234
[**2153-12-2**] 04:59PM BLOOD PT-13.0 PTT-26.4 INR(PT)-1.1
[**2153-12-2**] 04:59PM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-141
K-3.5 Cl-105 HCO3-28 AnGap-12
[**2153-12-7**] 05:50AM BLOOD WBC-4.0 RBC-2.84* Hgb-8.0* Hct-23.8*
MCV-84 MCH-28.3 MCHC-33.7 RDW-15.6* Plt Ct-148*
[**2153-12-7**] 05:50AM BLOOD Glucose-91 UreaN-13 Creat-0.6 Na-139
K-4.2 Cl-107 HCO3-26 AnGap-10
[**2153-12-6**] Discharge Chest x-ray: Stable bilateral small pleural
effusions, right greater than left.
Brief Hospital Course:
Ms. [**Known lastname 61896**] was admitted the day before surgery for routine
preoperative workup. Warfarin was discontinued five days prior
to admisstion. Preoperative evaluation was unremarkable and she
was cleared for surgery. On [**12-3**], Dr. [**Last Name (STitle) 1290**]
performed a minimally invasive PFO closure. For further surgical
details, please see seperate dictated operative note. Following
the operation, she was brought to the CSRU for invasive
monitoring. She initially experienced bradycardia and
temporarily required Neo and fluid boluses to maintain
hemodynamics. Within 24 hours, she awoke neurologically and was
extubated. Her hemodynamics and heart rate gradually improved,
and Neo was weaned without difficulty. Low dose beta blockade
was initiated and she transferred to the SDU on postoperative
day two. Her hematocrit ranged between 22-24%. She remained in a
normal sinus rhythm, heart rate ranging between 50-60 beats per
minute. Low dose beta blockade was not advanced due to
intermittent bradycardia and her systolic blood pressure
remained in the 80-100 mmHg range. Given that she remained
asymptomatic, no blood transfusions were given. The rest of her
postoperative course was unremarkable and she was discharged to
home on postoperative day four. She will no longer require
Warfarin anticoagulation.
Medications on Admission:
Warfarin - stopped [**11-27**]
Asacol
Canasa
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every [**7-19**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-17**]
hours as needed for pain.
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. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Patent Foramen Ovale - s/p surgical closure, Postoperative
Anemia, Bradycardia, History of Stroke in [**2152-6-11**], Ulcerative
Colitis, Raynauds Disease, History of Thrombophlebitis, s/p
Ex-lap for Ovarian Torsion
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. Monitor wounds for signs of infection. Please call
with any concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**5-16**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**3-16**] weeks - call for appt.
Local cardiologist, Dr. [**First Name (STitle) 1075**] in [**3-16**] weeks - call for appt.
Completed by:[**2153-12-10**]
|
[
"443.0",
"V12.59",
"556.9",
"745.5",
"427.89",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.71",
"88.72",
"99.04",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4754, 4816
|
2349, 3688
|
339, 388
|
5076, 5083
|
1735, 2326
|
5290, 5609
|
1286, 1329
|
3783, 4731
|
4837, 5055
|
3714, 3760
|
5107, 5267
|
1344, 1716
|
282, 301
|
416, 956
|
978, 1169
|
1185, 1270
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,960
| 127,247
|
24046
|
Discharge summary
|
report
|
Admission Date: [**2154-1-14**] Discharge Date: [**2154-1-20**]
Date of Birth: [**2097-6-25**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Levaquin / Dextromethorphan / Adhesive Tape /
Actigall / Zithromax
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
S/p gallstone pancreatitis, now resolved, presenting for
scheduled cholecystectomy.
Major Surgical or Invasive Procedure:
1. Open cholecystectomy with intraoperative cholangiogram.
2. Incisional hernia repair with implantation of prosthetic
mesh.
History of Present Illness:
The patient is a 56-year-old man who is status post open gastric
bypass surgery approximately 9 months previously. He lost
approximately 135 pounds before he
developed gallstone pancreatitis. The pancreatitis had resolved
and therefore cholecystectomy was indicated. He unfortunately
did have an enormous ventral incisional hernia which rendered
laparoscopic approach impractical. We
therefore elected for open repair with mesh.
Past Medical History:
Hypertension
Diabetes, type 2
Hyperlipidemia
Gastroesophageal reflux
Ostructive sleep apnea on CPAP
History of kidney stones
Osteoarthritis of the hips, knees and thumbs
Fatty liver
Colonic polyps (benign)
History of iron deficiency anemia
Social History:
Tobacco: none
ETOH: occasional wine
Married, lives with wife
Family History:
Non-contributory
Physical Exam:
Vital signs: T 97.4 HR 76 BP 116/64 RR 14 O2 sat 98% RA
General: alert and oriented, no acute distress
Cardiovascular: RRR, no murmurs, rubs or gallops
Pulmonary: clear to ascultation bilaterally
Abdomen: obese, soft, minimally tender around incision site, non
distended, no guarding or rebound, incision clean, dry and
intact, there are two abdominal JP drains, draining clear
serosanguinous fluid
Extremities: 1+ pedal edema bilaterally
Pertinent Results:
[**2154-1-15**] Hct-36.7
[**2154-1-18**] Hct-29.8
[**1-15**]/ Glucose-161 UreaN-18 Creat-1.8 Na-134 K-4.9 Cl-98 HCO3-26
AnGap-15
[**2154-1-20**] Glucose-159 UreaN-15 Creat-1.5 Na-137 K-5.0 Cl-99
HCO3-28 AnGap-15
[**2154-1-14**] Intraoperative cholangiogram
IMPRESSION: 1. Normal common bile duct and intra- and
extra-hepatic ducts,
cystic duct and gallbladder.
CXR [**2154-1-16**]
FINDINGS: In comparison with the study of [**1-3**], the patient has
taken a
better inspiration. There is increased opacification at the left
base
consistent with pleural effusion and compressive atelectasis.
Calcified
granuloma is again seen in the right mid to upper region
laterally. No
evidence of vascular congestion.
Brief Hospital Course:
The patient presented to pre-op on [**2154-1-14**]. Pt was
evaluated by anaesthesia and taken to the operating room for an
open cholecystectomy with intraoperative cholangiogram and
incisional hernia repair with implantation of prosthetic mesh.
There were no adverse events in the operating room; please see
the operative note for details. Blood loss was 200 cc. Pt was
extubated, taken to the PACU until stable, then transferred to
the [**Hospital1 **] for observation.
Neuro: The patient was alert and oriented throughout his
hospitalization; pain was well controlled with Dilaudid PCA at
first and then oral Roxicet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU: He was initially on bariatric stage 1 diet, which was
advanced sequentially to stage 5, and well tolerated.
FEN: The patient's intake and output were closely monitored. On
POD #1 it was noted that the patient had a low urine output and
he was aggresively resscitated with multiple fluid boluses. This
was accompanied by an acute rise in Cr from a baseline of 0.6 to
1.9 at this peak on POD 2. Nephrology was consulted and
suggested his ARF developed in the setting of mild hypotension
and an ACE-I inhibitor (patient was taking lisinopril at home).
They recommended continued fluid ressucitation and avoidance of
metformin, lisonopril and NSAIDS or other nephrotoxins. During
the next few days his urine output markedly improved and
normalized, while his Cr came down to 1.5 and will continue to
improve.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; he 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 stage 5
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:
Lisinopril 10 mg daily
Metformin 1000 mg [**Hospital1 **]
Pioglitazone 15 mg daily
Sertraline 50 mg daily
Vitamin supplements
Discharge Medications:
1. pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. sertraline 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
8. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*500 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
1. Acute gallstone pancreatitis with cholelithiasis.
2. Incisional hernia.
3. Acute renal failure, most likely mild ATN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage 5 diet until your follow up appointment. Do
not self advance diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS. Do NOT resume
taking Lisinopril and Metformin until further notice.
You will be starting some new medications:
1. 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.
2. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
3. You should continue taking a chewable complete multivitamin
with minerals. No gummy vitamins.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**11-23**] 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 steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Please RECORD THE OUTPUT FROM EACH ONE OF YOUR DRAINS SEPARATELY
TWICE DAILY. Bring the record with you to your next appointment
with Dr. [**Last Name (STitle) **].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2154-1-24**] 4:00
Completed by:[**2154-1-20**]
|
[
"327.23",
"553.21",
"530.81",
"584.5",
"401.9",
"V45.86",
"574.20",
"280.9",
"571.8",
"V12.72",
"250.00",
"715.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"53.61",
"87.53"
] |
icd9pcs
|
[
[
[]
]
] |
5878, 5948
|
2602, 4982
|
424, 551
|
6112, 6112
|
1868, 2579
|
8406, 8588
|
1370, 1388
|
5159, 5855
|
5969, 6091
|
5008, 5136
|
6287, 6851
|
1403, 1849
|
301, 386
|
7885, 8383
|
579, 1011
|
6876, 7873
|
6127, 6239
|
1033, 1275
|
1291, 1354
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,809
| 131,743
|
1663
|
Discharge summary
|
report
|
Admission Date: [**2123-4-8**] Discharge Date: [**2123-5-1**]
Date of Birth: [**2048-8-27**] Sex: F
Service: [**Year (4 digits) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6736**]
Chief Complaint:
Weakness, lightheadedness, worsening hematuria
Major Surgical or Invasive Procedure:
1. Left selective renal angiography - [**2123-4-8**] - Interventional
Radiology,
2. Right percutaneous nephroureteral stent change - [**2123-4-14**] -
Interventional Radiology
3. Left antegrade ureteroscopy - [**2123-4-17**] - Dr. [**First Name (STitle) **] [**Name (STitle) **]
4. Aortogram, Left internal and external iliac arteriograms -
[**2123-4-22**] - interventional radiology
5. Cystoscopy, left ureteral stent removal - [**2123-4-23**] - Dr. [**First Name (STitle) **]
[**Name (STitle) **]
6. Right percutaneous nephroureteral stent removal, placement of
right percutaneous nephrostomy tube, bilateral ureteral balloon
occlusion, bilateral antegrade nephrostograms.
7. Aortogram, Left common, internal, and external iliac
arteriogram, coil embolization of left internal iliac artery -
[**2123-4-24**] - interventional radiology
8. Placement of PICC line - [**2123-4-29**] - interventional radiology
9. Left common, internal, and external iliac arteriogram, -
[**2123-4-30**] - interventional radiology
History of Present Illness:
74 F with h/o colon cancer s/p chemotherapy and pelvic radiation
c/b colovesical fistula and colostomy. She also has a history
of chronic bilateral ureteral obstruction, for which she is
managed by bilateral percutaneous nephroureteral stents that are
periodically changed. She developed hematuria around the time of
L percutaneous nephroureteral stent change [**2123-3-30**] and underwent
selective angiography of left kidney with selective embolization
of a left renal angiodysplasia [**2123-4-1**]. Her Hct on discharge
was 28.
Tonight she felt hematuria worsened @9PM then felt lightheaded
and weak. She was brought to the ED and Hct was found to be 13.
Past Medical History:
1)Colon cancer-s/p chemotherapy and pelvic radiation c/b
colovesical fistula and colostomy
2)B/L nephrouretal tubes from hydronephrosis vs. RPF
3)Benign HTN
4)Annular lesion in the left proximal femur
Social History:
Lives with husband and daughter. Denies tobacco/ETOH use. Not
working.
Family History:
Non-contributory
Physical Exam:
Sitting in bed, comfortable, talkative
RRR
CTAB
Abd S, overweight, NT, ND
R PCN and L PCN sites without lesions.
L PCN with clear yellow, R PCN wtith clear yellow urine
Pertinent Results:
[**2123-4-7**] 11:35PM BLOOD WBC-9.9 RBC-1.35*# Hgb-4.1*# Hct-12.8*#
MCV-95 MCH-30.4 MCHC-32.1 RDW-15.5 Plt Ct-296
[**2123-4-12**] 06:35AM BLOOD WBC-6.8 RBC-3.66* Hgb-11.2* Hct-33.5*
MCV-91 MCH-30.5 MCHC-33.4 RDW-15.2 Plt Ct-241
[**2123-4-12**] 06:35AM BLOOD Glucose-81 UreaN-22* Creat-1.7* Na-145
K-4.4 Cl-108 HCO3-30 AnGap-11
[**2123-4-13**] 06:38AM BLOOD WBC-6.0 RBC-3.49* Hgb-10.5* Hct-31.1*
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.2 Plt Ct-220
[**2123-4-30**] 04:44AM BLOOD Hct-29.7*
[**2123-4-30**] 04:44AM BLOOD UreaN-17 Creat-1.2* Na-138 K-4.0 Cl-107
Brief Hospital Course:
The patient was admitted to Dr. [**Last Name (STitle) 9614**] [**Last Name (STitle) 159**] service and was
initially brought to the [**Hospital Ward Name 517**] SICU for hemodynamic
monitoring. She went to the angiography suite, where she
underwent selective angiography of her L kidney to examine for
potential bleeding vessels, none of which were observed. She
also had her percutaneous nephroureteral stent upsized from 8Fr
to 10Fr. She was transfused a total of 8u of pRBCs for a hct of
13. A tagged RBC scan was then performed to r/o any other
potential sources of bleeding. The scan was negative for active
bleeding of significant rate. The pt was maintained on
continuous bladder irrigation, which also served to irrigate the
urine in her PCNUs bilaterally. Her hct responded appropriately
to the blood transfusions and her hct on [**2123-4-12**] was 33.5. She
was reevaluated on [**2123-4-13**] and noted to have clear yellow urine
from her L percutaneous nephroureteral stent. She then went to
the IR suite for a R percutaneous nephroureteral stent change.
However, on HD 8, she was noted to have persistent bloody output
from both PCNs. IR recommended obtaining an MRV to investigate
sources of venous bleeding. This was performed, which was
negative. On [**2123-4-17**], she was taken to the OR for antegrade
ureteroscopy, which was essentially negative for a definitive
source of bleeding. She was left with a PCN and a double J
stent.
On PODs [**1-24**], she continued to bleed, requiring multiple blood
transfusions. She was discussed at the interdisciplinary
GU-radiology conference, where the possibility of a fistula
between a vessel and the ureter was discussed. On [**2123-4-22**], she
went to the angiography suite and underwent an aortogram and
arteriogram of the L internal and external iliac arteries, which
was negative for active extravasation. On [**2123-4-23**], she went to
the operating room to have her L ureteral stent removed under
local anesthesia, and then went to the IR suite for bilateral
ureteral balloon occlusion and bilateral antegrade
nephrostograms to look for any ileoureteric fistulas. None were
noted.
On [**2123-4-24**], she had an episode of syncope while sitting on the
toilet and passing a large clot per urethra. She was given
additional blood transfusions. She was also taken to the IR
suite for angiography with the L ureteral stent not in place,
which demonstrated a fistula between an iliac vessel (likely
internal iliac), and her L ureter. An occluding stent could not
be placed, so the L internal iliac artery was coiled. She was
transferred to the [**Hospital Unit Name 153**] for further management, where she was
resuscitated and transfused. She was transferred to the floor
on [**2123-4-26**]. Her R PCN was clear yellow urine, but her L PCN
continued to have bloody output.
On the night of [**2123-4-28**] she had a R IJ CVL placed with some
difficulty. However, the placement of the tip of the CVL was an
issue, and it was removed after IR placed a PICC line on [**2123-4-29**].
On [**2123-4-29**], her L PCN was noted to have slightly dark, but clear
yellow urine. She was taken to the IR suite on [**2123-4-30**] for a
repeat arteriogram, which was negative for fistula. No stent
was placed. On discharge, her urine from her nephrostomy tubes
was clear yellow. Her bladder was irrigated for small clots,
and there was little to no active bleeding. The foley catheter
was removed. Her nephrostomy tubes were left open to gravity.
Her PICC line was removed.
She was then discharged home in stable condition with
instructions to call Drs. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Name (STitle) **] for follow-up
appointments.
Medications on Admission:
1. Hydrochlorothiazide 25 mg PO daily
2. Enalapril 10 mg PO daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Left ileoureteric fistula
Discharge Condition:
Stable
Discharge Instructions:
-Leave your R percutaneous nephrostomy tube open to gravity.
-Leave your L percutaneous nephrostomy tube open to gravity.
Diet
You may return to your normal diet immediately. Because of the
raw surface of your bladder, alcohol, spicy foods, acidy foods
and drinks with caffeine may cause irritation or frequency and
should be used in moderation. To keep your urine flowing freely
and to avoid constipation, drink plenty of fluids during the day
(8 - 10 glasses).
Activity
Your physical activity doesn't need to be restricted. However,
if you are very active, you may see some blood in the urine. We
would suggest to cut down your activity under these
circumstances until the bleeding has stopped.
Bowels
It is important to keep your bowels regular during the
postoperative period. Straining with bowel movements can cause
bleeding. A bowel movement every other day is reasonable. Use a
mild laxative if needed, such as Milk of Magnesia [**2-23**]
Tablespoons, or 2 Dulcolax tablets. Call if you continue to have
problems. If you had been taking narcotics for pain, before,
during or after your surgery, you may be constipated. Take a
laxative if necessary.
Medication
You should resume your pre-surgery medications unless told not
to. In addition you will often be given an antibiotic to prevent
infection. These should be taken as prescribed until the bottles
are finished unless you are having an unusual reaction to one of
the drugs.
Problems [**Name (NI) **] Should Report to Us
a. Fevers over 101.5 Fahrenheit.
b. Heavy bleeding, or clots (See notes above about blood in
urine).
c. Inability to urinate.
d. Drug reactions (Hives, rash, nausea, vomiting, diarrhea).
e. Severe burning or pain with urination that is not improving.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 9614**] [**Last Name (STitle) 3726**] on monday to arrange for a follow-up
appointment.
Please also call for a follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of IR.
Completed by:[**2123-5-1**]
|
[
"599.71",
"591",
"593.4",
"V55.6",
"447.2",
"285.1",
"593.82",
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"V44.3",
"780.2",
"E879.2",
"584.9",
"458.8",
"733.90",
"V87.41",
"401.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.91",
"39.79",
"55.93",
"38.93",
"55.39",
"55.03",
"88.42",
"59.8",
"99.29",
"97.62",
"88.45"
] |
icd9pcs
|
[
[
[]
]
] |
7168, 7174
|
3211, 6949
|
374, 1390
|
7244, 7253
|
2635, 3188
|
9042, 9302
|
2413, 2431
|
7065, 7145
|
7195, 7223
|
6975, 7042
|
7277, 9019
|
2446, 2616
|
288, 336
|
1418, 2083
|
2105, 2308
|
2324, 2397
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,277
| 147,189
|
52620+59444
|
Discharge summary
|
report+addendum
|
Admission Date: [**2131-2-28**] Discharge Date: [**2131-3-13**]
Date of Birth: [**2093-10-20**] Sex: F
Service: MICU
CHIEF COMPLAINT: Transferred from [**Hospital1 5042**] for management of
congestive heart failure
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old
female with past medical history significant for non
Hodgkin's lymphoma in [**2115**] treated with chemotherapy and
radiation complicated by histoplasmosis, pulmonary fibrosis,
Aspergillus leading to left pneumonectomy in [**2122**]. The
patient also suffers from cardiomyopathy with last ejection
fraction measured in [**2124**] at 20%. The patient is being
transferred for [**Hospital1 5042**] to [**Hospital6 2018**] Medical Intensive Care Unit for management of her
congestive heart failure. The patient was admitted to
Medical Intensive Care Unit at [**Hospital3 **] between [**1-6**] and [**1-31**] of this year for Pseudomonas pneumonia
requiring intubation for hypercapnic respiratory failure. At
that time, the patient failed extubation and tracheostomy was
placed. The patient was discharged to [**Hospital1 5042**] for pulmonary
weaning, however she had minimal success in coming off of the
respirator. Per report, the patient's low systolic blood
pressures in the 80s to 90s lead to holding off her ACE
inhibitors as well as Lasix and gradual increase in her
weight.
PAST MEDICAL HISTORY:
1. Non Hodgkin's disease in [**2115**] treated with CHOP and XRT,
complicated by Histoplasma, ARDS, pulmonary fibrosis,
bronchiectasis, Aspergillus leading to left pneumonectomy in
[**2122**]. The patient's last pulmonary function tests are from
[**2130-9-18**] and revealed FVC of 0.6, FEV1 to FVC of 68 and
severely depressed total lung capacity indicating severe
mixed obstructive and restrictive disease.
2. Tuberculosis in [**2121**]
3. Status post splenectomy
4. Anxiety and depression/insomnia
5. Cardiomyopathy with ejection fraction of 20% in [**2124**]
SOCIAL HISTORY: The patient is single, lives with her mom.
Recently has been in [**Hospital1 5042**]. She reports five year tobacco
use in college. Rare alcohol and no intravenous drug use.
ALLERGIES: SULFA, OXACILLIN, VERAPAMIL
ADMISSION MEDICATIONS:
1. Pulmicort tube feeds at 65 cc [**First Name8 (NamePattern2) **] [**Last Name (un) **]
2. Trazodone 100 q hs
3. Captopril 6.25 tid
4. Lasix 60 qd
5. Atrovent 4 puffs qid
6. Serevent 6 puffs [**Hospital1 **]
7. Protonix 40 mg qd
8. Ativan 1 mg q6h prn
9. Guaifenesin prn
10. Fleet's prn
11. Heparin subcutaneous 5000 units [**Hospital1 **]
12. Albuterol nebulizers prn
13. Serzone 25 [**Hospital1 **]
14. Digoxin 0.125 qd
15. Haldol 1 mg q 4 prn
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Temperature 98.5??????, heart rate 114, blood
pressure 94/49, weight 152 pounds up from a dry weight of 112
to 114, respiratory rate 35, O2 saturation 100% on 50% O2
with pressure support of 15.
GENERAL: The patient appeared as a chronically ill young
female in no apparent distress.
HEAD, EARS, EYES, NOSE AND THROAT: Her jugular veins were
distended to the angle of jaw. Mucous membranes were moist.
Extraocular movements were intact. Pupils were round and
reactive to light.
LUNGS: Diffusely heard wheezes.
HEART: Tachycardic, normal S1 and S2.
ABDOMEN: Soft, distended, nontender, tympanic on the right
and dull on the left. PEG tube in place leaking stomach
contents - food.
EXTREMITIES: 4+ edema to mid thigh bilaterally with good
distal pulses.
LABORATORY FINDINGS ON ADMISSION: Sodium 130, phosphate 3.7,
chloride 85, bicarbonate 40, BUN 19, creatinine 0.6, glucose
96, calcium 7.8, magnesium 1.8. Her white count was 8.8,
hematocrit 27.6, platelet count 429. The differential on the
white count was 83 polys, 8 lymphocytes, 7 monocytes, 2
eosinophils.
IMAGING: Her chest x-ray showed left sided whiteout, small
right pleural effusion.
HOSPITAL COURSE: During this hospitalization the patient's
issues included:
1. CONGESTIVE HEART FAILURE: On admission, the patient was
severely fluid overloaded. With aggressive Lasix diuresis,
the patient was able to return to her dry weight of
approximately 114 pounds. The patient's blood pressure as
well as renal function tolerated diuresis well. An
echocardiogram was obtained to confirm her cardiac function
and revealed LV function of approximately 30%. Her right
ventricular cavity was markedly dilated. There was severe
global right ventricular free wall hypokinesis. The abnormal
septal motion was consistent with right ventricular
pressure/volume overload. The aortic valve appeared
structurally normal without aortic regurgitation. Mitral
valve leaflets were mildly thickened. There was mild 1+
mitral regurgitation. There was severe 4+ tricuspid
regurgitation. The main pulmonary artery was dilated with at
least moderate pulmonary artery systolic hypertension. At
discharge, the patient was on 160 mg of Lasix po and a low
dose of captopril for afterload reduction. With these
medications, the patient was able to maintain systolic
pressure of around 80 without any signs of hypoperfusion.
2. SUPRAVENTRICULAR TACHYCARDIA: The patient had a history
of supraventricular tachycardia. During this
hospitalization, she had repetitive episodes of tachycardia
to 160 leading to slight shortness of breath and anxiety.
The patient was started on low dose Lopressor with
improvement in the frequency of the supraventricular
tachycardia episodes. She was able to tolerate 12.5 mg of
Lopressor [**Hospital1 **] without significant change in her blood
pressure.
3. VENT DEPENDENCE: The patient had history of difficulty
weaning from respiratory in light of recent pneumonia. As
her diuresis progressed, the patient was able to decrease her
ventilatory support. Over the last four days prior to
admission, the patient was tolerating trach mask trials of
three hours and pressure support of [**4-22**] during the day. At
night, the patient preferred to be rested on pressure control
ventilation set at FIO2 of 40%, PEEP of 5 and a driving
pressure of 20.
4. GASTROINTESTINAL: During this hospitalization, the
patient had two gastrointestinal issues. Issue #1 revolved
around her leaking G-tube. Surgery was consulted and was
able to replace the tube with a larger caliber tube.
However, the patient persisted with slightly increased
leaking around the G-tube. Her second issue was
constipation. She required very aggressive bowel routine
including magnesium citrate and milk of molasses to maintain
regular bowel movements.
5. ANXIETY, DEPRESSION AND INSOMNIA: During this
hospitalization, the patient initially had problems sleeping
and appeared to be very anxious. Psychiatry consultation was
obtained and with their recommendation her medications were
changed to Remeron and Risperdal in addition to prn po
Ativan. In addition, the patient remained on Haldol. By the
end of the hospitalization, she reported improvement in her
insomnia.
6. PROPHYLAXIS: During this hospitalization, the patient
was maintained on subcutaneous heparin and Protonix.
7. FREQUENT BLOOD LOSS: A PICC line was placed on [**3-9**].
8. INFECTIOUS DISEASE: During this hospitalization, the
patient remained on percussions for prior Methicillin
resistant Staphylococcus aureus pneumonia. She remained
mostly afebrile with one episode of low grade temperatures to
100.4??????. The urine cultures from that day grew probable
Enterococcus. The patient was not treated with antibiotics
with good resolution of low grade fever following change of
the Foley. While in the hospital, the patient was started on
her inhaled tobramycin for history of Pseudomonas pneumonia.
On the date of discharge, she was on day #5 out of #21 for
the therapy.
DISCHARGE MEDICATIONS:
1. Vitamin C 500 mg po pg tube [**Hospital1 **]
2. Zinc 220 mg po qd
3. Colace 100 mg po bid
4. Serevent metered dose inhaler 6 puffs [**Hospital1 **]
5. Atrovent metered dose inhaler 4 puffs qid
6. Risperdal 0.5 mg po pg tube tid
7. Tobramycin inhaled 300 mg nebulizer q 12 hours
8. Magnesium citrate 75 mg pg tube [**Hospital1 **], titrate to one bowel
movement per day.
9. Lopressor 12.5 mg po bid, hold for systolic blood
pressure less than 75
10. Tube fees at goal
11. Lasix 160 mg po qd
12. Captopril 6.25 mg pg tube tid, hold for systolic blood
pressure less than 70
13. Remeron 30 mg po qd
14. Digoxin 0.125 mg po qd
15. Heparin subcutaneous 5000 units [**Hospital1 **]
16. Micro KCL capsules 400 milliequivalents po qd
17. Protonix 40 mg po qd
18. Simethicone 80 mg po tid
PEG TUBE DRESSING CHANGES:
1. Cleanse the skin beneath the phalange on the PEG tube
with normal saline and dry.
2. Apply non stain barrier and wipe beneath the phalange
dry.
3. Do not place any dressing beneath the flange
4. Gently apply dressing to top of the flange and secure
with paper tape
Compression ulcer dressing change q 3 days and prn.
1. Cleanse ulcer pore with normal saline and dry.
2. Apply non stain barrier, wipe on all sites and allow to
dry.
3. Apply Duoderm 4x4 dressing. Apply paper tape to picture
frame edges of Duoderm.
PRN MEDICATIONS:
1. Fleet enemas
2. Prn lactulose 30 mm per G-tube q6h prn
3. Haldol 1 mg po q4h prn agitation or insomnia
4. Ativan 1 mg po q2h prn anxiety
5. Guaifenesin 10 ml po q6h prn cough
6. Albuterol nebulizers q4h prn
7. Dulcolax 10 mg po pr qd
8. Milk of molasses tid prn, titrate to one bowel movement
qd
DR.[**Last Name (STitle) 2466**],[**First Name3 (LF) 2467**] 12-746
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2131-3-13**] 15:35
T: [**2131-3-13**] 15:44
JOB#: [**Job Number 108608**]
Name: [**Known lastname 447**], [**Known firstname **] Unit No: [**Numeric Identifier 17771**]
Admission Date: [**2131-2-28**] Discharge Date: [**2131-3-15**]
Date of Birth: [**2093-10-20**] Sex: F
Service:
This is an addendum to the discharge summary dictated two
days ago. The patient's discharge was delayed due to lack of
beds at the [**Hospital **] [**Hospital 17772**] Hospital where the patient is
being transferred. Meanwhile, the only significant change
was the change in her discharge Lasix dose, which is
currently 120 mg po q.d.
[**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**], M.D.
[**MD Number(1) 2099**]
Dictated By:[**Last Name (NamePattern1) 156**]
MEDQUIST36
D: [**2131-3-15**] 12:48
T: [**2131-3-15**] 14:02
JOB#: [**Job Number **]
|
[
"416.0",
"V44.0",
"482.41",
"424.0",
"508.1",
"536.42",
"425.4",
"707.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.72",
"97.02"
] |
icd9pcs
|
[
[
[]
]
] |
7780, 10558
|
3906, 7757
|
2232, 2699
|
2714, 3510
|
156, 238
|
267, 1382
|
3525, 3888
|
1404, 1974
|
1991, 2209
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,866
| 115,222
|
42241
|
Discharge summary
|
report
|
Admission Date: [**2197-8-28**] Discharge Date: [**2197-9-9**]
Date of Birth: [**2113-6-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Painless jaundice
Major Surgical or Invasive Procedure:
ERCP with precut sphincterotomy [**2197-8-28**]
EGD [**2197-8-31**]
History of Present Illness:
84 yo F with history HTN, HL, and Type 2 DM who presented with
fatigue, nausea, was noted to be jaundiced at initial
presentation to [**Hospital3 **] on [**8-26**]. Patient reports eating
avocados from [**Country 149**], which triggered her nausea and vomiting
about 2 weeks ago. She has had increased confusion over past few
weeks, forgetting her way home once, so that her husband took
her license away. No longer able to do daily 1 hour walk. At
OSH, she was found to have Total bilirubin of 8.7, direct
bilirubin 5.7, AST=2319, ALT=[**2144**], alk phos 132, and INR 1.9.
RUQ ultrasound showed gallbladder wall thickening but no stones
in GB or bile ducts, no CBD dilation, and question of
intrahepatic bile duct dilation. Acetaminophen level was
negative. She had a U/A showing [**5-15**] WBC and received one dose of
Ceftriaxone and Flagyl for asymptomatic bacteriuria.
She underwent ERCP and small sphincterotomy at [**Hospital1 18**] on [**8-28**],
which showed only mildly dilated CBD 8 mm. Hepatitis serologies
were sent. AST and ALT continued to trend down to 1808 and 1632,
respectively. Her T. Bili was 10.7, D. Bili was 7.7, and alk
phos was 113. Hepatology was consulted on [**8-29**]. Per report,
patient was found to be encephalopathic with food all over her
and asterixis. She has had no recent changes in meds. FSG was
106. Per PCP, [**Name10 (NameIs) **] only has very very mild cognitive deficit
at baseline. She was transferred to ICU for management of
altered mental status in setting of fulminant liver failure.
On the floor, her VS were T 99.3, HR 77, BP 133/51, 18, 94% RA.
She was AOx3. She has lost 10 pounds in past 2 weeks due to lost
appetite. She denies nausea, vomiting, abdominal pain,
constipation, or diarrhea.
Past Medical History:
Hypertension
Hyperlipidemia
Hard of Hearing
Anemia
Cataracts s/p surgery
Type II DM - diet controlled
Social History:
Lives with her husband; previous homemaker. Has several adult
children who live nearby. Life-long non-smoker. No ETOH use.
Family History:
Sister died of ovarian cancer. No family history of liver
disease.
Physical Exam:
ADMISSION EXAM
T=96 BP=114/56 HR=60 RR=16 SaO2=97%RA
Pleasant, alert, awake, in NAD.
Jaundiced.
HEENT negative.
Neck - no adenopathy or masses
Lungs-CTAB
CV-RR, grade II/VI systolic murmur at base
Abd-soft, non-tender, non-distended, NABS. No HSM.
Extr-non-pitting symmetric edema bilaterally in both LE (not
acute, per patient).
Neuro-A&Ox3. Negative neuro exam. Mild asterixis
.
DISCHARGE EXAM
97.8 131/63 72 18 98% RA
General: Alert, oriented, jaundiced
HEENT: Sclera icteric, ecchymosis over L. eye MMM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: inspiratory crackles at bases b/l. Good air movement. No
respiratory distress.
CV: RRR normal S1 + S2, II/VI systolic murmur at apex
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
GU: foley
Ext: warm, well perfused, 2+ pulses, trace edema in LE.
Neuro: A&Ox3, CN II-XII intact. Strength 4/5 in upper and lower
extremities
Skin: jaundiced
Pertinent Results:
At [**Hospital3 **]:
[**2197-8-27**]
Creat = 0.6
T. Bili=9.3
D. Bili=5.2
AST=2319
ALT=[**2144**]
Troponin I <0.06 x2
Alk phos = 120
Amylase =74
WBC=8400
Hct=37.3
Acetaminophen level = negative
UA=[**5-15**] WBC
Hepatitis serologies as per OSH ([**Hospital1 **]):
- Hep A Ag Total - reactive
- HbSAg - reactive
- HbSAb- non-reactive
- Hb core Ab: reactive
- HCV Ab: non-reactive
CA-19 33 (ref value 33)
---
At MICU:
ALT 1632-->752
AST 1808-->619
Alk Phos 113-->81
T. Bili 10.7-->9.5
Lipase 188
GGT 114
AMA neg, Smooth pos (1:20)
[**Doctor First Name **] neg
AFP 23.3
HIV neg
calTIBC-243* Ferritn-1266* D-Dimer-296 TRF-187*
Hapto-50
IgM HBc-POSITIVE*
HBcAb-POSITIVE IgM HAV-NEGATIVE
HBsAg-POSITIVE* HBsAb-NEGATIVE IgM HAV-NEGATIVE
IgG-1871* IgA-699* IgM-114
.
OTHER IMAGING/STUDIES
Liver ultrasound with Dopplers [**2197-8-29**] - Normal appearance of
the liver parenchyma and liver vasculature.
No ascites.
.
Liver biopsy
Liver, transjugular needle core biopsy:
Markedly fragmented biopsy demonstrating:
1. Nodular hepatic parenchyma with cholangiolar proliferation,
septal and bridging fibrosis with multifocal incomplete nodule
formation and paucity of identifiable central veins, suspicious
for cirrhosis (trichrome and reticulin stains evaluated).
2. Moderate portal/septal, periseptal and lobular mixed
inflammation consisting of lymphocytes, plasma cells,
neutrophils and few eosinophils with scattered apoptotic
hepatocytes and focal hepatocyte necrosis with drop-out/minimal
collapse.
3. Moderate cholestasis with focally prominent feathery
degeneration of hepatocytes.
4. No viral inclusions or granulomata identified on H&E;
immunostains for CMV, HSV, HBSAg and HBCAg are in progress and
will be reported in an addendum.
5. Iron stain is negative for significant iron deposition.
.
Head CT without contrast [**8-30**]
1. Left cerebral hemisphere hyperdensity likely due to
calcification but
hemorrhage can not be excluded. Repeat non-contrast CT of the
head is
recommended.
2. Symmetric ventriculomegaly with prominent sulci and
preservation of
white/[**Doctor Last Name 352**] matter differentiation. Most likely secondary to
normal
age-related volume loss. Diffuse periventricular and deep white
matter
hypodensities most likely secondary to chronic small vessel
ischemic disease.
.
Head CT without contrasts [**9-7**] (after fall)
1. Hematoma overlying the superior aspect of the left orbit.
2. Punctate focus of hyperdense material in the right parietal
lobe within an extra-axial location. Although this may be due to
streak, given its location, this would be concerning for a tiny
focus of subarachnoid hemorrhage.
3. Stable calcification or mineralization within the left
cerebellum.
4. Stable atrophy and small vessel microvascular change
6. Focal steatosis present; no areas of hemorrhagic necrosis
seen.
Note: The features are suspicious for cirrhosis (within the
limits of evaluation given specimen fragmentation), with a
superimposed significant active hepatitis. The differential
includes viral, drug or autoimmune-mediated etiologies. Further
correlation with clinical and serologic findings is needed to
distinguish amongst these entities.
.
Repeat Head CT
1. No hemorrhage.
2. Hematoma over left supraorbital ridge, unchanged.
.
ERCP
Multiple ulcers were seen in duodenum.
Major papilla was floppy.
There was a long intramural course of distal CBD.
Deep cannulation of CBD was not successful. Given the rising
bilirubin and reported intrahepatic ductal dilatation on
ultrasonogram, the decision was made for precut sphincterotomy.
Because of the elevated INR, only small sphincterotomy was
performed.
The intrahepatic ducts were partially opacified. They appeared
normal.
CBD was normal and measured 8 mm.
The pancreatic ducts of the head, neck and body of pancreas were
normal.
No filling defect was seen.
Otherwise normal ercp to third part of the duodenum.
.
EGD [**8-31**]
No esophageal varices.
Friability and erythema in the whole stomach compatible with
gastritis
Blood in the second part of the duodenum coming from the
ampulla; consistent with hemobilia.
Ulceration in the first part of the duodenum compatible with
superficial ulceration without stigmata of recent bleeding.
Otherwise normal EGD to third part of the duodenum
.
EGD [**9-3**]
Ulcer in the stomach body
Ulcer in the duodenal bulb
Active bleeding from ampulla was noted, most likely hemobilia
from transjugular liver biopsy, 4cc Epi injection was performed
in the setting of prior pre-cut at the ampulla. (injection)
Otherwise normal EGD to third part of the duodenum
.
DISCHARGE LABS:
[**2197-9-9**] 05:26AM BLOOD WBC-7.9 RBC-3.62* Hgb-11.6* Hct-33.1*
MCV-92 MCH-32.0 MCHC-35.0 RDW-19.2* Plt Ct-79*
[**2197-9-9**] 05:26AM BLOOD PT-19.5* PTT-38.2* INR(PT)-1.8*
[**2197-9-9**] 05:26AM BLOOD Glucose-101* UreaN-19 Creat-0.5 Na-139
K-3.4 Cl-104 HCO3-30 AnGap-8
[**2197-9-9**] 05:26AM BLOOD ALT-81* AST-80* AlkPhos-81 TotBili-15.8*
[**2197-9-9**] 05:26AM BLOOD Calcium-7.7* Phos-2.3* Mg-1.7
Brief Hospital Course:
84yo F p/w painless jaundice to OSH transferred to [**Hospital1 18**] for
further workup found to have serologies indicative of active
Hepatitis B infection, hospital course complicated by GI bleed
secondary to transjugular liver biopsy.
.
# Liver failure - Patient initially admitted with painless
jaundice, found to have marked tranaminitis >1000 and Tbili
10.7. She also had mild encephalopathy with asterixis on exam.
RUQ u/s without concern for obstruction or cholecystitis.
Tylenol level 0. ERCP was unremarkable except for multiple
duodenal ulcers; hepatitis serologies demonstrated HBsAg
positive, HBsAb negative, HBcAb positive, suggesting new HBV
infection vs reactivation. Patient underwent transjugular liver
biopsy, which demonstrated cirrhosis and active hepatitis; it
was felt this was consistent with reactivation of infection.
Patient was started on tenofovir. LFTs trended down.
Encephalopathy improved.
.
# GI Bleed - Patient's course was complicated by melena and
acute anemia following transjugular liver biopsy. EGD showed
hemobilia. Angiogram during active bleeding was negative, and
thus her bleed was thought to be venous. The patient was
followed by liver, IR, and surgery for persistent bleed. The
patient was stabilized with transfusions. On day 6 of
admission, patient had large episode of BRBPR. Massive
transfusion protocol was intitiated. She underwent repeat EGD
that showed persistent hemobilia. The ampulla was injected with
epinephrine and bleeding remained stable. During admission, the
patient received a total of 13 U PRBC, 11 FFP, 2 platelets, 4
cryoprecipitate, and Vit K. HCT remained stable in the 30s prior
to discharge with no additional evidence of rebleeding.
Remained on protonix [**Hospital1 **] on discharge until further follow up.
.
#H. pylori - EGD showed ulcers in stomach and duodenum. H.
pylori antibody positive. Patient was started on triple therapy
with clarithromycin, amoxicillin, and pantoprazole for 2 weeks.
.
#HTN - Blood pressures remained stable. Home medications
(lisinopril, HCTZ/triamterene, and diltiazem) were held
initially. Lisinpril was restarted prior to discharge.
#DM - Patient on Janumet at home. D/C'ed janumet for question of
drug-related injury and risk of lactic acidosis with underlying
hepatic dysfunction. Patient placed on SS humalog while
inpatient. A1c most recently of 5.7 and therefore, well
controlled. Can continue to hold Janumet after discharge with
plans to follow up blood sugars with PCP.
.
TRANSITIONAL ISSUES:
- liver enzymes should be checked in 1 week and faxed to Dr.
[**Last Name (STitle) **]
- patient should follow up in liver clinic as [**Last Name (STitle) 1988**]
- Blood pressures will need to be followed. Diltiazem and
HCTZ/triamterene were stopped on this admission and may need to
be restarted if blood pressures remain elevated.
- Janumet was stopped. Patients blood sugars will need to be
followed.
- Patient will need to complete treatment for H. pylori (ends
[**9-16**]). She will need an H. pylori stool antigen checked to
ensure eradication after completion of treatment.
- Pantoprazole 40 mg [**Hospital1 **] should be continued until follow up
with primary care or liver doctor. At this point, she may be
able to decrease dose back to once daily.
- Patient will need a follow up EGD in [**6-14**] weeks.
- Aspirin was stopped in the setting of GI bleed. If blood
counts remain stable, can consider restarting at follow up
appointment.
Medications on Admission:
ASA 81 mg/day
Protonix 40mg/d
HCTZ/triamterene (37.5/25) qday
Diltiazem CD 120mg qd
MOM [**Name (NI) **] PRN constipation
NTG sl prn cp
Lisinopril 10 mg qd
Janumet (sitagliptin/metformormin)
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H
(every 4 hours) as needed for encephalopathy.
6. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 7 days.
7. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 7 days.
8. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous ASDIR (AS DIRECTED): administer QACHS as per
sliding scale .
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnoses: Hepatitis B reactivation, GI bleed, H. pylori
infection
Secondary diagnoses: Hypertension, Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 91568**],
You were admitted with weakness, jaundice, and elevated liver
enzymes in your blood suggesting some injury to your liver. You
had a procedure called an ERCP with sphincterotomy and this did
not show any blockage in your bile ducts. It did not show the
reason behind the liver injury. It did, however, show that you
have ulcers in your small intestine. You also were found to be
positive for an infection called H. pylori which can cause these
ulcers, and you were started on 3 medications which you will
need to take for a total of 14 days.
You were also found to be bleeding likely from the site of your
liver biopsy and had 2 upper endoscopies to help fix this. In
the process, you were given a lot of blood products.
Your liver blood work studies revealed that you have a
reactivation of Hepatitis B. You were started on a medication
called tenofovir. You should continue taking this medication and
you will need to follow up with your liver doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
You also fell and hit your head. You had a scan of your head
which did not show any evidence of a bleed.
The following changes have been made to your medication regimen:
You should STOP taking:
- Janumet
- HCTZ/triamterene
- diltiazem
- milk of magnesia
- aspirin (You can discuss restarting Aspirin with your primary
care doctor if your blood counts continue to remain stable)
You should START
- tenofovir
- lactulose
- rifaxamin
- clarithromycin (until [**9-7**])
- amoxicillin (until [**9-7**])
Please start taking pantoprazole twice daily
You should STOP taking the medication Janumet. The metformin
component in this medication can cause a serious (potentially
fatal) complication called lactic acidosis if your liver is not
working normally. Your diabetes was controlled reasonably well
by diet alone here. Please continue following a diabetic diet,
check your blood sugars at home, keep a log of the results and
bring the log to your primary care physician to determine what,
if any, medications you need to switch to for your diabetes.
You should avoid medications such as aspirin, advil (ibuprofen),
alleve (naproxen), and other medications in this family (NSAIDs)
as it can worse or cause additional stomach ulcers.
If you need to use Tylenol (acetaminophen) for pain or fever, do
NOT exceed [**2186**] mg per day (500 mg four times per day) as higher
doses can cause further liver injury.
Followup Instructions:
Department: LIVER CENTER
When: FRIDAY [**2197-9-22**] at 9:00 AM
With: [**Last Name (LF) **],[**First Name3 (LF) **] (LIVER CENTER) [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need to follow up with your primary care doctor within
7 days of discharge from your extended care facility.
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital3 **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 41731**], [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 17503**]
Completed by:[**2197-9-10**]
|
[
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"285.1",
"288.60",
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"532.70",
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"783.21",
"571.5",
"531.70",
"276.69",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"50.13",
"44.43",
"45.13",
"88.47",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
13046, 13061
|
8546, 11049
|
321, 391
|
13224, 13224
|
3527, 8105
|
15888, 16599
|
2452, 2520
|
12260, 13023
|
13082, 13157
|
12045, 12237
|
13407, 15865
|
8121, 8523
|
2535, 3508
|
13178, 13203
|
11070, 12019
|
264, 283
|
419, 2170
|
13239, 13383
|
2192, 2296
|
2312, 2436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,284
| 101,297
|
25674
|
Discharge summary
|
report
|
Admission Date: [**2192-7-5**] Discharge Date: [**2192-7-16**]
Date of Birth: [**2116-8-4**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
1) Diffuse abdomenal pain
2) Admitted for cardiac catherization of renal artery stenosi
Major Surgical or Invasive Procedure:
Exploratory Laporatomy with right colectomy
Cardiac catheterization with stenting of LAD
History of Present Illness:
THE FIRST HALF OF THE HISTORY AND PHYSICAL AS WELL AS THE BRIEF
HOSPITAL COURSE WAS DONE BY THE ADMITING CARDIOLOGY TEAM AND THE
SECOND WAS DONE BY THE SURGERY TEAM, RESPECTIVELY:
75 yo F with HTN, Hyperlipidemia, DM, h/o CVA in [**2186**], AFib,
breast cancer s/p radiation and lumpectomy initally admitted to
[**Hospital 1474**] Hospital for CHF and a SBP of 240. She ruled out for MI
at that time. She was trasferred to [**Hospital1 18**] for evaluation of
Renal Artery Stenosis seen on MRI on [**2192-6-21**]. She underwent
cardiac cath on [**2192-7-5**] showing single vessel CAD. The LMCA was
free of disease. The LAD had severe proximal calcium with an 80%
stenosis in the mid vessel. The LAD was stented with a
drug-eluding stent. The LCX had a 50% stenosis in the mid
vessel. The RCA had moderate diffuse disease with a 40% proximal
stenosis. Selective angiography of the renal arteries showed a
50% stenosis of the left and a 20-30% stenosis of the right
renal artery.
.
She is being transferred from CMI to [**Hospital Unit Name **] for acute on chronic
renal insufficiency, increasing CK-MB post procedure, and
intermittent Aflutter with poor conduction seen on telemetry.
Her ACEI, Diuretic, and Dig are currently being held. An EP
consult was obtained. Her BP is being controlled BP with
hydralazine.
.
Currently pt denies CP/SOB/N/V/belly pain.
.
Surgery was consult for her abdomenal pain.
Past Medical History:
HTN
CVA [**2186**] with residual right sided weakness
NIDDM
s/p Appendectomy and hysterectomy
Breast cancer [**2186**] s/p right lumpectomy and radiation
AFib
Social History:
Lives with husband. [**Name (NI) **] 6 children. Quit tob [**1-11**]. Denies EtOH
or drug use.
Family History:
Denies FH of heart disease.
Physical Exam:
BP 168/89 (152-181/39-55), HR 51 (50-64), RR 20, 91% RA, Wt 62.7
kg, I/O 600/900
.
Gen: well appearing female in NAD
HEENT: MMM, anicteric
Neck: no JVD, b/l carotid bruits
CV: irregularly irregular, III/VI systolic murmer at LUSB
radiating throughout chest and into carotids
Lungs: rhonchi right base o/w clear
Abd: soft, NT/ND, pos BS, no abd bruit
Groin: small right hematoma, no bruit
Ext: no edema, weak DP/PT pulses
Neuro: A&Ox3
Pertinent Results:
[**2192-7-12**] 03:47AM BLOOD PT-17.1* PTT-34.9 INR(PT)-1.9
[**2192-7-10**] 10:11AM BLOOD PT-18.9* PTT-32.3 INR(PT)-2.4
[**2192-7-9**] 06:00AM BLOOD PT-22.9* PTT-33.9 INR(PT)-3.5
[**2192-7-12**] 03:47AM BLOOD LD(LDH)-239 CK(CPK)-941*
[**2192-7-10**] 03:31AM BLOOD WBC-21.6*# RBC-3.45* Hgb-10.1* Hct-28.7*
MCV-83 MCH-29.2 MCHC-35.1* RDW-15.7* Plt Ct-291
Brief Hospital Course:
75 yo F with HTN, PAF, h/o CVA, mild RAS, CAD s/p drug-eluding
stent of LAD on [**7-5**] now with increasing Cr post procedure and
episode of AFlutter.
.
1. CAD s/p drug-eluding stent to LAD. Currently chest pain free.
Initial bump in CK-MB post procedure now trending down. Will
continue to follow. groin site with bruit but no hematoma or
ooze. evaluated with femoral ultrasound which was negative.
.
2. Rhythm. h/o PAF with Aflutter noted on tele. Awaiting EP
consult. Restarted on Coumadin. Goal INR 1.5-2.0. Continue
Amiodarone. d/c digoxin
.
3. Acute on Chronic Renal Insufficiency likely secondary to dye
load from cath. Baseline Cr unclear. [**Name2 (NI) **] diurectic and ACEI for
now and continue to monitor Cr. Worsening renal function most
likely from contrast nephropathy. Hydrated and monitored for
fluid overload treated with lasix. Had echocardiogram on [**7-6**]
which revealed....
.
4. DM. Continue on outpt regimen of Glyburide with ISS.
.
5. HTN. Continue outpt regimen of Amlodipine and Metoprolol with
hydralazine while holding ACEI and diuretic.
.
6. Hyperlipidemia. Continue statin.
.
7. PPX. Ranitidine, INR 1.4 on coumadin
Because of her abdomenal pain, Surgery was consulted. A CT of
the abdomen was obtained showing marked thickening of the right
colon and proximal transverse colon indicating grangrenous
bowel. A decision was made to take the patient immediately to
the operating room for an exploratory laporotomy.
Intra-operatively, the patient was found to have ischemic bowel
with gangrene and a right colectomy was performed. She
tolerated the procedure well and was transferred to the surgical
intensive care unit. The she was intubated and sedated and
closely monitorred by both the ICU team and the primary team, as
well as other consulting services to optimize her recovery. She
slowly recovered over the course of a few days and was
extubated. She soon became strong enough to be transferred to
the surgical floor were she began to tolerate regular meals,
pass flatus, and have good urine output. She also started to
work with the physical therapist to regain he straingth.
Eventually, she was able to be close to her baseline and was in
a good enough condition to be discharged home with services.
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): For refills please call Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*5*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain: If 3rd
tab needed seek medical attention.
Disp:*100 Tablet, Sublingual(s)* Refills:*0*
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. Warfarin Sodium 2 mg Tablet Sig: Two (2) Tablet PO ONCE
(once) for 1 doses.
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
Disp:*80 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
NECROTIC CECUM
Discharge Condition:
FAIR
Discharge Instructions:
PLEASE GO TO THE CALL OR GO TO THE ER IF SUDDEN PAIN IN ABDOMEN,
NAUSE/VOMITING, FEVER, OR ABDOMENAL DISTENTION. TAKE
MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS CAREFULLY.
FOLLOW WITH [**First Name8 (NamePattern2) **] [**Doctor Last Name **] IN [**1-8**] WEEKS (SEE BELOW) AND DOCTOR
[**Date Range **]/[**Hospital **] CLINIC WITHIN A WEEK. [**Month (only) **] SHOWER. DO NOT SCRUB
WOUND, PAD DRY. STRIPS WILL FALL OFF ON ITS OWN IN ABOUT 4 DAYS.
Followup Instructions:
DR. [**Last Name (STitle) **]([**Telephone/Fax (1) 2300**] ([**Telephone/Fax (1) 2300**] IN [**1-8**] WEEKS AND DR.
[**Last Name (STitle) **]
Completed by:[**2192-9-13**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"45.73",
"36.01",
"37.22",
"99.04",
"38.93",
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icd9pcs
|
[
[
[]
]
] |
6785, 6856
|
3110, 5359
|
399, 489
|
6915, 6922
|
2733, 3087
|
7427, 7602
|
2235, 2264
|
5382, 6762
|
6877, 6894
|
6946, 7404
|
2279, 2714
|
272, 361
|
517, 1925
|
1947, 2107
|
2123, 2219
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,670
| 158,994
|
30029
|
Discharge summary
|
report
|
Admission Date: [**2108-5-25**] Discharge Date: [**2108-6-22**]
Date of Birth: [**2058-8-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
s/p fall and transfered from [**Hospital1 **]
Major Surgical or Invasive Procedure:
placement [**Last Name (un) 8745**] bolt
History of Present Illness:
HPI: Patient is a 49 yo male who was reportedly intoxicated and
suffered a fall down 15 stairs landing on concrete. GCS in the
field unknown. Was brought to [**Hospital 1562**] Hospital where he was
reportedly unconscious but moving upper extremities. Was
emergently intubated. CT there showed multiple fractures of the
foramen magnum, fractures of the posterior frontal roof of both
orbits right gretaer than left, left temporal bone fracture
intersecting upon the left carotid canal, significant cerebral
edema, small 1-2 cm bilateral epidural hematomas 1-2cm each.
This is per discussion with the radiologist at [**Hospital1 **] [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 71645**] [**Telephone/Fax (1) 71646**].
Per ED at OSH, pupils were 4mm bilaterally and reacted well.
Also had retrobulbar hemorrhage bilaterally.
Past Medical History:
PMHx: unknown
Social History:
Social Hx: unknown
Family History:
Family Hx: unknown
Physical Exam:
PHYSICAL EXAM:
O: T: BP:128 /86 HR:79 R 16 O2Sats 100vent
Gen: intubated. Off sedation. Last had Vecuronium and fentanyl
60 minutes prior to exam.
HEENT: large ammount of facial/head trauma. Bleeding from
external auditory meatus bilaterally. Pupils 2.5mm and trace
reactive. EOMs: not tracking
Neck: c collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro: GCS 3. intubated. Unresponsive. No spontaneous
movemnt.
NO withdrawl to nox x 4. No rectal tone.
Cranial Nerves:
I: Not tested
II: Pupils trace reactive 2.5mm bil.
III, IV, VI: not tracking.
V, VII: facial trauma but apperas symetric.
IX, X: [**Doctor First Name 81**]: XII: intubated
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. No withdrawl/movement.
Sensation: no withdrawl.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes up bilaterally
Pertinent Results:
CT OSH: multiple fractures of the foramen magnum, fractures of
the posterior frontal roof of both orbits right gretaer than
left, left temporal bone fracture intersecting upon the left
carotid canal, significant cerebral edema, small 1-2 cm
bilateral
epidural hematomas 1-2cm each.
[**2108-5-24**] 11:45PM UREA N-10 CREAT-0.8
[**2108-5-24**] 11:45PM AMYLASE-39
[**2108-5-24**] 11:45PM ASA-NEG ETHANOL-252* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-5-24**] 11:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2108-5-24**] 11:45PM WBC-31.9* RBC-5.27 HGB-15.9 HCT-47.0 MCV-89
MCH-30.1 MCHC-33.8 RDW-14.0
[**2108-5-24**] 11:45PM PLT COUNT-280
[**2108-5-24**] 11:45PM PT-11.8 PTT-22.3 INR(PT)-1.0
[**2108-5-24**] 11:45PM FIBRINOGE-158
[**2108-5-24**] 11:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]->1.035
[**2108-5-24**] 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
49M s/p fall w/ sig head and facial trauma, fxs of foramen
magnum and
L temp bone w/ possible impingement into carotid canal,sig
edema,
SAH, R frontal SDH, CTA:. Mult fx skull base, L occip, L temp, L
sphenoid bones, bilat sup orbital roof fx, L lateral orbital
wall fx, and L max sinus fx; Diffuse SAH bilat and basilar
cisterns, L cerebellar IPH, and extraaxial hemorrhage R
supraorbital region and posterior fossa; no definite arterial
damage very low liklihood for cavernous fistula via MRI. He had
a bolt placed for 24 hours and was dc'd as he began to awake and
move all extremties. He required high doses of Ativan and was
monitored in the ICU for 10 days. He required a PEG and Trach
placed
On [**6-4**] he was moved to our step down unit, he was awake, alert
and inconsistently following commands trying to mouth words. He
was noted to have clear drainage from nose on [**6-5**] and
eventually required a lumbar drain that was in place for 6 days
and the csf drainage stopped without out further evidence of a
leak.
He had his trach removed and he passed a speech and swallow. He
as has been tolerating a regular diet. Our surgical team was
unwilling to remove his PEG until it had been in place for a
month which will be [**6-30**]. He had no infection disease issues
while being hospitalized.
He was noted to have a left ecchymotic eye on [**6-21**] he apparently
fell so a repeat CT scan was done and there was no new blood or
fractures and his prior blood has resolved.
Neurologically he was orientated x3 intermittently he
occassionally he had difficulty with the date. His motor
strenght was full, sensation intact, he difficulty with
multistep commands and calculation. His judgement was impaired
but he had no behavioral issues.
Medications on Admission:
Medications prior to admission: unknown
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-14**]
Drops Ophthalmic PRN (as needed).
2. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
3. Oxycodone 5 mg/5 mL Solution Sig: [**2-14**] PO Q6H (every 6 hours)
as needed for pain.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day) as needed.
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Head trauma
Discharge Condition:
neurologically improved
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR HEAD INJURY
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST
Completed by:[**2108-6-22**]
|
[
"070.70",
"305.50",
"V60.0",
"E880.9",
"349.81",
"802.6",
"518.5",
"800.12",
"482.82",
"305.00",
"801.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.72",
"38.91",
"96.6",
"38.93",
"01.18",
"03.31",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
6422, 6492
|
3420, 5180
|
365, 407
|
6548, 6574
|
2367, 3397
|
7711, 7926
|
1374, 1395
|
5271, 6399
|
6513, 6527
|
5206, 5206
|
6598, 7688
|
1425, 1945
|
5238, 5248
|
279, 327
|
435, 1283
|
1961, 2348
|
1305, 1321
|
1337, 1358
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,828
| 155,588
|
34799
|
Discharge summary
|
report
|
Admission Date: [**2117-2-16**] Discharge Date: [**2117-2-23**]
Date of Birth: [**2083-2-27**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2117-2-16**]: Living related renal transplant to right iliac fossa
History of Present Illness:
33y.o. Male with h/o FSGS who completed transplant workup to
receive kidney from his mother. In preparation for transplant,
he had a total of 4 plasmapheresis treatments prior to admission
for transplant on [**2-16**]. He received hemodialysis from left AVF.
Past Medical History:
FSGS: nonresponsive to chemotherapy and steriods. Neg [**Doctor First Name **].
Hypogammaglobulinemia with normal complement. Neg HIVx4, HBsAg.
Hypertriglyceridemia, Hyperlipidemia: Most recent TG 1464, total
cholesterol 436, HDL 33.
HTN
Social History:
Lives with sister and her young child. Denies tobacco, EtOH,
drug use.
Family History:
father- HTN
Physical Exam:
See preop notes
Pertinent Results:
[**2117-2-23**] 05:28AM BLOOD WBC-6.7 RBC-3.42* Hgb-10.2* Hct-28.8*
MCV-84 MCH-29.8 MCHC-35.3* RDW-15.0 Plt Ct-185
[**2117-2-18**] 01:55AM BLOOD PT-11.7 PTT-26.6 INR(PT)-1.1
[**2117-2-23**] 05:28AM BLOOD Glucose-126* UreaN-28* Creat-1.2 Na-134
K-4.8 Cl-105 HCO3-24 AnGap-10
[**2117-2-23**] 05:28AM BLOOD Calcium-8.9 Phos-1.9* Mg-1.8
[**2117-2-23**] 05:28AM BLOOD tacroFK-9.8
Brief Hospital Course:
On [**2117-2-16**], he underwent living related renal transplant into
RLQ from his mother. A 6 [**Name2 (NI) 18252**] double J urethral stent and 19
Fr. [**Doctor Last Name 406**] drain were placed. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please
refer to operative note for complete details. Of note, he was a
difficult intubation likely secondary to bronchospasm. Five
attempts at intubation were made and he was hypoxic to 50's for
five mins before an airway was ultimately placed. The thought
was that he was bronchospastic. Given the difficult intubation,
the decision was made to keep the patient intubated and he was
transferred to the SICU postop for further management. Also, 8
liters of ascites were removed intraop.
He was extubated on [**2-17**]. Prbc were transfused on [**2-17**] and [**2-18**]
for hot drop to 22. Urine output increased and creatinine
decreased daily. Plasmapheresis treatments were done on [**3-22**] and [**2-21**] via a right temporary pheresis line. Urine protein
creatinine ratios were done daily noting a slight increase in
ratio from 1.0 to 2.2.
Nephrology followed throughout this hospital course making
recommendations. Immunosuppressive was administered and
consisted of ATG (3 doses given), solumedrol taper daily to
prednisone 20 mg daily, cellcept and Prograf. Prograf doses were
adjusted daily per trough levels. Dose was increased to 8 mg [**Hospital1 **]
at discharge to home. Blood pressures were elevated. Amlodipine
and Metoprolol were given with better BP control.
Diet was advanced and tolerated. Bisacodyl and MOM were
administered with passage of BMs. Abdomen was large due to body
habitus. RLQ incision was painful (worse when standing). Pain
meds were switched to Dilaudid with improved relief. Incision
was without redness or drainage. The [**Doctor Last Name 406**] drain outputs were
serosanguinous averaging approximately 340 cc per day at time of
discharge to home. Drain fluid was sent for creatinine and was
1.4 less than serum Creatinine ruling out urine leak. He was
taught how to empty the JP. He demonstrated that he was capable
of managing this at home without VNA. He did well with his
medication teaching.
The plan is to send him home to f/u on [**2-25**]. He is scheduled to
have pheresis and renal biopsy on [**3-1**]. Biopsy results would
guide future pheresis treatments.
Medications on Admission:
[**Last Name (un) 1724**]: calcium acetate (unknown), fluoxetine (unknown), Lasix 100
prn, lisinopril 40', metoprolol XL 100', minoxidil 10',
nifedipine 90'', omeprazole, simvastatin 40', Ambien, Renal vit
1tab', MMF 1000'', Lactulose (unknown)
Discharge Medications:
1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
8. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
9. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
11. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
13. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
14. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a
day.
15. Outpatient Lab Work
Thursday [**2-25**] at [**Hospital **] Medical Office Building, [**Location (un) **] then
every Monday and Thursday
Discharge Disposition:
Home
Discharge Diagnosis:
FSGS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, inability to keep down food,
fluids or medications, diarrhea, constipation, increased
incisional pain, pain over the graft kidney, redness, drainage
or bleeding of the incision, increased drainage from abdominal
drain or drainage stops
or other concerning symptoms
- You will have your labwork drawn every Monday and Thursday at
the [**Hospital **] Medical Building [**Location (un) 453**].No heavy lifting greater
than 10 pounds
No driving if taking narcotic pain medication
Take all meds exactly as directed
You may shower, no tub baths or swimming
Drain and record the drain output, bring a copy of the drain
outputs with you to the transplant clinic appointment. Monitor
the drainage for change in color, if it develops a foul odor or
you see blood in the drain.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2117-2-25**] 1:10
Monday [**3-1**] you are scheduled for kidney biopsy at 9:30 after
paracentesis (drainage of fluid from your abdomen)at 8:30.
Arrive at 7:30am and go to Radiology DayCare Unit located on
[**Location (un) **] of the [**Hospital1 **] Building (enter lobby of [**Hospital Ward Name 121**]
building to get to [**Hospital1 **]. Go to end of corrider where
security is located. Take left at the end then left again. You
will get checked in and have labs drawn.
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2117-3-5**] 8:10
|
[
"403.91",
"V45.11",
"585.6",
"583.89",
"519.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"99.71",
"00.91"
] |
icd9pcs
|
[
[
[]
]
] |
5578, 5584
|
1499, 3896
|
308, 380
|
5633, 5633
|
1100, 1476
|
6684, 7447
|
1036, 1049
|
4192, 5555
|
5605, 5612
|
3922, 4169
|
5784, 6661
|
1064, 1081
|
264, 270
|
408, 669
|
5648, 5760
|
691, 931
|
947, 1020
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,616
| 128,459
|
17917+17918
|
Discharge summary
|
report+report
|
Admission Date: [**2140-8-8**] Discharge Date: [**2140-9-21**]
Date of Birth: [**2082-4-6**] Sex: F
Service: Liver Transplant Service
CHIEF COMPLAINT: Persistent biliary leak.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
female, status post right donor hepatic lobectomy on [**2139-11-23**], complicated by postop biliary leak requiring Roux-en-
Y hepaticojejunostomy to the left lateral segment duct on
[**2140-1-29**], status post multiple embolization coils
within the liver, coiling of small bile ducts from segment IV
leaking into the perihepatic space. History of transhepatic
catheter placed for a small contained leak at the
anastomosis. Patient last discharged from [**Hospital Ward Name 26168**]
[**First Name (Titles) **] [**Last Name (Titles) **] on [**2140-7-31**], during which time she was
admitted for PICC line placement and TPN. Patient is
readmitted for surgery for [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] Roux-en-Y and
jejunostomy tube placement.
ALLERGIES: Ethylene that caused anaphylaxis, heparin
antibody causing low platelets, history of Zosyn and
meropenem drug rash, and vancomycin history of red man.
MEDICATIONS ON ADMISSION: Protonix 40 mg q. 12 h, Dilaudid 2
mg tab 1 tab p.o. q. 6 h, oxycodone 10 mg SR q. 12 h, Colace
100 mg p.o. b.i.d., Dulcolax p.r.n., nortriptyline 25 mg p.o.
at bedtime, Tylenol p.r.n., calcium carbonate 500 p.o.
b.i.d., clonazepam 0.5 mg p.o. at bedtime, Senokot 1 tab p.o.
b.i.d., ursodiol 300 mg capsule 1 capsule p.o. b.i.d.,
Mirapex 0.25 mg 1 p.o. once daily, atenolol 50 mg 1 p.o. once
daily, insulin sliding scale p.r.n. q.i.d. and TPN.
PAST MEDICAL HISTORY: Significant for hypertension,
migraines, gastritis, ulcers, left renal mass. Also
significant for heparin-induced thrombocytopenia.
PAST INFECTIONS: VRE/staph in JP drain.
PAST SURGICAL HISTORY: Right hepatic donor lobectomy
[**2139-11-23**], hepaticojejunostomy [**2140-1-29**], left
partial nephrectomy [**2137**], TAH/BSO.
SOCIAL HISTORY: Widowed, nonsmoker, no alcohol.
HISTORY OF BRIEF HOSPITAL COURSE: The patient was taken to
the OR on [**2140-8-9**] for persistent bile leak operation,
medial segmentectomy segment IV, extensive lysis of
adhesions, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] Roux-en-Y hepaticojejunostomy with
feeding jejunostomy tube for persistent bile leak, surgeon
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], assistant [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], resident. The
patient was stable intraoperatively. No complications with
general anesthesia. The patient required 6 units of packed
red blood cells and 2 units of FFP. The patient received 7500
cc of LR. EBL was approximately 3500 cc. Urine output was 825
cc. Postoperatively, the patient was transferred to the SICU
for further care. The patient had a PTC, feeding jejunostomy
and a JP bulb in place.
The patient did well postoperatively. Pain was managed with
PCA. Vital signs were stable. The PTC drain initially 70-85
cc of bilious drainage. The JP drained approximately 75-100
cc/D. The patient was afebrile. Vital signs were stable. She
was initiated on IV antibiotics per ID consultation. The
patient was maintained on fluconazole 400 mg initial dose,
then 200 mg once daily for history of [**Female First Name (un) 564**] parapsilosis.
Second antibiotic was linezolid for history of VRE and
sensitive to Enterococcus and MRSA. Third antibiotic that she
was maintained on was levofloxacin for Klebsiella and
Enterobacter. She continued on the linezolid for 8 days. She
was maintained on the levofloxacin IV for a total of 14 days.
She was maintained on fluconazole for a total of 1 week.
On [**2140-8-21**], she spiked a temp to 101.8. Urine,
blood and a JP fluid sample was sent for culture. Blood
cultures were subsequently negative. The JP fluid was
positive for Klebsiella, Staph aureus coag-positive and
Enterococcus species. She was maintained on the previously
mentioned antibiotics per ID. Urine culture was negative. The
PTC continued to drain approximately 50-100 cc/D, and this
trended down on postop day 11 to 0.
She underwent a tube cholangiogram on [**2140-8-18**] that
revealed that the transhepatic catheter demonstrated complete
apposition of the jejunal limb with the liver edge, a small
pinpoint area of extravasation was noted at this junction.
Postoperatively, she remained n.p.o. Abdomen was distended.
She complained of abdominal pain. A KUB demonstrated postop
ileus. J-tube feedings were started and initially titrated
up. The patient complained of nausea, abdominal distention
and abdominal pain. She was given antiemetics to manage her
nausea. Her tube feeding was held. Her pain medication was
decreased to minimize ileus. On [**2140-8-21**], she
underwent an abdominal and pelvic CT with contrast. This CT
demonstrated multiple small perihepatic collections, many
were unchanged from the preoperative status. An increased
amount of ascites was noted. The JP was identified in the
medial segmentectomy bed. More inferior to this area there
was a discrete collection noted measuring 3.5 x 2.8 cm. This
was noted to most likely represent a small postop fluid
collection. The spleen appeared slightly enlarged, but
otherwise normal. The intrahepatic biliary drain was noted
running through the central portion of the left lobe of the
liver, unchanged from the previous study.
Psychiatry was consulted to assist with management of
anxiety. Seroquel was started. Initially, the patient
appeared calmer and was able to sleep better. It was then
noted that the patient was extremely agitated and anxious.
Psychiatry was reconsulted, and the Seroquel was decreased.
She was felt to have acuesthesia. This medication was
eventually tapered off, and she was started on lorazepam for
anxiety 1 mg at bedtime. This provided improved relief of
anxiety. The Dilaudid doses were gradually tapered to
minimize excessive sedation and postop ileus. The patient's
mental status improved on the Ativan.
On [**9-2**], she had a temperature of 101. A chest x-ray
was obtained. This revealed a large right pleural effusion
that was persistent. No pneumothorax was noted. The left lung
was clear. Interventional pulmonary was consulted to do a
thoracentesis. A diagnostic thoracentesis was done. Pleural
fluid was sent for cytology. The pleural fluid was negative
for any malignant cells, and there was no growth on the
pleural fluid culture. IV linezolid was stopped on postop day
24. On postop day 29, she developed a temperature of 101.7.
Blood and urine cultures were resent. Blood cultures were
subsequently positive for Staph coag-positive organisms,
sensitive to vancomycin. Linezolid 600 mg IV b.i.d. was
reinstituted on postop day 31, when blood cultures were noted
to be positive. Aztreonam was also restarted at 500 mg IV q.
8 h. JP fluid was positive for gram-negative rods heavy
growth and Staph aureus coag-positive sensitive to
vancomycin, and fungal culture revealed [**Female First Name (un) 564**], Torulopsis
glabrata.
LFTs were monitored on a daily basis. AST and ALT were
stable. Her alkaline phosphatase ranged from 1100-1300. On
postop 40, the alkaline phosphatase was noted to trend
upwards. At this point, the PTC drain output was
approximately 30 cc/D. A cholangiogram was done. This
revealed the biliary tube was cracked at or just below the
skin. A very small amount of contrast leaked from the biliary
catheter. At this point, the tube was patent otherwise. The
PTC catheter was capped at this point. Alkaline phosphatase
trended up to 2253 on postoperative ay 42. The PTC drain was
uncapped. The alkaline phosphatase was repeated. This
decreased slightly to 2082 and continued to be in this range,
2102.
The patient continued on IV linezolid for another total of 2
weeks. This was stopped on [**9-21**]. Previously noted JP
culture grew Staph aureus coag-positive sensitive to
vancomycin, and bile culture from [**2140-9-4**] was
positive for Enterococcus. She grew 2 species. Both were
sensitive to vancomycin. This was resistant to ampicillin,
levofloxacin and penicillin.
On hospital day 40, the patient refused to continue with her
TPN. She had been maintained on this for most of her hospital
course for malnutrition and complaints of abdominal bloating,
fullness and intermittent nausea. An attempt was made to
allow the patient to eat. She was not able to maintain
sufficient calories to maintain her body weight. After
meeting with the patient and discussing options, she decided
to continue with cycled TPN. A nutrition consult was
obtained, and the TPN was adjusted accordingly to meet the
patient's ideal caloric intake.
Throughout this hospital course, [**Doctor First Name 5627**] was followed by
psychiatry for ongoing management of depression, anxiety and
agitation secondary to prolonged hospital course. She did
well with the Ativan at bedtime and denied any suicidal
ideation on discharge.
She was followed by physical therapy. She was assessed and
felt to be safe to go home without rehab on postop day 44.
She was discharged home to her sister's care on cycled TPN.
She completed her course of p.o. linezolid. Her abdominal PTC
was capped. She did continue with her [**Location (un) 1661**]-[**Location (un) 1662**] which
drained approximately 30-25 cc/D of tan, slightly pink, thick
drainage. Both tube sites were clean without erythema or
drainage. Her feeding jejunostomy was maintained capped
throughout this hospital course. Vital signs on discharge
were stable. She was afebrile. Blood pressure ranged 144/89
to 159/90 to 118/74. During this hospital course, she had
received several transfusions for a hematocrit as low as 25.
On discharge, her hematocrit was 31.2, white blood cell count
8.8. Her renal function was normal with a creatinine of 0.5
and a BUN of 14. On discharge, her AST was 113, ALT 103,
alkaline phosphatase 2102, total bilirubin 1.8, and an
albumin of 3.1. Throughout this hospital course, her urine
cultures were negative. Her blood culture was positive for
Staph aureus coag-positive on 1 set, and this was sensitive
to vancomycin. Because of her history of red man syndrome,
she was given linezolid. Subsequent blood cultures were
negative.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PhD [**Numeric Identifier 8353**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2140-9-22**] 11:53:21
T: [**2140-9-22**] 12:56:45
Job#: [**Job Number 49636**]
Admission Date: [**2140-8-8**] Discharge Date: [**2140-9-21**]
Date of Birth: [**2082-4-6**] Sex: F
Service: Liver Transplant Surgery Service
CONTINUED:
The patient was discharged home on postoperative day 44. She
was alert and oriented. She was ambulatory. Pain was
controlled with Dilaudid 2 mg p.o. p.r.n. b.i.d. She was
taking minimal pain medication. She was tolerating small
amounts of regular diet. Her caloric intake was approximately
600 calories. She was sent home with [**Hospital6 1587**] and home infusion company for cycle TPN over 16
hours. The cycle total parenteral nutrition was to provide
approximately 1700 calories per day. She was to instructed to
keep a food diary. Visiting nurse was set up to assist with
her drain care. She went home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**] [**Last Name (NamePattern1) 1662**] drain and
she was self emptying this [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]. She had a capped
PTC tube and a capped J tube. The J tube was to be flushed
with 10 cc of saline q.d. and not to be aspirated. Her PICC
line site was clean. Vital signs were stable.
DISCHARGE MEDICATIONS: Were albuterol 90 mcg per actuation 1
to 2 puffs q 4 hours p.r.n., Protonix 40 mg p.o. b.i.d.,
Tylenol 325 mg tablet 1 to 2 tablets p.o. q 6 hours p.r.n.,
simethicone 80 mg [**12-20**] to 1 tablet p.o. q.i.d. as needed,
Colace 100 mg p.o. b.i.d., metoprolol 100 mg p.o., b.i.d.,
Marinol 2.5 mg twice a day, lorazepam 0.5 mg 1 tablet p.o.
b.i.d., lorazepam 1 mg p.o. q.h.s., Mirapex 0.125 mg 1 tablet
at bedtime p.r.n. for restless legs, Dilaudid 2 mg p.o.
b.i.d. p.r.n., insulin regular sliding scale b.i.d., 0 units
for glucose of 81 to 120; 121 to 160 units - 2 units; 161 to
200 - 4 units; 201 to 240 - 6 units; 241 to 280 - 8 units;
281 - 320 - 10 units; greater than 300 [**Name8 (MD) 138**] M.D. She was
given a prescription for PICC line supplies.
She was instructed to have laboratory work done on Friday,
[**2140-9-23**] for CBC, chem-10, liver function tests and
the results to be faxed to Dr.[**Name (NI) 1369**] office, to follow up
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2140-9-28**] at 11:20.
DISCHARGE DIAGNOSES: Left medial segmentectomy.
Feeding jejunostomy, lysis of adhesions and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] Roux-
en-Y hepaticojejunostomy.
Depression.
Anxiety.
Malnutrition.
Right pleural effusion.
Hypertension.
Migraines.
Ileus.
Restless leg syndrome.
Constipation.
Heparin-induced antibody.
Patient was set up for visiting nurse for home physical
therapy, social work, IV therapy, for teaching and social
work for assistance in managing anxiety. Patient will follow
up as well in the transplant as well with a social worker.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PhD [**Numeric Identifier 8353**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2140-9-22**] 12:09:13
T: [**2140-9-22**] 14:01:58
Job#: [**Job Number 39138**]
|
[
"287.4",
"567.81",
"568.0",
"263.9",
"401.9",
"790.7",
"571.5",
"996.59",
"511.9",
"E934.2",
"723.1",
"293.0",
"576.8",
"285.1",
"997.4",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"50.22",
"54.59",
"46.32",
"97.55",
"51.37",
"44.61",
"96.6",
"99.04",
"87.54",
"99.07",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
2109, 11766
|
12863, 13693
|
11790, 12841
|
1225, 1670
|
1892, 2024
|
173, 199
|
228, 1198
|
1693, 1868
|
2041, 2085
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,526
| 179,287
|
15804+15837
|
Discharge summary
|
report+report
|
Admission Date: [**2140-11-25**] Discharge Date: [**2140-12-8**]
Date of Birth: [**2072-11-9**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 68-year-old
gentlemen who was transferred from [**Hospital3 417**] Hospital
with cholangitis for possible endoscopic retrograde
cholangiopancreatography.
The patient had been in his usual state of health until two
to three days prior to admission at the [**Hospital3 417**]. He
developed fever and abdominal pain. Denied nausea, vomiting,
diarrhea. Also noted productive cough, but denied chest pain
or shortness of breath. He presented to the Emergency Room,
was noted to have abdominal pain, fever and jaundice.
Work-up at the outside hospital included a right upper
quadrant ultrasound which showed no cholelithiasis and a
common bile duct of 7.5 mm. He was noted to have a
transaminitis with AST 190, ALT 273, alkaline phosphatase of
357. He had a total bilirubin of 4.1. He was also noted to
have a white blood cell count of 17.3.
At the outside hospital, he was also noted to be dyspneic and
was ruled out for myocardial infarction with cardiac enzymes
which were negative. He was also ruled out for pulmonary
embolism with a CT scan. He was found to have an infiltrate
on the right on chest x-ray and was treated for presumed
congestive heart failure with Lasix. He was also treated
with ampicillin, Flagyl and gentamicin for presumed biliary
sepsis after a blood culture came back positive for
Klebsiella pneumoniae.
Patient was then transferred to the [**Hospital6 649**] on [**11-25**] for possible endoscopic
retrograde cholangiopancreatography.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2132**].
2. Hypertension.
3. Hypercholesterolemia.
4. Newly diagnosed with diabetes at the outside hospital.
MEDICATIONS AT HOME:
1. Captopril 50 mg po t.i.d.
2. [**Doctor First Name **] 60 mg po q.d.
3. Labetalol 200 mg po b.i.d.
4. Clonidine .3 mg po b.i.d.
5. Zocor.
ALLERGIES: He had no known drug allergies.
FAMILY HISTORY: Denied family history of heart disease,
hypertension or diabetes.
SOCIAL HISTORY: He lives with his wife in [**Name (NI) 1474**]. Retired
electrical technician. Has no smoking history. Denies
alcohol use. No recent travel.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs:
Temperature 98.9. Heart rate 85. Blood pressure 148/84.
Respiratory rate 28. Oxygen saturation 94% on four liter
nasal cannula. He was generally mildly tachypneic, but alert
and oriented times three and in no acute distress. Head,
eyes, ears, nose and throat: Pupils equal, round and
reactive to light. Extraocular eye movements intact.
Sclerae mildly icteric. Neck was supple, jugular venous
pressure 6-7 cm and carotids 2+. Chest: Crackles noted
bilaterally, half way up the chest and crackles anteriorly
over the right. No wheeze, no retractions. Cardiac: Normal
S1, S2 with a mild systolic ejection murmur [**3-9**] at the left
upper sternal border. No S3 or S4. Abdomen was distended
but soft, diffusely tender with a positive [**Doctor Last Name **] sign. No
rebound, no guarding. Extremities: Warm, pulses 2+ and no
edema.
LABORATORIES: White blood cell count 16.3, hematocrit 40.6,
platelet count 115,000. Chem-7: Sodium 136, potassium 4.1,
chloride 100, bicarbonate 24, BUN 27, creatinine .8,
platelets 282,000, ALT 202, AST 88, alkaline phosphatase 459,
total bilirubin 13.6. Electrocardiogram showed a normal
sinus rhythm at 88 beats per minute, normal axis, normal
intervals, left ventricular hypertrophy, old Q waves in II,
III and aVF. Electrocardiogram looked unchanged from prior.
Chest x-ray with cardiomegaly and diffuse infiltrates, right
upper lobe greater than the left.
HOSPITAL COURSE: By systems:
1. Pulmonary: The patient was noted on presentation to be
dyspneic. On the second hospital day, he developed
progressive respiratory failure and was intubated. Further
chest x-ray's during his hospital course demonstrated
progressive bilateral infiltrates that were thought to
represent pneumonia progressing to adult respiratory distress
syndrome. A chest CT on the [**12-1**] showed
multilobar consolidation versus collapse. He underwent
bronchoscopy and bronchoalveolar lavage which were
nondiagnostic. On [**12-1**], he underwent a thoracentesis
for a right pleural effusion, which was transudative. He
remained on the ventilator until [**12-6**] when he was
extubated uneventfully. His prolonged course on the
ventilator was secondary to underlying progression of
pneumonia adult respiratory distress syndrome and then
subsequent congestive heart failure which improved with
diuresis. After extubation, he was ventilating well on room
air, not requiring any oxygen and his pulmonary status had
improved remarkably.
2. Cardiac: Patient received an echocardiogram on [**11-29**] which showed left ventricular systolic function to be
severely depressed with an ejection fraction of 25-30% and
left ventricular wall motion akinesis. He was treated with
aspirin and diuresed with Lasix for his congestive heart
failure. He was also noted to have labile hypertension which
was thought to be secondary to anxiety on ventilation. He
was treated with Captopril and metoprolol, which improved his
hypertension, and subsequent to extubation, his blood
pressure decreased markedly, but he remained on
antihypertensives.
3. Gastrointestinal: Patient initially presented with fever,
right upper quadrant pain, jaundice and transaminitis
consistent with cholangitis. He was seen by the Biliary Team
here who deferred endoscopic retrograde
cholangiopancreatography secondary to his pulmonary status
and his improving LFTs. His LFTs continued to improve and he
was covered on broad spectrum antibiotics, ampicillin,
levofloxacin and Flagyl. The Biliary Team suggested an
elective endoscopic retrograde cholangiopancreatography some
time in the future. Right upper quadrant ultrasound here on
the [**11-28**] showed a heterogenous liver, a common
bile duct measuring 7.5 mm, no cholelithiasis and a left
portal vein thrombosis. Gastrointestinal was consulted for
the left portal vein thrombosis, they recommended no
anticoagulation and continued broad spectrum antibiotics. He
was treated with TPN, transitioned to tube feeds and then
after extubation tolerated a house diet. His LFTs resolved
to normal levels and on extubation he denied abdominal pain,
was having bowel movements and no further gastrointestinal
complication.
4. Infectious Disease: Patient was initially treated with
broad spectrum antibiotics for a blood culture positive for
klebsiella pneumoniae at the outside hospital. The broad
spectrum antibiotics were discontinued on [**12-1**] and he
was continued on the levofloxacin. Cefepime was added for
double coverage of Klebsiella. He had no growth on multiple
cultures here including blood, sputum, urine, fungal
cultures, bronchoalveolar lavage and thoracentesis. A chest
and abdomen CT were done on [**12-1**] for persistent fevers.
Chest CT demonstrated multifocal consolidation and the
abdominal CT showed no free air, no abscess, no source of
infection. He was continued on the levofloxacin and the
cefepime and was subsequently afebrile for the remainder of
his course. His microbiology was no growth in any cultures
at this hospital.
5. Endocrine: The patient was newly diagnosed with diabetes
mellitus at the outside hospital. During this hospital stay,
he was on an insulin drip and transitioned to insulin sliding
scale. He will be discharged on an oral hypoglycemic.
6. Lines: Patient had a left subclavian and a left arterial
line placed on the [**11-26**]. The left subclavian was
switched to a right internal jugular on [**12-5**]. The
lines functioned properly.
7. Prophylaxis: He was on heparin subcutaneously and
Protonix during his hospital stay. He was full code and
communications were with his wife and family who visited
regularly.
DISPOSITION: The patient will be discharged to a
rehabilitation facility.
DISCHARGE CONDITION: Patient will be discharged in stable
condition.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Cholangitis.
3. Pneumonia.
4. Newly diagnosed with diabetes mellitus.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1730**] 12-290
Dictated By:[**Last Name (NamePattern1) 45473**]
MEDQUIST36
D: [**2140-12-8**] 22:11
T: [**2140-12-8**] 22:39
JOB#: [**Job Number 45474**]
Admission Date: [**2140-11-25**] Discharge Date: [**2140-12-9**]
Date of Birth: [**2072-11-9**] Sex: M
Service: [**Company 191**]
The patient was admitted to the [**Company 191**] Service overnight. The
patient did well. No complaints of chest pain, shortness of
breath or abdominal pain.
DISPOSITION: Patient to be discharged home today. Patient
underwent evaluation by PT and OT and they deemed him safe to
good home. Patient will have VNA, OT and PT at home. He
will follow up with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 29041**] on [**12-19**] at
10:15 AM. Dr.[**Name (NI) 45529**] phone # is [**Telephone/Fax (1) 3183**].
DISCHARGE MEDICATIONS:
1. Captopril 100 mg p.o. t.i.d.
2. [**Doctor First Name **] 60 mg p.o. q.d.
3. Lansoprazole 30 mg p.o. q.d.
4. Glyburide 1.2 mg p.o. q.d.
5. Spironolactone 25 mg p.o. q.d.
6. Lopressor 50 mg p.o. t.i.d.
7. Lasix 40 mg p.o. b.i.d.
8. Miconazole powder 2% applied t.i.d. p.r.n.
9. Aspirin 325 mg p.o. q.d.
10. Lactulose 15 cc q. eight hours p.r.n.
Note patient's Zocor 40 mg p.o. q.d. was not restarted due to
his recent LFT abnormalities. Patient's PCP should restart
the Statin as an outpatient. Also notes that the Glyburide
was started due to patient's recently diagnosed type 2
diabetes mellitus. The Glyburide should be titrated up on an
outpatient.
FOLLOW UP: As mentioned above, patient to follow up with Dr.
[**Last Name (STitle) 29041**] on [**12-19**] at 10:15 AM. As recommended by the
GI Service, patient is to undergo an outpatient MRCP. MRCP
should be set up by Dr. [**Last Name (STitle) 29041**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1730**] 12-290
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2140-12-9**] 13:08
T: [**2140-12-9**] 13:22
JOB#: [**Job Number 45530**]
cc:[**Telephone/Fax (1) 45531**]
|
[
"452",
"250.00",
"518.81",
"511.9",
"486",
"428.0",
"V45.81",
"576.1",
"038.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"34.91",
"96.72",
"38.91",
"38.93",
"99.15",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8139, 8188
|
2099, 2166
|
8209, 9233
|
9256, 9924
|
3817, 8117
|
1891, 2082
|
9936, 10454
|
157, 1659
|
1681, 1870
|
2183, 3799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,455
| 178,105
|
42702
|
Discharge summary
|
report
|
Admission Date: [**2115-1-21**] Discharge Date: [**2115-2-14**]
Date of Birth: [**2063-7-30**] Sex: M
Service: SURGERY
Allergies:
Codeine / Demerol / Oxycodone
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
[**2115-1-25**] - IVC filter placement
[**2115-1-28**] - tracheostomy, PEG tube placement
[**2115-2-1**] - non-instrumented fusion C5-T6
History of Present Illness:
50M unrestrained driver s/p rollover MVC with ejection. Pt was
found 10 ft from his car with +LOC. On arrival to the [**Name (NI) **], pt was
hypotensive to SBP 50s but mentating appropriately with GCS 15.
Exam revealed loss of motor and sensory function below the
xiphoid process. Despite fluid resuscitation he remained
hypotensive and was started on pressors with suspicion of
neurogenic shock. Imaging revealed T3-T5 vertebral body
fractures with severe spinal cord injury concerning for
transection, along with multiple bony thoracic fractures and a
small left hemopneumothorax. He was admitted to the TSICU for
close monitoring.
Following admission to the TSICU he underwent closure of
extensive scalp lacertaions. His respiratory mechanics worsened;
found to have progressed to flail chest in the setting of
multiple bilateral rib fractures. Given his increasing fatigue,
he was intubated, and a left subclavian line was placed. A
post-intubation/line film revealed a significantly increased
left pneumothorax with increasing pressor requirement. A chest
tube was placed which drained approximately 500cc blood upon
placement, with hemodynamic improvement thereafter.
Past Medical History:
PMH: bipolar disorder
PSH: appy
Social History:
1ppd x 30 yrs
heavy EtOH in the past, trying to cut down
Family History:
N/C
Physical Exam:
Vitals: T 99.4, HR 59, BP 133/52, RR 20, O2 50% trach collar
Gen: a&o x3, nad
CV: rrr, no murmur
Resp: cta bilat
Abd: soft, NT, ND, +BS
Extr: warm, 2+ pulses
Pertinent Results:
CT Head [**2115-1-21**]: 1. No acute hemorrhage or intracranial process.
2. Left occipital condyle fracture better assessed on cervical
spine CT.
3. Bilateral extensive deep scalp lacerations (degloving injury)
with debris and gas within the wounds.
CT C-Spine [**2115-1-21**]: 1. Multiple fractures in the cervicothoracic
junction including: C7 spinous process, T1 vertebral body, both
T1 pedicles and transverse processes, T2 body, T2 left inferior
facet and right transverse process. Extensive fracture of T3
which is detailed with the CT torso report.
2. Bilateral small pneumothoraces, upper lung contusions, large
paravertebral hematoma surrounding the upper thoracic spine with
extensive bilateral upper (posterior displaced and comminuted)
rib fractures.
3. Acute fracture of the left occipital condyle.
CT Torso [**2115-1-21**]: 1. Severe injury to the thoracic spine with a
flexion teardrop injury at T3 likely causing severe spinal cord
injury. Additional fractures of vertebrae: C7 - T9, described in
detail above. Extensive paravertebral hematoma without active
bleeding.
2. Extensive ribcage injury involving every rib, many displaced
and segmental.
3. Bilateral scapula fractures, sternal fracture with
retrosternal hematoma.
4. Bilateral small hemothorax, small bilateral pneumothores and
pulmonary
contusion in the upper lungs.
MRI Spine [**2115-1-21**]: 1. Multiple fractures of the upper thoracic
spine, most notably with instable 3 column burst fracture of T3.
The latter demonstrates significant retropulsion with cord
compression and cord signal abnormality, representing either
contusion, edema, ischemic change or a combination of those.
Burst fracture of T4 with mild retropulsion and no cord
abnormality. Injury to the anterior and posterior longitudinal
ligaments; assessment of other ligaments is limited. Small
amount of epidural hematoma is posisbly noted and distinction
from osseous component is limited. Osseous details are better
seen on prior CT. (Pl. note that the injury is at T3 and T4
levels and not T10 as mentioned on the wet read.)
2. Mild Compression fracture of T1.
3. Multilevel spinous, transverse process and rib fractures,
better
characterized on previous CT torso.
4. Extensive signal abnormality along the posterior paraspinal
soft tissues and interspinous ligaments from C2 through T8,
suggesting soft tissue edema, multilevel disruption of the
posterior ligamentous complex or, most likely, a combination of
both.
5. Stable extent of pre/paravertebral hematoma and hemothorax.
6. Degenerative changes in the cervical spine.
7. A 2.0cm lesion in the right kidney-? cyst- see prior CT Torso
study
Brief Hospital Course:
Mr. [**Known lastname 51284**] was evaluated in the ED as a trauma activation, and
the following injuries were identified:
-Scalp degloving/lacerations
-C7 spinous process fracture
-T1 body fracture
-T3 flexion teardrop comminuted fx w/ retrolisthesis
-Severe spinal cord injury at T3 w/ concern for transection
-T4, T5 burst fx
-Paraspinal hematoma, upper T spine
-Sternal fx w/ retrosternal hematoma
-Rib fx (R [**1-28**], L [**11-23**], [**6-30**])
-Small L hemo-PTX
-Bilateral apical pulmonary contusions
-Bilateral scapular fx
-Occipital condyle fx
He was admitted to the TICU for evaluation and monitoring. His
extensive scalp lacerations were thoroughly irrigated and
debrided, then closed. His hospital course is detailed below,
and he was discharged to vent rehab.
Neuro: He had pain control issues throughout his admission to
the ICU, for which the chronic pain service was consulted. He
suffered a severe spinal cord injury at the level of his
thoracic spine injuries, with complete bilateral lower extremity
paralysis. He went to the operating room for fusion of his
spinal fractures, but was unable to tolerate the prone position.
Instead of having an instrumented fusion, as planned, he had a
non-instrumented fusion with bone matrix, and was placed in a
[**Location (un) 36323**] brace post-operatively. This was changed to a Halo on
[**2115-2-8**].
CV: He was initially hypotensive and bradycardic, consistent
with spinal shock, and required pressors at the beginning of his
hospital stay. The pressors were slowly weaned, and he remained
hemodynamically stable.
Resp: He was breathing well on arrival to the hospital, though
he had extensive bilateral rib fractures. Overnight on HD 1, he
developed respiratory distress, and imaging was consistent with
flail chest, so was intubated. He was kept intubated for the OR
with spine, and was unable to wean from the vent
post-operatively. He also developed a pneumonia, which was
treated with appropriate antibiotics. He underwent tracheostomy
on HD 8. He has been able to wean to CPAP/PSV, and has been
tolerating trach collar the past 24 hours. His rib fractures
were evaluated by thoracic surgery, who did not think he would
benefit from rib plating. He will be discharged to vent rehab.
GI/GU: He was kept NPO with IVF while intubated. He was
initially started on tube feeds through an OG tube, then
transitioned to feeds through his PEG after placement on HD 8.
He was cleared to start an oral diet on [**2-13**], and was given
sips, which he tolerated well. His PEG tube was inadvertently
removed by the patient on [**2-13**], and was replaced with a foley
catheter. Catheter position in the stomach was confirmed with
contrast x-ray. He will have this exchanged under fluoroscopy
next week for a formal G-tube, but may have feeds through the
foley until that time. He developed a transaminitis on HD 14,
which continued to increase, and a HIDA scan was obtained, which
was normal. He was started on ursodiol for presumed
cholestasis, with improvement in his LFT's. His foley catheter
was removed on [**2115-2-13**] and he began having intermittent straight
caths performed, which will be continued at rehab. He developed
a UTI on [**2115-2-13**], which is being treated with cipro x7 days.
Heme: An IVC filter was placed for protection from embolism, and
heparin subcutaneously was given for DVT prophylaxis. His
hematocrit intermittently drifted to the low 20's, though he
never manifested signs or symptoms of acute bleeding, and always
responded appropriately to transfusion. A CT scan obtained to
evaluate his abdomen on [**2115-2-8**] showed migration of his IVC
filter above the renal veins. IR attempted to retrieve and
replace the filter on [**2115-2-12**], but were unable to do so, as
there was clot in the filter. He will be given a 2-week course
of lovenox, and then will have a repeat CT scan. If the clot
burden has resolved, he will then have the filter retrieved and
replaced by IR.
ID: He developed a moraxella pneumonia while intubated, and was
appropriately treated with antibiotics. He continued to spike
fevers despite antibiotics, so ID was consulted. After
completing his antibiotic course, he remained afebrile without
leukocytosis. He was started on cipro for a UTI on [**2115-2-13**], and
will complete a 7-day course of antibiotics at his rehab
facility.
Medications on Admission:
-Simvastatin 40mg daily
-Potassium citrate 20mEq TID
-Nexium 40mg daily
-Abilify 20mg daily
-Carbamazepine 200mg [**Hospital1 **]
-Fluoxetine 40mg daily
-Hydroxyzine 50mg Q6H PRN
-Topamax 200mg [**Hospital1 **]
-Gabapentin 300mg TID
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing,
dyspnea.
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain.
5. fluoxetine 20 mg/5 mL Solution Sig: Ten (10) ml PO DAILY
(Daily).
6. insulin regular human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED).
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours).
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
10. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
11. senna 8.8 mg/5 mL Syrup Sig: Five (5) mL PO BID (2 times a
day).
12. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
13. lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q4H
(every 4 hours) as needed for Anxiety.
14. hydromorphone (PF) 1 mg/mL Syringe Sig: 1-2 mg Injection Q3H
(every 3 hours) as needed for breakthrough pain.
15. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
16. lorazepam 2 mg/mL Syringe Sig: [**11-19**] ml Injection Q4H (every 4
hours) as needed for Anxiety.
17. enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg
Subcutaneous Q12H (every 12 hours).
18. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
19. Cipro 500 mg/5 mL Suspension, Microcapsule Recon Sig: Five
Hundred (500) mg PO twice a day for 5 days.
20. Outpatient Lab Work
Please check creatinine weekly.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
s/p polytrauma
bilateral rib fractures
thoracic spinal cord injury
bilateral scapula fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the Acute Care Surgery Service after your
traumatic injuries. You were kept in the ICU during your stay,
and required multiple surgical procedures. You are now being
discharged to rehab to continue your recovery. Please follow
these instructions to aid in your recovery.
*Please take all medications as prescribed.
*Please contact our office if you develop fever, chills,
increased pain, or drainage from your wounds.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-2-26**] 3:15
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-2-26**] 3:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-2-26**] 3:45
[**2115-2-28**] - Acute Care Surgery Clinic, 3:45pm
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **] SURGICAL ASSOCIATES
Clinic starts at 1pm. [**Month (only) 116**] come directly from spine appointment
and will try to work-in for earlier visit.
[**2115-2-28**] - [**Doctor Last Name **],SPINE, 11am
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] SPINE CENTER (SB)
Completed by:[**2115-2-14**]
|
[
"807.4",
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"276.0",
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"E816.0",
"276.7",
"560.1",
"958.4",
"801.06",
"807.08",
"453.2",
"599.0",
"806.21",
"263.9",
"E879.8",
"707.09",
"296.50",
"996.1",
"997.31",
"707.20",
"811.00",
"576.8",
"285.1",
"E878.1",
"873.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"38.7",
"96.6",
"81.05",
"33.24",
"03.53",
"43.11",
"31.1",
"86.89",
"34.91",
"96.72",
"34.04",
"86.28",
"84.52",
"38.97",
"02.94",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
11273, 11409
|
4659, 9047
|
297, 435
|
11548, 11548
|
1983, 4636
|
12190, 12948
|
1785, 1790
|
9330, 11250
|
11430, 11527
|
9073, 9307
|
11724, 12167
|
1805, 1964
|
250, 259
|
463, 1639
|
11563, 11700
|
1661, 1694
|
1710, 1769
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,369
| 162,787
|
22341
|
Discharge summary
|
report
|
Admission Date: [**2133-6-13**] Discharge Date: [**2133-6-18**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
ICH s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o male with hx of hypertension very active was at town dump
pulling on a rope which broke fell from standing to asphault.
Went to outside hospital was GCS 15 had decrease mental status 2
hours later in setting of Dilantin adminstration and was
intubated he did have increase in the size of the bleed.
Past Medical History:
HTN, Hyperlipidemia, CABG, Carotid stenosis (s/p carotid
endarectomy)
Social History:
Active [**Age over 90 **] y/o lives with wife, non [**Name2 (NI) 1818**], 2 scotches a night
Family History:
non-contributory
Physical Exam:
On Admission:
T: BP:138/52 HR:52 R 18 O2Sats 100%
Gen: Intubated has collar
HEENT: Pupils: 2mm non reactive, 2cm open laceration at occiptal
area EOMs unable to test
Neck: Collar .
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status:
Intubated off sedation
No commands
No eye opening
Localizes briskly on left and not as briskly on right. Withdraws
legs briskly left>right.
Toes downgoing bilaterally
Reflexes symmetric decreased at patella +1
Pertinent Results:
Labs on Admission:
[**2133-6-13**] 03:35PM BLOOD WBC-13.2* RBC-3.47* Hgb-10.5* Hct-31.2*
MCV-90 MCH-30.2 MCHC-33.6 RDW-14.0 Plt Ct-211
[**2133-6-13**] 03:35PM BLOOD PT-14.5* PTT-28.3 INR(PT)-1.3*
[**2133-6-13**] 03:35PM BLOOD Fibrino-286
[**2133-6-14**] 02:05AM BLOOD Glucose-137* UreaN-25* Creat-0.9 Na-140
K-4.1 Cl-107 HCO3-24 AnGap-13
[**2133-6-14**] 02:05AM BLOOD CK(CPK)-90
[**2133-6-13**] 03:35PM BLOOD Lipase-27
[**2133-6-14**] 02:05AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2133-6-14**] 02:05AM BLOOD Albumin-3.6 Calcium-8.2* Phos-2.8 Mg-2.0
[**2133-6-13**] 03:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
Head CT [**6-13**]:
FINDINGS: There is a nondisplaced obliquely oriented fracture of
the left
occipital bone extending into the left temporal bone. There is
partial
opacification of the left mastoid air cells, as well as abnormal
density in
the left middle ear, which may represent fluid or soft tissue.
There are no
other fractures identified. There is increased density in the
left external
auditory canal, likely representing cerumen. There is extensive
mucosal sinus disease involving the bilateral maxillary sinuses,
sphenoid sinuses, ethmoid air cells, and frontal sinuses. This
causes obstruction of bilateral ostiomeatal complexes. The right
maxillary sinus is relatively hypoplastic. There is no osseous
destruction or erosion. There are no suspicious lytic or
sclerotic lesions. The globes and orbits are unremarkable. There
is no evidence for intra- or pleural inflammation or hematoma.
Extra-axial muscles are intact and normal in contour and
configuration. There are dense calcifications of the cavernous
carotid arteries noted.
IMPRESSION:
1. Subtle nondisplaced fracture of the left occipital bone
extending into the left temporal bone, associated partial
opacification of the left mastoid air cells and minimum
intensity, possibly soft tissue versus fluid, in the left middle
ear. There are no other fractures identified.
2. Diffuse mucosal sinus disease, hypoplasia of the right
maxillary sinus.
CT C-spine [**6-13**]:
FINDINGS: There is no prevertebral soft tissue abnormality.
There is mild
straightening of the normal cervical lordosis, likely related to
positioning. Additionally, there is a slight rotation of C1 on
C2, which may be related to rotation. However, rotatory
subluxation can have a similar appearance. No acute fracture is
identified. There are multilevel degenerative changes, which are
most severe at the levels of C5-6 and C6-7. The epidural canal
appears grossly unremarkable, without evidence of epidural
hematoma. Of note, CT is not as sensitive as MR [**First Name (Titles) **] [**Last Name (Titles) 2742**] of
the thecal sac. Visualized lung apices reveal scarring. There
are extensive atherosclerotic calcifications of the vertebral
arteries, and right carotid artery. A left occipital bone
non-displaced fracture extends into the left temporal bone with
opacification of the left mastoid air cells and left middle ear
are better assessed on concurrent head CT. Mucosal thickening of
bilateral maxillary sinuses are only partially imaged.
IMPRESSION:
1. No evidence of cervical spine fracture.
2. Slight rotation of C1 on C2, may be positional. Of note,
rotatory
subluxation may have a similar appearance, if there is a
clinical concern for ligamentous injury, MRI is suggested.
Brief Hospital Course:
Pt was transferred to the ICU while intubated and sedated. He
was given platlets due to worsened Head CT from outside hospital
and had been on ASA. His neurological exam was poor however was
later extubated on [**6-14**]. His respiratory status was labile and
there concern that due to poor neurologic status and poor
respiratory function he would need to be re-intubated. After
discussion with the familt they wanted to purse medical
treatment without re-intubation. His respiratory status did
inprove with Lasix and was tolerating face mask. He did not
follow commands however would localize with the R upper and LUE
was antigravity and moves BLE spont. His neurologic exam then
began to decline on [**6-16**] it was noted that he did not withdraw
BLE and withdrew RUE to noxious localizing with the LUE. On [**6-17**]
it was discussed with the family that his prognosis was poor.
The family ultimately decided not to re-intubate patient and
allow for him to pass comfortably. He was then made CMO and
passed on [**6-18**] at 2301.
Medications on Admission:
ASA 81mg, Lipitor 40mg QD,Norvasc 10mg QD, Toprolol XL 50mg,
Nitroglycerin ad lib patch
Discharge Disposition:
Expired
Discharge Diagnosis:
Left Parietal IPH
Discharge Condition:
Expired
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2133-7-9**]
|
[
"873.0",
"518.81",
"E888.1",
"V45.81",
"401.1",
"801.12",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6012, 6021
|
4836, 5872
|
279, 286
|
6083, 6215
|
1431, 1436
|
858, 876
|
6042, 6062
|
5898, 5989
|
891, 891
|
227, 241
|
314, 638
|
1450, 4813
|
1200, 1412
|
660, 731
|
747, 842
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,160
| 178,924
|
16602
|
Discharge summary
|
report
|
Admission Date: [**2186-4-17**] Discharge Date: [**2186-4-19**]
Date of Birth: [**2125-4-25**] Sex: F
Service: SURGERY
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern1) 15344**]
Chief Complaint:
metastatic breast cancer
Major Surgical or Invasive Procedure:
s/p port removal and placement
History of Present Illness:
60 year old female with metastatic breast cancer presents for
port removal due to manufacturer recall and placement of new
port.
Past Medical History:
metastatic breast cancer
hypertension
Physical Exam:
T98.6 HR 80, BP 160/70 R 18 100% on 15L
NAD
RRR
CTA-B
s/nt/nd
no c/c/e
Brief Hospital Course:
MS. [**Known lastname 47063**] was noted to have a right apical pneumothorax on
post-operative CXR. She felt well and had minimal respiratory
complaints but was transferred to the Fenard ICU for closer
monitoring, given her high O2 requirement. Follow-up CXRs
showed no increased size to her pneumothorax.
On POD #1, she was transferred to the floor. She continued to
do well, with minimal respiratory difficulties. By POD #2, Ms.
[**Known lastname 47064**] CXRs showed a stable right apical pneumothorax, she
had no respiratory complaints, and had good pain control and was
tolerating pos.
She was discharged home in stable condition.
Medications on Admission:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO QD ().
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO QD ().
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p port removal
s/p R port placement c/b pneumothorax
L breast cancer metastatic
hypertension
Discharge Condition:
Good
Discharge Instructions:
If you have any difficulty breathing, chest pain, shortness of
breath, nausea/vomiting, or fevers/chills, please seek medical
attention.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2186-4-24**] 1:30
Please call [**Telephone/Fax (1) 47065**] (Radiology) to schedule an outpatint
chest x-ray for [**2186-4-21**] and [**2186-4-28**] -- and call Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 15345**] when studies are performed.
|
[
"512.1",
"198.5",
"285.9",
"401.9",
"174.9",
"197.0",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2282, 2288
|
667, 1310
|
304, 337
|
2427, 2433
|
2618, 3052
|
1809, 2259
|
2309, 2406
|
1336, 1786
|
2457, 2595
|
572, 644
|
240, 266
|
365, 495
|
517, 557
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,349
| 132,142
|
35576
|
Discharge summary
|
report
|
Admission Date: [**2145-7-22**] Discharge Date: [**2145-7-23**]
Date of Birth: [**2078-1-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
s/p fall 3 feet while on boat
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 y/o male with history of CAD had two stents placed 2
years ago and has been on [**First Name3 (LF) **] and [**First Name3 (LF) **], HTN,
Hyperlipidemia,arthritis was on a boat this afternoon and
stepped
down on to a cooler and slipped off falling 3 feet on to ribs
and
striking left side of head. He had no LOC, no naseau and
vomitting. He was able to row himself to shore on a smaller
boat.
He went to the ER because he was bleeding was difficult to
control from scalp laceration. He went to [**Hospital3 **] Hospital and
had a CT that showed a traumatic SAH.
Past Medical History:
CAD (s/p stent placement on [**Hospital3 **] and [**Hospital3 **]), HTN,
Hyperlipidemia,arthritis
Social History:
Married lives with wife on [**Hospital3 **]. He is a retired
architect/contractor; Non smoker, occasional alcohol
Family History:
Noncontributory
Physical Exam:
O: T:98.4 BP:125/80 HR:62 R 18 O2Sats 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3.0 to 2.5mm EOMs full
Neuro: lacIeration behind left ear
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-20**] 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 3mm to light, 2.5 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-24**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger,
On Discharge: Nonfocal neurologically
Pertinent Results:
CT HEAD
FINDINGS: Subarachnoid hemorrhage centering around the left
sylvian fissure
and extending around the left frontal, parietal, and temporal
lobe is
unchanged in appearance and extent since the previous study.
There is no new
acute hemorrhage. There is no significant mass effect. The
ventricles and
sulci are normal in size and configuration. [**Doctor Last Name **]-white matter
differentiation
is preserved. Visualized paranasal sinuses and mastoid air cells
are clear.
Visualized soft tissues of the orbits and nasopharynx are within
normal
limits.
IMPRESSION: Stable appearance and extent of left-sided
subarachnoid
hemorrhage. No new acute hemorrhage.
Brief Hospital Course:
patient presented to [**Hospital1 18**] s/p falling while on a boat and
striking his head. He was admitted to the ICU for monitoring
overnight where he remained stable. He had a repeat Head CT on
the morning of [**2145-7-23**] which was stable. he was deemed fit for
discharge and was discharged home without services on [**2145-7-23**].
Medications on Admission:
[**Last Name (LF) **], [**First Name3 (LF) **], Lisinopril, Norvasc, Crestor, Metoprolol
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-21**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*25 Tablet(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain/fever.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic Subarachnoid Hemorrhage
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.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You may resume taking [**Month/Day (2) **] in 1 week on [**2145-7-29**] and Aspirin
on [**2145-7-24**]
?????? You have been prescribed Dilantin. Please continue taking this
for 7 days
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:
??????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:[**2145-7-23**]
|
[
"414.01",
"E885.9",
"716.90",
"272.4",
"V45.82",
"873.0",
"852.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
4686, 4692
|
3205, 3547
|
348, 355
|
4770, 4770
|
2515, 3182
|
6059, 6482
|
1218, 1235
|
3686, 4663
|
4713, 4749
|
3573, 3663
|
4921, 6036
|
1250, 1414
|
2471, 2496
|
279, 310
|
383, 949
|
1707, 2457
|
4785, 4897
|
971, 1070
|
1086, 1202
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,790
| 167,494
|
13080
|
Discharge summary
|
report
|
Admission Date: [**2150-4-14**] Discharge Date: [**2150-5-5**]
Date of Birth: [**2072-8-9**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Mr. [**Known lastname **] is a 77 y/o male with history of a-fib on coumadin
with a history of falls. He fell on [**2150-4-11**] striking the back
of
his head with laceration, but no loss of consciousness. On
[**2150-4-13**] he noted increased headaches with subsequent nausea and
vomiting. Family noted that he became more confused, and he was
taken to outside hospital for evaluation. Head CT at OSH
revealed approximately 5 x 3 cm right parietal/temporal
intraparenchymal hemorrhage with associated 5 mm of midline
shift. Approximately 5mm right frontal parietal subdural
hematoma is also noted with 3 mm falcine subdural hematoma as
well. At OSH the patient was noted to be confused but following
commands with all 4 extremities. He also demonstrated slight
weakness in left upper extremity. Upon admission to [**Hospital1 18**] ER,
he
was intubated, sedated, and paralyzed.
Major Surgical or Invasive Procedure:
craniotomy to evacuate subdural hematoma
thoracentesis
intubation/extubation
PEG placement
History of Present Illness:
Mr. [**Known lastname **] is a 77 y/o male with history of a-fib on coumadin
with a history of falls. He fell on [**2150-4-11**] striking the back
of
his head with laceration, but no loss of consciousness. On
[**2150-4-13**] he noted increased headaches with subsequent nausea and
vomiting. Family noted that he became more confused, and he was
taken to outside hospital for evaluation. Head CT at OSH
revealed approximately 5 x 3 cm right parietal/temporal
intraparenchymal hemorrhage with associated 5 mm of midline
shift. Approximately 5mm right frontal parietal subdural
hematoma is also noted with 3 mm falcine subdural hematoma as
well. At OSH the patient was noted to be confused but following
commands with all 4 extremities. He also demonstrated slight
weakness in left upper extremity. Upon admission to [**Hospital1 18**] ER,
he
was intubated, sedated, and paralyzed.
Past Medical History:
Diabetes Mellitus
History of CAD
History of Mitral regurgitation
S/P CABG with LIMA graft in [**2148**], MV repair.
Hypertension
Hypercholesterolemia
Chronic Kidney Disease 2
Sigmoid resection/polypectomies
Social History:
retired engineer
denies tobacco
[**3-3**] etoh/day
Family History:
non-contributory
Physical Exam:
GEN: Elderly male, trach in place, no response to voice but
retracts to painful stimuli. appears comfortable. no grimace.
opens eyes slightly to voice
HEENT: PERRL. Trach in place. JVP approx 8 cm. no facial droop
noted
CV: irregularly irregular; 2/6 systolic murmur at apex. no S3/S4
LUNGS: coarse BS bilaterally with decreased BS and few crackles
in Left lower base
ABD: soft, obese. NT (no grimace). normal BS. PEG tube in place.
no erythema around site
EXT: 1+ dependant edema in inner thighs/sacrum. 2+ peripheral
pulses. Maculopapular rash on BUE/BLE and on trunk
NEURO: no response to voice, but retracts to painful stimuli.
increased tone in RUE/RLE. 2+ biceps reflex. Flaccid LUE. opens
eyes to voice
Pertinent Results:
[**2150-4-16**] 10:52 pm BLOOD CULTURE Source: Line-Triple lumen.
**FINAL REPORT [**2150-4-22**]**
Blood Culture, Routine (Final [**2150-4-22**]): NO GROWTH.
[**2150-4-20**] 4:03 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2150-4-22**]**
GRAM STAIN (Final [**2150-4-20**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2150-4-22**]):
RARE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2150-4-20**] 8:32 am SWAB Source: Rectal swab.
**FINAL REPORT [**2150-4-22**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2150-4-22**]):
No VRE isolated.
[**2150-4-28**] 10:57 am PLEURAL FLUID
**FINAL REPORT [**2150-5-4**]**
GRAM STAIN (Final [**2150-4-28**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2150-5-1**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2150-5-4**]): NO GROWTH.
[**2150-4-30**] 7:49 am URINE Source: Catheter.
**FINAL REPORT [**2150-5-2**]**
URINE CULTURE (Final [**2150-5-2**]): NO GROWTH.
[**2150-4-13**] CT HEAD:
IMPRESSION:
1. 8.3 x 2.8 cm right parietooccipital intraparenchymal
hemorrhage with surrounding vasogenic edema.
2. Subdural hematoma along the right frontoparietal convexity,
falx, and right tentorium.
3. 3.2 x 1.8 cm right parietooccipital extra-axial hyperdense
fluid collection concerning for epidural hematoma.
4. Subfalcine herniation, effacement of the right frontal sulci
and mass effect over the right lateral ventricle with
compression of the occipital [**Doctor Last Name 534**].
5. Intraventricular hemorrhage.
NOTE ON ATTENDING REVIEW:
1. There is also mild mass effect on the right ambient cistern
(series 2, im 13).
2. Dedicated bone algorith images are not available but on the
visualized images, no obvious fractures are noted.
3. A small focus of hemorrhage is also noted in the cerebral
aqueduct. ( series 2, im 12)
[**2150-4-14**] CT C-SPINE:
IMPRESSION:
1. Fracture of ossified anterior longitudinal ligament at the
C3-4 level. High-density material in the anterior spinal canal
at the C2 through C4 levels may represent small epidural
hemorrhage versus the posterior longitudinal ligament. Fractures
through fused osteophytes cannot be excluded at other levels and
MR is recommended to evaluate extent of injury.
2. Ossified posterior longitudinal ligament at C6-C7 level
causes canal narrowing. CT is not able to provide intrathecal
detail compared to MR; MR is recommended for evaluation of
spinal cord injury if clinically indicated.
3. Limited views through the base of the skull demonstrate
increase size of known right intraparenchymal hemorrhage, left
intraventricular hemorrhage, and hemorrhage within the aqueduct,
as compared to CT head performed 11 hours earlier.
[**2150-4-14**] MRI C-SPINE:
IMPRESSION:
1. Increased signal in anterior disc at the C4-5 level
consistent with injury of this disc and likely injury of the ALL
at this level.
2. Increased signal throughout the intervertebral disc at C6-7
and in the prevertebral soft tissue at this level consistent
with injury to this disc and likely to the ALL, with protrusion
of this disc posteriorly. Also likely injury to the PLL at this
level.
3. DISH along the cervical spine, without evidence of bony
fracture or parivertebral hematoma.
[**2150-4-15**] CT HEAD:
IMPRESSION:
1. Right temporoparietal occipital hemorrhagic contusion
unchanged. Stable right subdural and epidural hematoma. Interval
increase in intraventricular hemorrhage in left occipital [**Doctor Last Name 534**].
2. Subfalcine herniation, effacement of right hemispheric sulci,
and mass effect on the right lateral ventricle, unchanged. No
evidence of uncal herniation.
[**2150-4-15**] EEG:
IMPRESSION: This is an abnormal portable EEG due to the abnormal
background consisting of low voltage, disorganized, and slow
activity
admixed with bursts of moderate amplitude bifrontally
predominant
generalized mixed frequency slowing. This constellation of
findings is
consistent with a mild to moderate encephalopathy suggestive of
dysfunction of bilateral, subcortical, or deep midline
structures.
Medications, metabolic disturbances, and infection are among the
common
causes of encephalopathy but there are others. There were no
areas of
prominent focal slowing although encephalopathic patterns can
sometimes
obscure focal findings. There were no epileptiform features and
no
electrographic seizure activity was noted. Note is made of some
irregularity in the cardiac rhythm.
[**2150-4-16**] CT HEAD:
IMPRESSION:
1. No significant change in the intraparenchymal, subdural,
epidural and subarachnoid hemorrhage.
2. No significant change in the intraventricular hemorrhage in
the occipital [**Doctor Last Name 534**] of the left lateral ventricle in the body of
the right lateral ventricle, mass effect and shift of the
midline structures.
[**2150-4-18**] CT HEAD:
IMPRESSION:
No change in intracranial findings. Sinus abnormalities, likely
due to intubation.
[**2150-4-15**] ECHO:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. 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%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic root is
mildly dilated at the sinus level. There is no aortic valve
stenosis. No aortic regurgitation is seen. A mitral valve
annuloplasty ring is present. The mitral prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. No mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2149-12-3**] ,
no change.
[**2150-4-22**] CT CHEST:
IMPRESSION: No evidence of recent pneumonia. Bilateral pleural
effusions with subsequent dependent atelectasis and signs of
interstitial fluid overload. Subtle subpleural parenchymal scars
in the right lung. Cardiomegaly after bypass surgery and
valvular replacement, extensive coronary calcifications. Some of
the numerically increased but normally sized mediastinal lymph
nodes show calcifications. Endotracheal tube and nasogastric
tube in situ.
[**2150-4-22**] CT SINUS:
CONCLUSION:
1. Minimal increased midline shift to the left with no
significant change in the overall appearances of the
intracranial findings.
2. Opacification of the sinuses and mastoid air cells as
described above.
[**2150-4-22**] CT HEAD:
CONCLUSION:
1. Minimal increased midline shift to the left with no
significant change in the overall appearances of the
intracranial findings.
2. Opacification of the sinuses and mastoid air cells as
described above.
[**2150-4-24**] BLE ULTRASOUND:
IMPRESSION: No lower extremity DVT.
[**2150-4-24**] EEG:
IMPRESSION: This is an abnormal routine EEG due to the
disorganized,
low voltage and slow background admixed with bursts of moderate
amplitude generalized delta frequency slowing. This
constellation of
findings is consistent with a mild to moderate encephalopathy,
suggesting dysfunction of bilateral subcortical and deep midline
structures. Medications, metabolic disturbances and infection
are among
the common causes of encephalopathy but there are others. There
were no
areas of prominent focal slowing, although encephalopathic
patterns can
sometimes obscure focal findings. There were no epileptiform
features.
[**2150-4-26**] CHEST:
SINGLE AP UPRIGHT CHEST RADIOGRAPH: The patient is status post
median sternotomy and mitral valve repair. A thoracotomy tube is
in similar position. The cardiomediastinal silhouette is
partially obscured by a layering small left effusion which is
likely slightly smaller than on prior study however, difficult
to accurately assess given change in positioning. Allowing for
lower lung volumes the lungs are clear.
[**2150-4-27**] ABDOMEN ULTRASOUND
IMPRESSION:
1. No son[**Name (NI) 493**] finding to suggest cholecystitis.
2. Single 5-mm hyperechoic foci adjacent to the gallbladder
wall, projecting into the lumen may represent a small polyp or a
single non-shadowing gallstone. The ability to assess for
mobility of this structure was limited, as the patient could not
be turned due to his clinical status.
[**2150-4-27**] CT HEAD:
IMPRESSION:
1. Increasing size and mass effect of right subdural hematoma
with increasing subfalcine herniation and leftward midline
shift. The contents of the subdural hemorrhage have evolved and
are now mixed density with areas of high attenuation suggesting
acute-on-chronic hemorrhage.
2. Unchanged large right-sided intraparenchymal hemorrhage.
3. Pansinus disease.
[**2150-4-28**] CT SINUS:
IMPRESSION:
Mild progression of right maxillary sinus opacification.
Improvement of left maxillary and bilateral ethmoid
opacification. Sphenoid opacification is essentially unchanged.
Fluid levels in the maxillary and sphenoid sinuses.
[**2150-4-28**] PLEURAL FLUID:
Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
[**2150-4-29**] CT HEAD:
IMPRESSION: Stable appearance of intraparenchymal hemorrhage and
subdural hematoma and stable appearance of subfalcine
herniation.
[**2150-4-30**] CT HEAD:
IMPRESSION:
1. Status post burr hole evacuation of right-sided subdural
hematoma with partial decompression.
2. Stable large right parietotemporal intraparenchymal
hemorrhage and tiny left occipital subarachnoid hemorrhage.
[**2150-5-1**] CXR:
There has been interval worsening in left lower lobe
atelectasis. Right lower lobe atelectasis is unchanged.
Tracheostomy tube remains in standard position.
Cardiomediastinal contours are unchanged.
RIGHT UPPER QUADRANT ULTRASOUND:
The liver displays normal homogeneous parenchyma with no
intrahepatic ductal dilatation, the common hepatic duct is
normal measuring 4 mm. The gallbladder displays multiple folds
in the region of the neck and a single 5-mm hyperechoic
non-shadowing focus adjacent to the wall. The ability to assess
for free movement cannot be performed due to patient's intubated
status. No wall edema or pericholecystic fluid collections were
identified. Limited evaluation of the 13cm right kidney and 12.8
cm left kidney is unremarkable, with no hydronephrosis or renal
calculi. The portal vein remains patent with normal hepatopetal
flow.
IMPRESSION:
1. No son[**Name (NI) 493**] finding to suggest cholecystitis.
2. Single 5-mm hyperechoic foci adjacent to the gallbladder
wall, projecting into the lumen may represent a small polyp or a
single non-shadowing gallstone. The ability to assess for
mobility of this structure was limited, as the patient could not
be turned due to his clinical status.
[**2150-5-4**] 06:40AM BLOOD WBC-11.4* RBC-3.28* Hgb-10.3* Hct-30.8*
MCV-94 MCH-31.5 MCHC-33.5 RDW-14.7 Plt Ct-282
[**2150-5-1**] 01:43AM BLOOD WBC-11.4* RBC-2.78* Hgb-8.8* Hct-26.5*
MCV-95 MCH-31.6 MCHC-33.2 RDW-15.0 Plt Ct-358
[**2150-4-15**] 04:05AM BLOOD WBC-8.9 RBC-2.95* Hgb-9.7* Hct-28.6*
MCV-97 MCH-32.9* MCHC-33.9 RDW-15.7* Plt Ct-145*
[**2150-4-13**] 11:10PM BLOOD WBC-8.3 RBC-3.35* Hgb-11.1* Hct-32.4*
MCV-97 MCH-33.1* MCHC-34.2 RDW-15.0 Plt Ct-161
[**2150-4-27**] 06:30AM BLOOD Neuts-86.0* Lymphs-8.7* Monos-3.7 Eos-1.3
Baso-0.3
[**2150-4-30**] 05:47AM BLOOD PT-13.0 PTT-27.1 INR(PT)-1.1
[**2150-4-13**] 11:10PM BLOOD PT-18.2* PTT-27.3 INR(PT)-1.7*
[**2150-5-4**] 06:40AM BLOOD Glucose-138* UreaN-27* Creat-0.8 Na-141
K-3.8 Cl-109* HCO3-24 AnGap-12
[**2150-4-27**] 06:30AM BLOOD Glucose-160* UreaN-37* Creat-0.9 Na-143
K-4.3 Cl-114* HCO3-20* AnGap-13
[**2150-4-19**] 02:51AM BLOOD Glucose-112* UreaN-50* Creat-1.5* Na-150*
K-4.3 Cl-120* HCO3-23 AnGap-11
[**2150-4-13**] 11:10PM BLOOD Glucose-408* UreaN-36* Creat-1.3* Na-140
K-5.1 Cl-101 HCO3-25 AnGap-19
[**2150-5-4**] 06:40AM BLOOD ALT-35 AST-41* LD(LDH)-294* AlkPhos-289*
TotBili-0.8
[**2150-4-29**] 06:10AM BLOOD ALT-69* AST-67* LD(LDH)-294* AlkPhos-342*
Amylase-66 TotBili-1.1
[**2150-4-20**] 03:36PM BLOOD ALT-91* AST-150* LD(LDH)-301*
AlkPhos-228* TotBili-0.6
[**2150-4-29**] 06:10AM BLOOD Lipase-40
[**2150-4-25**] 04:09PM BLOOD Lipase-77*
[**2150-4-13**] 11:10PM BLOOD cTropnT-<0.01
[**2150-5-4**] 06:40AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.7
[**2150-4-29**] 06:10AM BLOOD TotProt-5.5* Calcium-7.9* Phos-3.6 Mg-2.3
[**2150-4-28**] 06:12AM BLOOD Calcium-7.8* Phos-3.4 Mg-2.4 Iron-21*
[**2150-4-22**] 02:55AM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.5*
Mg-2.3
[**2150-4-28**] 06:12AM BLOOD calTIBC-163* VitB12-1424* Folate-GREATER
TH Ferritn-432* TRF-125*
[**2150-4-25**] 03:02AM BLOOD Osmolal-313*
[**2150-4-22**] 02:55AM BLOOD Osmolal-318*
[**2150-4-20**] 03:36PM BLOOD Osmolal-314*
[**2150-4-27**] 06:30AM BLOOD TSH-0.84
[**2150-4-22**] 02:55AM BLOOD Phenyto-4.3*
[**2150-4-29**] 09:40PM BLOOD Type-ART pO2-350* pCO2-34* pH-7.44
calTCO2-24 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2150-4-29**] 09:40PM BLOOD Glucose-125* Lactate-1.2 Na-141 K-3.5
Cl-115*
[**2150-4-29**] 09:40PM BLOOD Hgb-9.0* calcHCT-27
[**2150-4-29**] 09:40PM BLOOD freeCa-1.06*
[**2150-4-30**] 07:49AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.010
[**2150-4-29**] 11:11AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2150-4-26**] 06:45PM URINE Color-RED Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2150-4-25**] 08:39PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2150-4-24**] 09:37PM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2150-4-20**] 03:36PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2150-4-18**] 12:45AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2150-4-13**] 11:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2150-4-30**] 07:49AM URINE Blood-LG Nitrite-NEG Protein->300
Glucose-100 Ketone-40 Bilirub-LG Urobiln-4* pH-8.5* Leuks-LG
[**2150-4-29**] 11:11AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2150-4-26**] 06:45PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2150-4-25**] 08:39PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2150-4-24**] 09:37PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2150-4-20**] 03:36PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2150-4-18**] 12:45AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2150-4-13**] 11:40PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2150-4-30**] 07:49AM URINE RBC->50 WBC-[**11-19**]* Bacteri-FEW Yeast-FEW
Epi-0-2
[**2150-4-29**] 11:11AM URINE RBC-[**3-4**]* WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2150-4-25**] 08:39PM URINE RBC->50 WBC-[**3-4**] Bacteri-RARE Yeast-NONE
Epi-0-2
[**2150-4-24**] 09:37PM URINE RBC->50 WBC-[**6-9**]* Bacteri-NONE Yeast-NONE
Epi-0-2
[**2150-4-18**] 12:45AM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-1
[**2150-4-13**] 11:40PM URINE RBC-[**11-19**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2150-4-28**] 10:57AM PLEURAL WBC-240* RBC-700* Polys-58* Lymphs-11*
Monos-0 Meso-12* Macro-19*
[**2150-4-28**] 10:57AM PLEURAL TotProt-1.0 Glucose-255 LD(LDH)-82
[**2150-4-20**] 4:03 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2150-4-22**]**
GRAM STAIN (Final [**2150-4-20**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2150-4-22**]):
RARE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
A/P 77 yo M with h/o Afib, CAD s/p CABG and MR s/p MVR, DM2,
HTN, CKD who was admitted to [**Hospital1 18**] after mechanical fall and
subsequent SDH and ICH resulting in AMS, depressed neuro
function eventually requiring intubation, paralysis, sedation
with difficulty weaning from vent, now s/p trach/peg and
complicated by fevers, transaminitis, leukocytosis and sputum
positive for Klebsiella.
#. Subdural Hemorrhage/Intraparenchymal hemorrhage:
The patient was admitted on [**2150-4-14**] s/p fall with right parietal
IPH. He had been on coumadin for A-Fib prior to admission. He
also injured his ALL at C4-5; his All and PLL at C6-7 and is in
a hard cervical collar for 8-12 weeks per Dr.[**Name (NI) 2845**]
recommendation. He was in the ICU until [**2150-4-26**] and was then
transferred to the neuro step-down unit. The patient's neuro
exam remained poor. He was able to open his eyes. He
spontaneously moved his right side, localized with the RUE. He
withdrew bilateral lower extremities, and the LUE was flaccid.
On [**2150-4-27**] he had a repeat head CT which showed increase in
hemorrhage. The attending [**Date Range 39992**] felt that he did not need
any emergent surgery as his exam had been stable for several
days. Then, the patient's mental status was slightly worse,
with a worsened appearance on CT Head, and he was taken to the
OR for a craniotomy on [**2150-4-29**]. Post craniotomy CT head showed
decrease in the size of the SDH and stable appearance of the
IPH. His neuro status slowly improved prior to discharge, and
at the time of discharge, he was able to open eyes to voice,
withdraw R>L to noxious stimuli, but he was not fully following
commonds. The patient will follow-up with Dr. [**First Name (STitle) **] in 4 weeks
with a repeat head CT. Also, at that time, they will
re-evaluate the hard c-collar and whether he will need to
follow-up with Dr. [**Last Name (STitle) 548**] 2-4 weeks after that visit.
#. Ventilator Associated Pneumonia: The patient required
intubation for protecting his airway. It was difficult to wean
him off the ventilator. He developed fevers and leukocytosis,
and his sputum grew Klebsiella. He was started on a 15 day
course of ciprofloxacin which he will continue until [**2150-5-6**]. He
had a trach placed on [**2150-4-22**] and was able to be weaned off the
vent several days later.He was also noted to have bilateral
pleural effusion, and he underwent a left thoracentesis which
was consistent with a transudative effusion and no infection.
He had pansinus disease on CT, but ENT felt this was consistent
with intubation and NG tubing, and likely not the source of his
leukocytosis. Cultures were negative. He was started on nasal
saline irrigation and flonase sprays which he will continue for
one more week.
#. Transaminitis: During the initial start of his fevers and
leukocytosis, the patient also developed a transaminitis. He
had been on dilantin, which ID felt may have been the cause of
his transmaninitis. It was stopped, and he was transitioned to
Keppra, and his transaminitis slowly improved. He was treated
for VAP as above. *** Dilantin should be added to allergy list.
Family aware.
#. Anemia: The patient had anemia- likely from chronic disease.
He required 2 units of pRBCs. His iron studies were WNL. He
was guaiac negative. This will need to be monitored by his PCP.
# DM2: The patient had difficult to control glucose levels, but
was maintained on NPH and HISS. His blood glucose levels were
in the 150-250 range at the time of discharge.
# Hypertension: The patient will continue metoprolol, losartan,
and furosemide. He was also started on amlodipine for BP
control. His goal SBP is <160.
#. Hematuria: The patient developed hematuria prior to
discharge. It was thought to be due to foley trauma. It
improved prior to discharge and he was having clear urine.
# CT head and sinuses revealed pan sinusitis. ENT consulted who
felt that this is consistent with intubation and NG tubing, and
likely not the source of his leukocytosis. Cultures were
negative. He was started on nasal saline irrigation and flonase
sprays which he will continue for one more week after discharge.
# A gall bladder polyp was seen on US ?????? Defer to PCP [**Name9 (PRE) 39993**]
up.
He was evaluated by PT and was discharged to rehab for
aggressive PT with the follow up in clinic with neuro surgery/
spine surgery.
Medications on Admission:
atenolol 50 qd
losartan 100 qd
zocor 10 qd
coumadin 2mg qd
proscar 5 qd
terazosin 5 qd
humulin 70/30 40 units am and 25 pm
B12 1000mcg sq monthly
aspirin 81 qd
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
5. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
8. Levetiracetam 100 mg/mL Solution Sig: Five Hundred (500) mg
PO BID (2 times a day).
9. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q6H (every 6 hours) as needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 doses: last dose [**2150-5-6**] PM.
12. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever or pain.
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day) for 1 weeks.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
15. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily) for 1 weeks.
16. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: AS
DIRECTED units Subcutaneous twice a day: 46 units QAM, 40 units
QPM.
19. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED units
Subcutaneous four times a day: per sliding scale.
20. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
21. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Intracranial hemorrhage, Fall
Ventilator associated pneumonia, klebseilla
Diabetes Mllitus type 2
Sinusitis
Pleural effusions
Hematuria
Iron deficiency anemia
Sacral decubitus ulcer
Heart failure, acute on chronic
h/o CAD
Drug induced hepatitis (phenytoin)
Discharge Condition:
stable
Discharge Instructions:
You were admitted for a subdural hemorrhage and a bleed in your
brain. You required intubation and extubation, as well as a
feeding tube placement. You also required surgery to remove
some of the blood in your head. Your course was complicated by
a pneumonia which is being treated with a 15 day course of
antibiotics. Physical therapy and occupational therapy felt
that you would benefit from rehabilitation.
Please continue all prescribed medications. Please keep all
scheduled appointments.
If you develop any of the following concerning symptoms, please
call your PCP, [**Name10 (NameIs) 39992**], or go to the ED: new weakness,
worsening in mental status, fevers, chills, diarrhea, chest
pains, or shortness of breath.
Followup Instructions:
You must remain in a hard collar for 8-12 weeks, and you should
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**] at 8 weeks for the evaluation
of this. Please call his office @ [**Telephone/Fax (1) 2992**].
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-6-1**] 11:45
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2150-6-1**] 1:30
Please followup with Dr. [**First Name (STitle) **] as scheduled. Discuss with him
during your appointment regarding your neck brace, and they will
determine if you need to followup with Dr. [**Last Name (STitle) 548**].
Please call your PCP Dr [**Last Name (STitle) 14522**] [**Telephone/Fax (1) 14525**] to schedule an
appointment within the next 2-4 weeks.
|
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"280.9",
"348.4",
"723.0",
"428.33",
"573.3",
"599.7",
"482.0",
"853.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"96.04",
"34.91",
"01.39",
"31.1",
"96.72",
"38.93",
"33.22",
"96.6",
"99.04",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
27584, 27681
|
20974, 25394
|
1155, 1248
|
27982, 27991
|
3246, 5390
|
28770, 29625
|
2481, 2499
|
25604, 27561
|
27702, 27961
|
25420, 25581
|
28015, 28747
|
2514, 3227
|
228, 1117
|
1276, 2165
|
13741, 20951
|
2187, 2396
|
2412, 2465
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,524
| 133,175
|
15775+15776+56689
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2112-10-13**] Discharge Date: [**2112-10-27**]
Date of Birth: [**2055-10-26**] Sex: M
Service: NEUROSUR
CHIEF COMPLAINT: This is a 56 year old man with metastatic
pancreatic carcinoma transferred to [**Hospital1 18**] for neurosurgery
for C-4 compression fracture. On [**2112-10-24**] had respiratory
arrest. Patient extubated on [**2112-10-24**], transferred to medical
team on [**2112-10-25**].
HISTORY OF PRESENT ILLNESS: This is a 56 year old man with
metastatic pancreatic adenocarcinoma (with known liver
metastases) who was at [**State 1558**] [**2112-10-13**]
receiving radiation therapy session nine of 14 to an anterior
neck mass. There he was noted to have neck drooping. MRI
showed a large mass at C-4 (mass was initially seen on
[**2112-9-29**], but was not causing symptoms at that time).
Therefore, patient was transferred to [**Hospital1 18**] for surgery. He
had right shoulder weakness one week prior to transfer to
[**Hospital1 18**]. He went to the operating room on [**2112-10-14**] and received
C-4 and partial C-3 vertebrectomy, C2-C5 anterior fusion with
anterior cages and screw plate fixation. Pathology on the
spinal mass from the operation was metastatic poorly
differentiated adenocarcinoma. Postoperatively patient
complained of difficulty swallowing. On [**2112-10-19**] he had an
acute episode of shortness of breath. Chest x-ray showed
patchiness at bases consistent with aspiration. Patient did
have an episode of choking on water shortly prior. CT of
chest was obtained which showed fatty infiltration of the
liver with multiple lesions, largest 2.7 cm, no pulmonary
embolus, bilateral consolidation in the lower lobes, severe
calcification of the coronary arteries consistent with
coronary artery disease. Patient was sent to the surgical
intensive care unit where he was started on levofloxacin and
Flagyl on [**2112-10-20**]. On [**10-20**] a swallow study showed high
aspiration risk. Tube feeds were recommended. A Dobbhoff
tube was placed on [**2112-10-21**]. The tube was placed by
interventional radiology because it could not be successfully
placed on the floor. On [**2112-10-22**] patient was transferred to
the surgical floor. On [**2112-10-23**] he was found tachycardiac and
unresponsive with respiratory rate of 5, systolic blood
pressure in the 80s. He was intubated. Arterial blood gas
was 6.99/138/197. Patient was given intravenous fluids and
transferred to the medical intensive care unit. Antibiotics
were changed from levofloxacin to ceftazidime (for greater
gram negative coverage) and vancomycin. He was hypernatremic
with sodium of 155. He was started on half normal saline.
Sodium was 145 on [**2112-10-25**]. He was extubated on the morning
of [**2112-10-24**]. He recalled difficulty clearing a thick mucus
plug prior to his episode of unresponsiveness that required
intubation. Patient pulled out his NG tube on [**2112-10-25**].
Overnight [**2112-10-24**] he was noted to be agitated and confused
and this was felt to be due to delirium and sundowning. On
[**2112-10-25**] antibiotics were switched back to levofloxacin and
Flagyl and he was transferred to the medical floor on this
day.
PAST MEDICAL HISTORY: Bladder cancer, transitional cell
diagnosed in [**2110**], status post BCG, status post transurethral
resection of bladder in [**2110**]. Pancreatic adenocarcinoma with
liver metastases. He has received four cycles of 5FU and
leucovorin. Previously he had been receiving gemcitabine,
but it was stopped because of severe edema. Hypertension.
Type 2 diabetes. Hypercholesterolemia. Depression.
Anxiety.
OUTPATIENT MEDICATIONS: Accupril, atenolol, Neurontin 600 mg
b.i.d., buspirone 15 mg b.i.d., Xanax, fentanyl patch 50 mcg
per hour, Percocet, Vioxx, insulin NPH 32 units q.a.m. and 66
units q.p.m.
TRANSFER MEDICATIONS: Medications on transfer to the medical
floor on [**2112-10-25**] included levofloxacin 500 mg IV q.24 hours,
fentanyl patch 50 mcg per hour q.72 hours, olanzapine 5 mg
q.h.s., Ambien 5 to 10 mg q.h.s. p.r.n., droperidol 0.625 mg
IV q.six hours p.r.n. nausea, Percocet one to two tablets
p.o. q.four hours p.r.n. pain, morphine 2 mg IV q.four hours
p.r.n., Flagyl 500 mg IV q.eight hours, Protonix 40 mg p.o.
q.24 hours, acetaminophen p.r.n., insulin sliding scale
(standing doses of insulin held because patient not eating),
buspirone 15 mg p.o. b.i.d., gabapentin 600 mg p.o. b.i.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father died of myocardial infarction at age
39. Mother alive at age 83.
SOCIAL HISTORY: Lives with mother in [**Name (NI) 34422**]. Has a grown
son in the area, another grown son on the west coast.
Brother and sister live in the area. Divorced. Quit tobacco
and alcohol 25 years ago. Was working in the glass bottle
industry until six months ago.
PHYSICAL EXAMINATION: On [**2112-10-25**] temperature max equals
temperature current equals 101.6; pulse 102 to 122, currently
102; blood pressure 130 to 174 over 72 to 90; respiratory
rate 22 to 31; O2 saturation 92% to 98% on 4 liters O2 nasal
cannula. In general, pleasant, middle aged man in a cervical
collar in no apparent distress. HEENT: pupils equal, round
and reactive to light 6 to 4 mm. Oropharynx slightly dry.
Neck difficult to assess given presence of neck brace. Chest
clear to auscultation bilaterally anteriorly. Crackles at
right base posteriorly. Decreased breath sounds at left
base. Cardiovascular regular rate and rhythm, normal S1, S2,
no murmur. Abdomen soft, nondistended, nontender with
hypoactive bowel sounds. He is moving all four extremities
spontaneously.
LABORATORY DATA: On [**2112-10-27**] WBC 14.6, hematocrit 24.2. On
[**2112-10-25**] WBC 23.2, hematocrit 27.2. On [**2112-10-22**] WBC 22.5,
hematocrit 31.3. On [**2112-10-20**] WBC 22.9, hematocrit 29.2. On
[**2112-10-15**] WBC 10.0, hematocrit 28.5. On [**10-12**] WBC 9.4,
hematocrit 34.7. Platelets 221 on [**2112-10-27**]. On [**2112-10-23**] PT
14.0, PTT 23.4, INR 1.4. On [**2112-10-13**] PT 13.6, PTT 23.7, INR
1.3; platelets 367. On [**2112-10-27**] sodium 139, K 3.7, Cl 105,
CO2 24, BUN 7, creatinine 0.4, glucose 259. On [**2112-10-12**]
sodium 139, K 5.0, Cl 101, CO2 27, BUN 23, creatinine 1.0.
Cardiac enzymes, CPK drawn on [**2112-10-23**] and [**2112-10-24**] was 57, 46,
49. Troponin was less than 0.3. On [**2112-10-26**] calcium 7.3,
phosphate 3.0, magnesium 1.6. Microbiology data included
blood culture [**2112-10-25**] anaerobic bottle with gram positive
cocci, aerobic bottle with coagulase negative Staphylococcus.
On [**2112-10-24**] blood culture no growth to date as of [**2112-10-27**].
Sputum culture [**2112-10-23**] positive for yeast, but appears to be
contaminant. On [**2112-10-20**] blood culture no growth as of
[**2112-10-27**]. Significant imaging studies included on [**2112-10-13**]
cervical spine x-rays showed complete destruction of the C-4
vertebral body, marked prevertebral soft tissue swelling.
There was slight anterior kyphosis. CT of chest [**2112-10-19**]
showed fatty infiltration of liver with some round,
relatively hyperdense lesions within it. Lesions are seen on
both sides of the lobes of the liver. The largest lesion had
a diameter of 2.7 cm. There was no pulmonary embolus
present. There was an air fluid level within the trachea
which may be consistent with secretions or aspiration. Chest
x-ray [**2112-10-19**] at lung bases bilaterally there are patchy
opacities which are new in comparison with the prior study,
question aspiration. Chest x-ray [**2112-10-20**] in the interval
there has been resolution of the previously visible right
middle lobe and left lower lobe opacities, however,
plate-like atelectasis persists at the bases. Chest x-ray
[**2112-10-25**] there is again evidence of patchy atelectasis at the
left lung base and minimal atelectatic changes may also be
present in the right lower lobe. No evidence of failure.
HOSPITAL COURSE: This is a 56 year old man with metastatic
pancreatic cancer who presented to [**Hospital1 18**] for cervical spine
surgery. His postoperative course was complicated by
aspiration pneumonia and respiratory arrest on [**2112-10-22**]. Much
of the hospital course has already been dictated in the
history of present illness.
1. Respiratory arrest. Per history it appears that the
arrest occurred because he had a large mucus plug that he was
unable to clear. Hypercarbia then led to depressed mental
status. When we saw patient on [**2112-10-27**] he was breathing
comfortably and reported only minimal sputum production. He
was continued on suctioning as well as chest P.T.
2. Pneumonia. Patient likely had aspiration pneumonia by
history with x-rays showing bibasilar opacities and by
increase in WBC from 10 to 20 on the day of the witnessed
aspiration event. Patient was continued on levofloxacin and
Flagyl. As of [**2112-10-27**] WBC count had fallen from 23.2 on
[**2112-10-25**] to 14.6 on [**2112-10-27**]. Patient was hemodynamically
stable and afebrile on [**2112-10-27**].
3. Spinal surgery. Neurosurgery recommended leaving the
collar in place for a full 12 weeks. Patient is allowed to
sit up in bed and get out to a chair.
4. Nutrition. Patient failed a repeat swallow study on
[**2112-10-26**] and had severe aspiration of both thin and thick
liquids. Prior to his admission to the hospital his ability
to swallow food had deteriorated greatly secondary to the
mass in his neck. At time of admission he was taking four
containers of yogurt a day, but had been unable to take other
foods. Given this poor baseline swallowing as well as his
difficulty with swallowing postoperatively, the decision was
made to have a G-tube placed for nutrition. G-tube placement
tentatively scheduled for [**2112-10-28**].
5. Diabetes. Patient had blood sugars covered with insulin
sliding scale while not taking oral intake. We plan to
transition back to standing doses of insulin after he is able
to have oral or tube feed intake.
6. Cancer. In terms of his cancer, he would not be
undergoing radiation therapy nor chemotherapy while he has an
active infection. This issue can be resolved after the
infection has resolved.
DISPOSITION: The patient may go to a rehabilitation facility
when he is medically cleared. Patient is up to date as of
[**2112-10-27**] at 12:00 p.m.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36
D: [**2112-10-27**] 12:18
T: [**2112-10-27**] 12:37
JOB#: [**Job Number 35754**]
Admission Date: [**2112-10-13**] Discharge Date: [**2112-11-2**]
Date of Birth: [**2055-10-26**] Sex: M
Service: [**Doctor Last Name 1181**]
ADDENDUM TO HOSPITAL COURSE THROUGH [**2112-10-27**]: 1. Pulmonary:
Per the previous discharge summary the patient had an
aspiration pneumonia. He was treated on Levofloxacin and
Metronidazole to complete a fourteen day course, which will
end on [**2112-11-5**]. The patient continues to show evidence of
bilateral lower lobe processes on chest x-ray and had
physical findings in those areas as well suggestive of
aspiration pneumonia. On [**10-31**] the patient had a low grade
fever. Chest x-ray was rechecked, which showed the
possibility of another aspiration event mostly seen in the
right lower lobe. The patient's temperature went as high as
101. He was continued on the Levo and Flagyl to cover what
was thought to be a recurrent aspiration event. At the time
of discharge the patient continues to run low grade
temperatures from 99 to 100.5. It is unclear if these
temperatures are due to his pneumonia or if they are a tumor
fever. Blood cultures and urine cultures are negative to
date from that previous spike to 101. The likelihood that
this is a tumor fever is very real. He continued to have
chest physical therapy and suctioning as needed, which he did
by himself with a yank hour suction. He had no complaints of
any difficulty breathing at the time of discharge.
2. Nutrition: As stated in previous discharge summary a PEG
was planned for [**10-28**]. A PEG was placed by
interventional radiology and after 24 hours tube feeds were
begun. Tube feeds consisted of ProMod with fiber and at the
time of discharge the patient is at his goal rate of 85 cc
per hour, which he is tolerating without a problem.
3. Type 2 diabetes: The patient continues to have high
finger sticks in the 200s and 300s. He has been covered with
an insulin sliding scale as well as NPH insulin fixed doses.
The doses of NPH were recently increased to 20 units in the
morning and 30 units in the evening. His outpatient doses,
however, were 32 units in the morning and 66 units in the
evening with slowly increase in the dosages of his NPH,
because he had been not eating for so long or titrating to
proper doses. In addition to the NPH he was covered with a
regular insulin sliding scale.
4. Hematology: The patient's hematocrit fell slowly over
the course of days to a low point of 24.2 and on the [**10-27**] he was transfused 1 unit of packed red blood cells,
which he tolerated without a problem. Since then his
hematocrit has remained stable at around 30. It is
recommended that while at rehab his hematocrit is followed
and that he is transfused if he drops below 25 as he has no
history of coronary artery disease.
5. Status post C4 vertebrectomy and C2-C5 anterior fusion:
The patient continues to have his neck collar in place, which
will have to be worn for twelve weeks. The patient is
instructed to follow up with Dr. [**Last Name (STitle) 1327**] three weeks after
discharge with AP and lateral C spine films prior to that
appointment. Throughout his stay on the [**Doctor Last Name **] Service the
patient had no symptoms of right upper extremity weakness as
he had prior to the surgery. He still does complain of pain
in his neck, which is well treated with morphine elixir 10 to
20 mg q 4 hours prn.
6. Anxiety: The patient's anxiety continued. Once the PEG
tube was placed we were able to restart his Buspirone and
Xanax with good effect.
DISCHARGE MEDICATIONS: Levofloxacin 500 mg per PEG tube q.d.
to end on [**2112-11-5**]. Flagyl 500 mg per PEG t.i.d. to end on
[**2112-11-5**]. Morphine elixir 10 to 20 mg q 4 hours prn,
Fentanyl patch 75 micrograms per hour q 72 hours to be
changed next on [**2112-11-3**]. Xanax 0.5 mg t.i.d. prn, Buspirone
15 mg b.i.d., Lansoprazole 30 mg q day, Zyprexa 5 mg q.h.s.,
Zyprexa 5 mg prn delirium or agitation. Compazine 10 mg per
PEG q 6 hours prn for nausea. NPH insulin 20 units q.a.m.,
30 units q.p.m., Tylenol 325 to 650 mg q 4 to 6 hours prn,
Gabapentin 600 mg b.i.d., regular insulin sliding scale,
Colace 100 mg b.i.d., Dulcolax suppository 10 mg pr h.s. prn.
DISCHARGE DIAGNOSES:
1. Stage four pancreatic cancer status post C4 vertebrectomy
and C2-5 anterior fusion.
2. Transitional cell carcinoma.
3. Hypertension.
4. Type 2 diabetes.
5. High cholesterol.
6. Anxiety.
7. Status post PEG tube placement on [**2112-10-28**].
DISCHARGE STATUS: The patient is discharged to [**Hospital3 45430**] Rehab Facility with instructions to follow up with
Dr. [**Last Name (STitle) 1327**] from neurosurgery in three weeks at [**Telephone/Fax (1) 1669**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 34939**]
Dictated By:[**First Name3 (LF) 18523**]
MEDQUIST36
D: [**2112-11-2**] 10:11
T: [**2112-11-2**] 10:30
JOB#: [**Job Number 45431**]
Name: [**Known lastname **], [**Known firstname 63**] Unit No: [**Numeric Identifier 8338**]
Admission Date: [**2112-10-13**] Discharge Date: [**2112-11-4**]
Date of Birth: [**2055-10-26**] Sex: M
Service: [**Doctor Last Name **]
AGE: 57-YEAR-OLD MALE.
ADDENDUM: The patient was not discharged as planned. On the
day of the proposed discharge, the patient continued to spike
fevers, as high as 101.7, axillary temperature. Chest x-ray
was obtained again, which showed possibly slightly worsening
of the infiltrate in the right lower lobe. In addition, the
patient had had increased sputum production with a change in
character, changing from yellow to green. The patient did
not require any increase in supplemental oxygen saturation
nor did he feel febrile in the setting of his fevers. At
this point, he was day #11 on Levofloxacin and Metronidazole.
Antibiotics were changed to Ceftazidime and Clindamycin to
broaden coverage to include Pseudomonal and Staphylococcus
coverage empirically. He defervesced and remained afebrile,
thereafter. The plan would be to continue the Ceftazidime
and to Clindamycin to complete another ten-day course.
DISCHARGE MEDICATIONS:
1. Ceftazidime 1 gram IV q.8h. to end on [**2112-11-13**].
2. Clindamycin 600 mg IV q.8h. to end on [**2112-11-13**].
3. Fentanyl patch 75 mcg per hour q.72 hours.
4. MSIR 10 mg to 20 mg per PEG q.4h. The patient may refuse
dose.
5. Dilaudid 2 mg per PEG q.4h.to 6h.p.r.n. pain.
6. Lansoprazole 30 mg per PEG q.d.
7. Zoloft 50 mg per PEG q.d.
8. Klonopin 0.5 mg per PEG t.i.d.
9. NPH insulin 30 units b.i.d.
10. Regular insulin sliding scale.
11. Colace 100 mg per PEG b.i.d.
12. Dulcolax 10 mg pr, q.d. p.r.n. constipation.
13. Compazine 10 mg per PEG q.6h.p.r.n. nausea.
14. Buspirone 15 mg per PEG b.i.d.
15. Gabapentin 600 mg per PEG b.i.d.
16. Heparin 5000 units subcutaneously q.12h.
17. Tylenol 325 mg to 650 mg q.4h. to 6h.p.r.n.
18. Zyprexa 5 mg per PEG q.h.s. p.r.n. agitation.
[**Name6 (MD) 511**] [**Name8 (MD) 512**], M.D. [**MD Number(1) 513**]
Dictated By: [**Name6 (MD) **] [**Name8 (MD) **], M.D.
MEDQUIST36
D: [**2112-11-4**] 13:27
T: [**2112-11-4**] 15:56
JOB#: [**Job Number 8339**]
|
[
"507.0",
"198.5",
"401.9",
"997.3",
"733.13",
"157.8",
"276.0",
"799.1",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"44.32",
"81.02",
"96.6",
"77.89",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4520, 4594
|
14925, 16835
|
16858, 17918
|
8017, 14229
|
3683, 3857
|
4898, 7999
|
162, 441
|
3880, 4503
|
470, 3226
|
3249, 3658
|
4611, 4875
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,337
| 149,181
|
48517
|
Discharge summary
|
report
|
Admission Date: [**2135-12-5**] Discharge Date: [**2136-1-5**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**12-16**] Exploratory lap with diverting ileostomy; G-J tube
placement; appendectomy; washout and VAC placment
History of Present Illness:
85 yo male with abdominal pain, distention and diarrhea for 1
week prior to admission. Was seen in [**State 108**] and diagnosed with
?hernia. He and his wife came back to [**State 350**] for further
workup. He was admitted to [**Hospital1 18**] with an obstructing splenic
mass.
Past Medical History:
HTN
Hiatal hernia
TIA (on Plavix)
Asthma
Spinal stenosis
AR and MR (requires SBE prophylaxis)
Social History:
Married and lives with wife
[**Name (NI) **] in [**Name (NI) 108**] during winter months
Family History:
Noncontributory
Physical Exam:
on discharge:
vitals: 98.9 81 148/74 20 94 (RA)
Chest: CTAB
CV: RRR
Abdomen: large midline granulating incision. Dressing C/D/I,
abdomen soft, NT, ND, large girth. Right sided colostomy bag.
Ext: No C/C/E, warm.
Pertinent Results:
Blood Urine CSF Other Fluid Microbiology
Recent
Last Day Last Week Last 30 Days All Results Hide Comments
From Date To Date
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2136-1-3**] 05:25AM 13.4* 3.39* 10.4* 31.6* 93 30.7 32.9
15.7* 440
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2135-12-25**] 02:12AM 79* 2 11* 5 1 0 2* 0 0
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2136-1-3**] 05:25AM 440
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
FDP
[**2135-12-18**] 04:04AM 611*
ART
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2136-1-3**] 05:25AM 141* 22* 0.9 131* 4.2 95* 31 9
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2136-1-3**] 05:25AM Using this1
1 Using this patient's age, gender, and serum creatinine value
of 0.9,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2135-12-28**] 01:27AM 36*
OTHER ENZYMES & BILIRUBINS Lipase
[**2135-12-18**] 04:04AM 35
ART
CPK ISOENZYMES CK-MB cTropnT
[**2135-12-28**] 01:27AM NotDone1 0.03*2
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2136-1-3**] 05:25AM 2.5* 8.1* 2.0* 1.7 PND
HEMATOLOGIC TRF
[**2136-1-3**] 05:25AM PND
LIPID/CHOLESTEROL Cholest Triglyc
[**2135-12-10**] 03:08PM 1021
CK CPIS TNT ADDED 7:50P [**2135-12-10**]
1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
IMMUNOLOGY CEA
[**2135-12-6**] 06:15AM <1.01
1 <1.0
MEASURED BY [**Doctor Last Name 8721**] ELECSYS (ECLIA)
LAB USE ONLY GreenHd HoldBLu
[**2135-12-28**] 01:27AM HOLD1
1 HOLD
DISCARD GREATER THAN 4 HOURS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat Vent Comment
[**2135-12-31**] 12:38PM [**Last Name (un) **] 7.45
[**2135-12-31**] 03:43AM [**Last Name (un) **] 99 46* 7.49* 36* 10
GREEN TOP1
1 GREEN TOP
L. SC CVL
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2135-12-27**] 08:49AM 102 4.1
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat COHgb
MetHgb
[**2135-12-23**] 12:54PM 96
CALCIUM freeCa
[**2135-12-31**] 12:38PM 1.20
[**2135-12-31**] 03:43AM 1.10*
Sinus rhythm
Left axis deviation - anterior fascicular block
Poor R wave progression - could be secondary to left anterior
fascicular block
Since previous tracing, right bundle branch block absent
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 192 84 420/442.14 23 -57 41
CHEST (PORTABLE AP)
Reason: sob, eval for effusion or chf
[**Hospital 93**] MEDICAL CONDITION:
84 year old man s/p diverting ileostomy w/ new line
REASON FOR THIS EXAMINATION:
sob, eval for effusion or chf
AP CHEST 9:23 A.M. ON [**12-27**].
HISTORY: Ileostomy. New central line. Suspect pleural effusion.
IMPRESSION: AP chest compared to [**12-23**] through 22:
Moderate bilateral pleural effusions, not changed appreciably
since [**12-26**]. Persistent severe left lower lobe atelectasis
and at least moderate cardiomegaly. Pulmonary vascular
congestion has worsened. Tip of the left subclavian line
projects over the left brachiocephalic vein. No pneumothorax.
PATHOLOGY REPORT:
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 102113**],[**Known firstname 1955**] [**2050-12-24**] 84 Male [**Numeric Identifier 102114**]
[**Numeric Identifier 102115**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: LEFT COLECTOMY AND OMENTUM, PROXIMAL BOWEL,
OMENTUM OF TRANSVERSE COLON & SPLEEN.
Procedure date Tissue received Report Date Diagnosed
by
[**2135-12-8**] [**2135-12-8**] [**2135-12-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/kg
DIAGNOSIS:
I. Specimen designated "proximal bowel" (A,B):
Segment of colon; no diagnostic abnormalities recognized.
II. Omentum of transverse colon (C,D):
No diagnostic abnormalities recognized.
III. Spleen (80 grams) (E,F):
Capsular fibrosis; fresh hemorrhage in the hilar area.
IV. Segmental resection of left colon (G-AC):
1. Adenocarcinoma; see synoptic report.
2. Diverticulosis.
V. Omentum (AD-AF):
No diagnostic abnormalities recognized.
Colon and Rectum: Resection Synopsis
MACROSCOPIC
Specimen Type: Colonic resection. Location: Transverse/left
colon.
Specimen Size
Greatest dimension: 86.5 cm.
Tumor Site: Splenic flexure.
Tumor configuration: Annular.
Tumor Size
Greatest dimension: 6.0 cm. Additional dimensions: 2.0
cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: Low-grade (moderately differentiated).
EXTENT OF INVASION
Primary Tumor: pT3: Tumor invades through the muscularis
propria into the subserosa.
Regional Lymph Nodes: pN1; (see comments): Metastasis in 1 to
3 lymph nodes.
Lymph Nodes
Number examined: 23.
Number involved: 2.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 180 mm.
Distal margin:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 170 mm.
Circumferential (radial) margin:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 55 mm.
Lymphatic Small Vessel Invasion: Present. Intramural.
Venous (large vessel) invasion: Absent.
Perineural invasion: Absent.
Tumor border configuration: Infiltrating.
Comments: One of the two positive lymph nodes is directly
beneath the colonic cancer. The second positive lymph node is
the apex mesenteric lymph node designated with a suture by the
surgeon.
Clinical: Obstructing colonic mass near splenic flexure.
Gross:
The specimen is received fresh in five parts, all labeled with
"[**Known firstname **] [**Known lastname **]" and the medical record number.
Part 1 is additionally labeled "proximal bowel" and consists of
a segment of bowel measuring 4.2 cm long x 5.4 cm in greatest
diameter, stapled at both ends. The specimen is inked and
opened to reveal mucosa that appears unremarkable, with no
evidence of masses, or areas of hemorrhage or ulceration. The
specimen is represented as follows: A = margins, B = remainder
of the representative sections through the mucosa.
Part 2 is additionally labeled "omentum of transverse colon" and
consists of a fragment of grossly unremarkable fatty tissue
measuring 7 x 4.4 x 1.6 cm. No nodules or tumors are
identified. It is serially sectioned to reveal unremarkable
fibrofatty cut surfaces. The specimen is represented in C-D.
Part 3 is additionally labeled "spleen" and consists of a spleen
weighing 80 grams and measuring 8.0 x 5.6 x 3.8 cm. On the
capsule are diffusely scattered fibrous patches. The specimen
is serially sectioned to reveal red cut surfaces without any
evidence of masses or nodules. The specimen is represented as
follows; E = multiple sections taken through the spleen and
capsule demonstrating the exudate. F = sections taken through
splenic hilum.
Part 4 is additionally labeled "left colectomy" and consists of
a segment of colon measuring 86.5 cm in length by 7 cm in
maximum diameter. It is stapled at both ends. It is inked and
opened to reveal a circumferential mass measuring 2.0 cm in
length, 17 cm from the distal end and 18 cm from the proximal
end. The circumference of the mass is 6.0 cm. The proximal end
of the colon is mildly dilated with respect to the distal end.
The serosa subjacent to the mass is not adherent or puckered.
The distance from the mass to the radial margin is 5.5 cm,
grossly. No other masses and no polyps are noted. The specimen
is represented as follows: G=proximal margin, H=distal margin,
I-M=sections through the mass, N=sections through grossly
unremarkable colon distal to mass, O=sections through grossly
unremarkable colon proximal to the mass, P=the bisected apex
mesenteric lymph node, which is indicated by the surgeon with a
suture. Q-AC=possible lymph nodes. Gross diagnosis by Dr. [**Last Name (STitle) 7108**]
is, "Annular carcinoma of the colon; final diagnosis pending
microscopic examination."
Part 5 is additionally labeled "omentum". It consists of a sheet
of fibroadipose tissue measuring 20.1 x 8.3 x 2.1 cm. It is
sectioned to reveal grossly unremarkable tissue, with no masses
or nodules present. It is represented in AD-AF.
Brief Hospital Course:
He was admitted to the Surgical service under the care of Dr.
[**Last Name (STitle) **]. He underwent abdominal CT imaging which revealed an
obstructing colonic mass. He was taken to the operating room on
[**12-7**] for left colectomy and splenectomy. Pathology showed a T3N1
colonic adenocarcinoma. Postoperatively he did fairly well until
[**12-16**] when he began to show signs of an anastomotic leak
(abdominal distention, pain, decreased UOP). He was taken back
to the operating room where an ex-lap with G-J tube placement,
appendectomy, and diverting ileostomy was performed.
Post-operatively, the patient required large amounts of volume
to support his hemodynamics. On POD 0, he also had an episode of
low oxygen saturations, hypos tension. He was bronched, and
chest was needled. A L SCL was placed and a swan floated. A
chest tube was also placed for a small pneumothorax. He was
also started on pressors. Three days later he began to improve,
diuresis was begun, and pressors were weaned. He tolerated his
tube feeds, chest tube d/c'd on [**12-23**], and he was successfully
extubated on [**12-24**]. He was subsequently transferred to the floor,
where he did well. Diuresis was continued, he began to tolerate
oral intake, and calorie counts were started. He was discharged
on post-operative days 26/20 in good condition, to rehab
facility where calorie counts will continue, and his nutritional
status will continue to be worked on. Appropriate follow-up was
arranged. His primary care doctor, Dr. [**Last Name (STitle) **], was notified, via
e-mail, that the patient will need follow-up with an oncologist
as an outpatient.
Medications on Admission:
Plavix 75'
Flomax 0.4'
Cozaar 50'
Lipitor 10'
Lopressor 25''
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ML
Injection TID (3 times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
4. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
5. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day): hold for HR <60; SBP <110.
8. Losartan 50 mg Tablet [**Last Name (STitle) **]: 1 [**12-6**] Tablet PO DAILY (Daily):
hold fro SBP <110.
9. Polyvinyl Alcohol 1.4 % Drops [**Month/Day (2) **]: 1-2 Drops Ophthalmic Q4-6H
(every 4 to 6 hours) as needed for dry eyes.
10. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet [**Telephone/Fax (3) **]: Two
(2) Packet PO TID (3 times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet [**Telephone/Fax (3) **]: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
12. Furosemide 20 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO BID (2 times
a day).
13. Insulin Regular Human 100 unit/mL Solution [**Telephone/Fax (3) **]: One (1) dose
Injection four times a day as needed for per sliding scale.
14. Impact/Fiber Liquid [**Telephone/Fax (3) **]: 80 cc/hr bag PO cycle over 12h
from 1800 to 0600 every night: Tubefeeding: Impact w/ fiber Full
strength;
Goal rate: 80 ml/hr
Cycle?: Yes, starting now Cycle start: 1800 Cycle end: 600
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 30 ml water qd.
Disp:*20 bags* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Obstructing splenic mass
Discharge Condition:
Stable
Discharge Instructions:
- continue to eat a regular diet, please take a nutrient
enriched shake (like ensure) with each meal.
- you are being discharged on your tube feeds. You will need to
continue your tube feeds until the amount of calories you take
by mouth improves. A nutritionist at the your new facility will
help guide this process.
- you may shower, but please keep your abdominal wound dry.
- the wound on your abdomen is open, you will need to continue
twice a day wet to dry dressing changes to help the wound heal.
- return to the emergency room should you experience any
increased drainage or redness from your abdominal wound, or
increased abdominal distention, decreased oral intake, recurrent
fever spikes, intractable nausea, or vomiting.
- you have a list of follow-up appointments below, please make
sure you call each office to confirm your scheduled date/time,
or to book an appointment if one has not already been done.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 1 week, call [**Telephone/Fax (1) 6439**] for an
appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Date/Time:[**2136-1-24**] 12:15
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2136-5-8**] 10:30
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2136-7-6**] 10:00
Please call Dr.[**Name (NI) 3588**] office for a follow-up appointment. The
number to call is [**Telephone/Fax (1) 3393**]. You will also need follow-up
with an oncologist. Your PCP is aware of this.
Completed by:[**2136-1-5**]
|
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42,177
| 133,955
|
35160
|
Discharge summary
|
report
|
Admission Date: [**2117-10-14**] Discharge Date: [**2117-10-15**]
Date of Birth: [**2036-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Gallstone pancreatitis/acute calculous cholecystitis
Major Surgical or Invasive Procedure:
ERCP [**10-15**]
History of Present Illness:
This is an 81 year-old male with a history of cardiomyopathy w/
EF 20% and Afib on Coumadin who presented to [**Hospital 8641**] hospital
with gallstone pancreatitis/acute calculous cholecystitis now
s/p cholecystectomy w/ retained CBD stone being transferred to
[**Hospital1 18**] for repeat ERCP. His initial sx started on [**8-9**] while he
was playing golf. He describes epigastric and RUQ abdominal pain
followed by nausea and vomiting and was admitted to [**Hospital 8641**]
Hospital on [**8-10**]. RUQ U/S performed on [**10-10**] showed innumerable
gallstones, mild GB wall thickening and small amt of
pericholecystic fluid with prominent CBD at 7mm. His labs were
significant at that time for leukocytosis to 16.3 (N 87%, 11
bands), INR 3.8, lipase 9,856, TBili 1.6 (direct 0.4), and mild
transaminitis. Both surgery and GI teams were consulted and felt
that his presentation was most consistent with acute
cholecystitis and acute pancreatitis (gallstone vs. EtOH). He
was monitored for several days while pancreatitis improved and
planned for cholecystectomy and intraop cholangiogram, during
which time he was treated with Zosyn. His WBC trended down to
7.4, AST/ALT returned to [**Location 213**], lipase trended down to 500s,
and TBili increased to 3.8 (DBili 1.0). His INR was reversed
with Vit K and FFP and he was brought to the OR on [**10-14**] and
gallbladder removed. He was found to have choledocholithiasis
under fluoroscopy. ERCP was attempted post-operatively, and had
a dilated pancreatic duct w/ apparent small stone, but team was
unable to selectively cannulate CBD so plan was made to transfer
to [**Hospital1 18**] for repeat ERCP.
Also of note, the patient had difficult to control atrial
fibrillation and cardiology c/s was obtained [**10-14**], recommending
increased dose of Toprol to 100mg daily as well as digoxin
0.25mg daily.
.
On transfer, the patient reports diffuse abdominal pain ([**7-1**]),
though no nausea, CP, palpitations or SOB. He required
supplemental O2 in the ambulance.
.
ROS: + Redness/pain on medial aspect of L great toe started
yesterday. The patient denies any fevers, chills, weight change,
melena, chest pain, shortness of breath, orthopnea, PND, lower
extremity oedema, cough, focal weakness, rash.
Past Medical History:
- Non-ischemia cardiomyopathy - LVEF 20% range (recent abnormal
stress test --> cardiac cath [**2117-9-1**] - nonobstructive coronary
dz)
- Atrial fibrillation on Coumadin
- Hypertension
- Hypothyroidism
- Hyperlipidemia
- Erectile dysfunction
- B12 deficiency
- s/p L inguinal hernia repain
- Colonic polyposis
Social History:
Lives alone in his home. He has cared for his wife who has
dementia and now is in [**Hospital3 **]. Worked for [**Company **], now retired. Never smoked. Drinks 0-2 alcoholic
beverages/day.
Family History:
Daughter recently diagnosed with colon cancer, brother with CAD
Physical Exam:
Tmax: 38.4 ??????C (101.1 ??????F)
Tcurrent: 37 ??????C (98.6 ??????F)
HR: 98 (96 - 122) bpm
BP: 155/90(106) {146/71(89) - 157/90(153)} mmHg
RR: 24 (22 - 27) insp/min
SpO2: 92%
Heart rhythm: AF (Atrial Fibrillation)
Height: 73 Inch
GEN: Mild distress secondary to pain
HEENT: EOMI, PERRL, sclera + icterus, erythema of posterior
oropharynx
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Irreg irreg. no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs decreased BS at bases bilaterally, no W/R/R
ABD: Distended, laparoscopic incisions without erythema or
discharge. Tender to palpation, no guarding or rebound
tenderness. +bowel sounds
EXT: Erythema/warm of head of the 1st metatarsal bone on the
left with slight extension onto dorsum of the foot. L ankle warm
compared to R. No edema. 2+ dp pulse b/l.
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: + Jaundice. otherwise no rashes
Pertinent Results:
[**2117-10-15**] 04:39AM BLOOD WBC-9.5 RBC-3.55* Hgb-11.3* Hct-32.1*
MCV-91 MCH-31.8 MCHC-35.1* RDW-13.1 Plt Ct-245
[**2117-10-15**] 04:39AM BLOOD PT-16.7* PTT-27.1 INR(PT)-1.5*
[**2117-10-15**] 04:39AM BLOOD Glucose-81 UreaN-11 Creat-1.0 Na-139
K-3.5 Cl-102 HCO3-26 AnGap-15
[**2117-10-14**] 10:37PM BLOOD ALT-30 AST-42* LD(LDH)-228 AlkPhos-142*
Amylase-143* TotBili-6.8* DirBili-3.6* IndBili-3.2
[**2117-10-15**] 04:39AM BLOOD Lipase-190*
[**2117-10-14**] 10:37PM BLOOD Lipase-557*
[**2117-10-15**] 04:39AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.9
[**2117-10-14**] 10:37PM BLOOD Albumin-3.4 Calcium-8.9 Phos-2.8 Mg-1.8
UricAcd-3.1*
Blood Cx: PENDING
Urine Cx: PENDING
[**Hospital 8641**] Hospital ([**Date range (1) 67260**]):
WBC 16.3 (N 87.4, Band 11) --> 10.0 --> 10.1 --> 10.4 --> 7.4
HCT 41.3 --> 38.5 --> 32.8 --> 30.2 --> 30.6
Plt 265 (stable)
INR 3.8 --> 4.3 --> 2.1 --> 1.8
Na 143, K 4.4, Cl 112, CO2 26, BUN 19 --> 12, Creat 1.3 --> 1.0
Lipase 9856 --> 3649 --> [**2026**] --> 371 --> 340 --> 534
Amylase 627 --> 52
AST 131 --> 22
ALT 98 --> 37
AP 95 (stable)
Uric acid 3.2
TBili 1.6 --> 3.5 --> 3.4 --> 3.9 --> 3.8
Direct bili 0.4 --> 1.0
BNP 273
.
U/A: negative gluc, neg ket, neg LE, neg nitr
Abd U/S [**10-10**] - Innumerable gallstones, mild GB wall thickening
and small amt of pericholecystic fluid with prominent CBD at
7mm.
.
Abd U/S [**10-13**] - Cholelithiasis w. thick gallbladder wall w/ some
pericholecystic fluid. Stone lodged into the gallbladder neck
with dilatation of the common duct up to 7mm and some
intrahepatic biliary duct dilatation.
Brief Hospital Course:
Assesment: This is an 81 yo M with CHF (EF 20%), Afib on
Coumadin presenting to [**Hospital 8641**] hospital w/ abd pain, found to
have acute gallstone pancreatitis and calculous cholecystitis,
now s/p lap chole and failed ERCP attempt at retreiving
visualized CBD stone with plan for repeat ERCP in am.
Plan:
1. Acute calculous cholecystitis/pancreatitis: See HPI for
pre-admission course. On admission to the ICU the patient was
febrile (100-101) with a WBC count of 9.2. The patient was
continued on on pip/tazo during his hospital course. An ERCP was
performed successfully on [**10-15**] without immediate complications.
2. Atrial fibrillation: Uncontrolled on transfer with rates in
120s. Pain control seems to be at least part of the issue and he
was started on IV morphine prn. The patient was started on rate
control with metoprolol and digoxin at the OSH. He was given
5mg IV lopressor for initial rate control and started in 37.5mg
metoprolol TID. Additionally, he was given 0.25mg of Digoxin in
the AM. The patient's INR was reversed for surgery (INR 1.5).
3. CHF (EF 20%): The patient had a new O2 requirement from
baseline. CXR revealed pulmonary edema. Additionally, the
patient has poor lung volumes secondary to splinting from the
pain. The patient has difficult fluid balance keeping up fluid
status post-op and preventing volume overload. His betablocker
and ACE-I were held during his admission, but should be
restarted post-ERCP.
4. L foot erythema: Pt with erythema on his right great toe.
The patient was given 1 dose of cochicine at the OSH. The
differenitial includes gout, cellulitis or septic joint
(unlikely given exam). Pt is on abx. Uric acid wnl, though
does have at least moderate alcohol intake putting him at
greater risk. Pt states pain has improved. Joint was monitored
during admission and erythema and swelling subsided.
5. Prophylaxis: Patient received heparin SQ for dvt prophylaxis
during admission.
Medications on Admission:
Home Medications:
Coumadin
Levothyroxine 75 mcg daily
Lisinopril 10mg po daily
Toprol XL 100mg po daily
Monthly B12 injections
.
Medications on transfer:
Zofran prn
Tylenol prn
Zosyn 3.375mg IV q6hr
Pantoprazole 40mg IV daily
Metoprolol 5mg IV q6hr
Percocet 1-2 tabs prn q4hr
Digoxin 0.25mg IV q6hr
One time dose of colchicine 0.6mg
Synthroid 75 mcg daily
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary
1. Gallstone pancreatitis/acute calculous cholecystitis
Secondary
- Non-ischemia cardiomyopathy - LVEF 20% range (recent abnormal
stress test --> cardiac cath [**2117-9-1**] - nonobstructive coronary
dz)
- Atrial fibrillation on Coumadin
- Hypertension
- Hypothyroidism
- Hyperlipidemia
- Erectile dysfunction
- B12 deficiency
- s/p L inguinal hernia repain
- Colonic polyposis
Discharge Condition:
Patient dishcarged in stable condition.
Discharge Instructions:
1. You were admitted for a gallstone, which was removed
successfully by ERCP. You are also receiving antibiotics for
this, which you should continue upon transfer to [**Hospital 8641**]
Hospital.
2. Unless otherwise indicated, you should resume all of your
home medications as taken prior to admission. It is very
important that you take your medications as prescribed.
3. It is very important that you make all of your doctor's
appointments.
4. If you develop worsening fever, chest pain, shortness of
breath or other concerning symptoms, please call your PCP or go
to your local Emergency Department immediately.
Followup Instructions:
Please fall up with your PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 80251**] in 1 week. You can
schedule an appointment by calling ([**Telephone/Fax (1) 80252**].
Completed by:[**2117-10-15**]
|
[
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icd9cm
|
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[
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icd9pcs
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3241, 3307
|
8384, 8774
|
7967, 7967
|
8861, 9481
|
3322, 4372
|
7985, 8096
|
278, 333
|
417, 2680
|
8121, 8325
|
2702, 3017
|
3033, 3225
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,559
| 115,981
|
46771
|
Discharge summary
|
report
|
Admission Date: [**2195-6-18**] Discharge Date: [**2195-6-28**]
Date of Birth: [**2127-6-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex / Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2195-6-22**] Aortic valve replacement (23mm St. [**Male First Name (un) 923**] Mechanical),
Coronary artery bypass grafting times one (Left internal mammary
artery to Left anterior descending artery)
History of Present Illness:
Mr. [**Known lastname 1124**] is a 67 year-old male with known aortic
stenosis/bicuspid aortic valve/coronary artery disease, now with
increasing dyspnea.
Past Medical History:
1. Coronary artery disease one vessel disease status post
catheterization on [**11-23**] with an left anterior descending
coronary artery stent.
2. Atrial fibrillation status post DCCV on the [**12-5**]. This was unsuccessful and he was subsequently
started on Amiodarone.
3. Hypercholesterolemia.
4. Status post acetabular fracture.
5. Seizure disorder 15 years ago.
Percutaneous coronary intervention in [**2188**]: 90% proxLAD, 70%
midLAD, 95% D1, 60% RI, mid systolic and diastolic dysfunction.
Social History:
Social history: Lives in [**Hospital1 **] with his Wife.
[**Name (NI) 1403**] at home making signs for museums and galleries is
significant for the absence of current .
There is no history of alcohol abuse or IVDU/illicit drug use or
tobacco use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Pulse: 56 Resp:18 O2 sat: 98 RA
B/P Right:100/61 Left:
Height: 5'4" Weight:180lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []kyphosis
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur III/VI SEM throughout
precordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right: 2+ Left:2+
Pertinent Results:
[**2195-6-26**] 04:24AM BLOOD WBC-9.6 RBC-3.05* Hgb-9.2* Hct-27.0*
MCV-88 MCH-30.1 MCHC-34.1 RDW-15.6* Plt Ct-192
[**2195-6-26**] 04:24AM BLOOD PT-19.9* PTT-52.3* INR(PT)-1.9*
[**2195-6-25**] 07:00PM BLOOD PT-16.9* PTT-35.8* INR(PT)-1.5*
[**2195-6-26**] 04:24AM BLOOD Glucose-104 UreaN-20 Creat-1.0 Na-142
K-3.4 Cl-104 HCO3-30 AnGap-11
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 99258**] (Complete)
Done [**2195-6-22**] at 12:25:07 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2127-6-26**]
Age (years): 67 M Hgt (in): 65
BP (mm Hg): 108/60 Wgt (lb): 170
HR (bpm): 45 BSA (m2): 1.85 m2
Indication: Intra-op TEE for AVR, CABG
ICD-9 Codes: 440.0, 424.1
Test Information
Date/Time: [**2195-6-22**] at 12:25 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW03-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *68 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 45 mm Hg
Aortic Valve - LVOT diam: 2.3 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
pre-bypass exam revealed normal wall function and severely
stenotic aortic valve. No PFO was recognized.
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
is seen in the LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Simple atheroma in aortic
root. Mildly dilated ascending aorta. Mildly dilated descending
aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Critical AS (area <0.8cm2). Moderate (2+)
AR.
MITRAL VALVE: Mild mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
post-bypass:
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. There is severe
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. There are simple atheroma in the aortic root. The
ascending aorta is mildly dilated. The descending thoracic aorta
is mildly dilated. The aortic valve is bicuspid. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Moderate
(2+) aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced
1. A mechanical prosthesis is well positioned in the aortic
position. Annulus is stable, leaflets open well. Washing jets
are seen. No perivalvular leaks are noted. Mean gradient is 4 mm
of Hg.
2. Bi ventricular function is preserved.
3. Aorta is intact post decannulation.
4. Other findings are unchanged
Brief Hospital Course:
Mr. [**Known lastname 1124**] was admitted on [**2195-6-18**] for a cardiac catheterization,
pre-operative work-up and intra-venous heparin. His surgery was
post-poned for an elevated INR and then his INR was allowed to
drift down without intervention. On [**2195-6-22**] he underwent an
aortic valve replacement (23mm St. [**Male First Name (un) 923**] Mechanical), coronary
artery bypass grafting times one (LIMA to LAD). Please see the
operative note for details. His bypass time was 133 minutes with
a crossclamp x of 104 minutes He tolerated this procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit. He remained hemodynamically
stable in the immediate post-op period and on the morning of
POD1 he was extubated.
On post-operative day two he was transferred to the stepdown
floor for continued recovery and post-op care. His tubes, lines
and drains were removed according to cardiac surgery protocol.
His activity was advanced with the assistance of physical
therapy and on POD #6 he was discharged home with visiting
nurses
Medications on Admission:
coumadin 2, ASA 81, lopressor 75, lasix 40
[**Hospital1 **], lipitor 80, amiodarone 200
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 BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*1 mdi* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*1*
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for AVR mech : Dr. [**Last Name (STitle) 99259**] to deose couamdin based on
INR for Mech AVR.
Disp:*30 Tablet(s)* Refills:*1*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO three times a
day for 7 days: 3 times daily for 7 days then twice daily on
going.
Disp:*75 Tablet(s)* Refills:*1*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days: check with your cardiologist if you should
continue this medication.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*1*
12. Outpatient Lab Work
check bun/creat, potassium and INR on [**6-29**].
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
aortic stenosis s/p Aortic Valve Replacement(mech), coronary
artery disease s/p Coronary artery bypass graft x1 , atrial
fibrillation
PMH: Congestive heart failure(diastolic), Hyperlipidemia,
seizure disorder, Rt hip fracture s/p repair, PTCA-stent(LAD),
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**]), please
call for appointment.
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 838**] (PCP) in [**1-23**] weeks ([**Telephone/Fax (1) 4775**]), please
call for appointment.
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiologist) in [**1-23**] weeks, please call for
appointment.
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
INR to be drawn on [**2195-6-29**] with results sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2716**] at
the Cardiology [**Hospital3 **] Fax [**Telephone/Fax (1) 9672**], Phone
[**Telephone/Fax (1) 99260**]. Plan confirmed with Ms. [**Name13 (STitle) 2716**] on [**6-26**].
Completed by:[**2195-6-28**]
|
[
"428.33",
"414.01",
"428.0",
"746.4",
"345.90",
"272.4",
"427.31",
"424.1",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.53",
"35.22",
"88.72",
"88.56",
"88.42",
"37.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10087, 10136
|
7222, 8308
|
300, 505
|
10435, 10442
|
2224, 7199
|
10953, 11803
|
1498, 1580
|
8447, 10064
|
10157, 10414
|
8334, 8424
|
10466, 10930
|
1595, 2205
|
253, 262
|
533, 690
|
712, 1215
|
1247, 1482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,355
| 107,865
|
52106
|
Discharge summary
|
report
|
Admission Date: [**2180-8-6**] Discharge Date: [**2180-8-24**]
Date of Birth: [**2100-5-15**] Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Procainamide / Cephalosporins
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
79-year-old male with ischemic CHF NYHA IV (EF 30%), BiV ICD,
pAFIB, CKD (Cr 1.6-1.8), hx of LGIB (angioectasia colonoscopy
[**2179**]), presenting with worsening fatigue and dyspnea, and a 20lb
weight gain over 2 months. Last discharge from [**Hospital1 18**] in early
[**Month (only) **] after a prolonged hospitalization for CHF exacerbation.
Closely monitored via home visits by [**First Name4 (NamePattern1) 2147**] [**Last Name (NamePattern1) 107826**], NP. Weight
has been steadily increasing, as diuretics were decreased due to
low blood pressures. Fatigue and dyspnea have also worsened
though he has remained ambulatory and independent. On morning of
admission, he was able to slowly get to the bathroom with walker
as well as dress himself, though complaining of significant
fatigue.
.
In the ED, initial vitals were 98.3 80 114/61 18 98% 2L Nasal
Cannula
and exam showed he was breathing comfortably when HOB >45
degrees (but not flat); no respiratory distress but
uncomfortable. Rales at bases.(+)LE edema to thighs. CXR was
unremarkable. Labs significant for K of 6.8 and a Cr of 2.0.
Patient given 40mg IV lasix and put out 200cc of urine. Also
given Ca gluconate, kayexalate, insulin/D50.
Vitals on transfer were T97.8, HR 84, BP 95/61, RR 15, POx
100%RA.
.
On arrival to the floor, patient was somnolent but arousable.
Complaining of dyspnea. No other complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
--- CHF (NYHA class IV, ACC/AHA stage D) - LVEF 30%
--- Atrial Fibrillation
- CABG: Yes, [**2152**]
- PERCUTANEOUS CORONARY INTERVENTIONS: None.
- PACING/ICD: Bivalve pacemaker and ICD
3. OTHER PAST MEDICAL HISTORY:
- dysphagia with large C3 osteophyte
- G-tube
- Pulmonary fibrosis
- Chronic GI bleeds
- Peripheral vascular disease
- Anemia
- Obesity
- Sleep apnea
- Restless legs syndrome
- Colonic Polyp
- Gout
- Lumbar spinal stenosis
- Nephrolithiasis
Social History:
Occupation: Retired security guard, worked at a pharmaceutical
company with chemical exposure. Lives with wife in [**Name (NI) 1468**].
Ambulatory with a walker at home.
Family: Married
Tobacco history: Smoked from age 6-35; quit at 35.
ETOH: 1-2 drinks per month.
Illicit drugs: Denies.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.2 116/49 70 18 98%
GENERAL: fatigued and difficult to arouse. Oriented x3. NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVP
CARDIAC: irregularly irregular, no murmurs rubs gallops
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Significant crackles
lower [**1-3**] bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. G-tube in place,
erythematous with drainage of pus
EXTREMITIES: 2+ edema R>L
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE
temp 96.7 HR 67 BP 85/41 O2 Sat 99% on 2L NC RR 12
GENERAL: alert and oriented x3 , fatigued, breathing comfortably
on RA
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink,
mild oral cyanosis.
NECK: Supple, JVP mildly elevated above clavicle
CARDIAC: tachy, irregular rhythm, 2/6 systolic murmur loudest in
the aortic band
LUNGS: Resp were unlabored, no accessory muscle use. No
wheezes/rhonchi/rales
ABDOMEN: Soft, mildly distended. No HSM or tenderness.
EXTREMITIES: warm, trace edema to the knees bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
Admission Labs:
[**2180-8-6**] 12:38PM WBC-9.2 RBC-3.25* HGB-9.5* HCT-30.3* MCV-93
MCH-29.2 MCHC-31.3 RDW-22.2*
[**2180-8-6**] 12:38PM PLT COUNT-201
[**2180-8-6**] 12:38PM GLUCOSE-113* UREA N-78* CREAT-2.0* SODIUM-133
POTASSIUM-6.8* CHLORIDE-96 TOTAL CO2-25 ANION GAP-19
[**2180-8-6**] 03:51PM K+-5.3
[**2180-8-6**] 12:38PM PT-16.7* PTT-26.3 INR(PT)-1.5*
Pertinent Labs:
Cardiac Enzymes
[**2180-8-6**] 12:38PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-2294*
[**2180-8-7**] 01:40AM BLOOD CK-MB-2 cTropnT-0.03*
[**2180-8-7**] 07:35AM BLOOD CK-MB-2 cTropnT-0.03*
Discharge Labs:
[**2180-8-18**] 02:31AM BLOOD WBC-7.5 RBC-2.87* Hgb-8.3* Hct-25.4*
MCV-89 MCH-29.0 MCHC-32.7 RDW-19.9* Plt Ct-307
[**2180-8-18**] 02:31AM BLOOD Glucose-156* UreaN-120* Creat-1.4* Na-143
K-5.3* Cl-93* HCO3-48* AnGap-7*
[**2180-8-18**] 02:31AM BLOOD Calcium-9.3 Phos-3.0 Mg-3.2*
[**2180-8-17**] 05:40AM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-68* pH-7.50*
calTCO2-55* Base XS-24
EKG [**2180-8-6**]: Probable atrial fibrillation with rightward axis.
Right bundle-branch block and intermittent demand ventricular
pacing. Compared to the previous tracing of [**2180-5-15**] no
significant change other than atrial fibrillation with a
moderately fast ventricular response.
Imaging:
CXR PA and LAT [**2180-8-6**]: PA and lateral radiographs demonstrate
unremarkable mediastinal and hilar contours. Cardiac silhouette
demonstrates stable enlargement. Biventricular pacemaker leads
are identified with leads positioned in the right atrium and
bilateral ventricles. Sternotomy sutures are midline and intact.
There is stable background of increased interstitial markings
consistent with the fibrotic lung changes identified on the [**5-14**], [**2180**] chest CT. There is a stable increased opacity at the
right lung base, which appears to correspond to more confluent
fibrotic changes identified on the prior CT. The bilateral
costophrenic angles are minimally blunted, which may reflect
scarring and chronic change, but trace pleural effusions may be
present. No pneumothorax is evident. Overall exam is relatively
unchanged compared to [**5-14**] and 28, [**2180**].
CT ABD & PELVIS [**2180-8-7**] W/O CONTRAST:
IMPRESSION:
1. Increased opacification in bilateral lower lobes including
ground-glass
opacification, consolidation and interlobular septal thickening
may represent pulmonary edema superimposed on background lung
disease; however, underlying infection cannot be completely
excluded in the correct clinical setting.
2. Foci of air in the subcutaneous fat likely represent
injection sites, but clinical correlation is recommended.
3. G-tube site is in normal position with no adjacent focal
fluid
collections.
4. Simple left renal cyst is noted.
5. Anasarca including a small quantity of ascites.
Brief Hospital Course:
Primary Reason for Hospitalization:
80 yo M with severe ischemic cardiomyopathy, atrial
fibrillation, and a biventricular pacemaker admitted for
worsening of his CHF, with a 20lb weight gain, dyspnea and
significant edema.
.
Active Issues:
# Goals of care: Palliative care was consulted to assist with
clarifying the patient and family's wishes regarding his goals
of care. He was often reluctant to participate in these
discussions and expressed that he would prefer his wife make
these decisions. His wife expressed understanding that his CHF
was endstage but did not want the focus to be on end-of-life but
rather on allowing him to live as well as possible. They agreed
that they would not want him to be intubated, and his code
status was changed to DNR/DNI. ICD was disabled, but continued
pacing because it may improve his symptoms. They also decided
that he would not be re-admitted to the hospital. On discharge,
it was decided that patient would go to inpatient hospice care
and prescriptions for PO morphine and lorazepam were given for
hospice care.
#Congestive Heart Failure with pulmonary edema- The patient was
not able to be diuresed on the floor due to hypotension, and was
transferred to the CCU for IV dopamine with lasix drip as
similar support was required for successful diuresis in the
past. It was determined his oral lasix regimen was no longer
effective and that his congestive heart failure was end stage.
Furthermore in order to keep the patient comfortable he would
likely require IV lasix at home. Palliative care was consulted
to facilitate definition of goals of care. The patient and his
wife expressed a desire for the patient to spend the remainder
of his life at home. Therefore arrangements were made for home
lasix therapy. He had a PICC line placed on [**2180-8-10**] and central
position confirmed. He continued diuresis with IV lasix, PO
metolazone, augmented with dopamine pressor support. He reached
his dry weight by [**8-16**], but was noted to have worsening
metabolic alkalosis (see below) and his diuretics were then
held. His weight at discharge was 84 kg. After discussion
with his wife, he was made DNR/DNI and his ICD was turned off,
with pacemaker still on given that it may increase patient
comfort (details below). He will be sent to inpatient hospice
care his end stage disease and has a prescription for home
oxygen (on 2L of nasal cannula on discharge). Patient was made
comfort measures only and lasix was not restarted. Lab tests
were discontinued. Patient was started on morphine as needed
for dyspnea and discomfort.
# Metabolic alkalosis: During his hospitalization his HCO3
steadily increased, and his VBG was c/w metabolic alkalosis with
pH 7.5. This was thought to be [**2-2**] volume contraction. He was
started on a trial of acetazolamide but this had no effect and
was discontinued. His diuretics were held and his potassium was
repleted with KCl. Lab tests were discontinued when patient was
made comfort measures only.
#Atrial fibrillation: Patient was in atrial fibrillation on
admission, not anticoagulated due to history of lower GI bleed.
Rates were initially in low 100s while on dopamine gtt. Home
metoprolol dose was increased from 6.25mg [**Hospital1 **] to 12.5mg [**Hospital1 **], and
his HR was stable in 70s-80s. When patient was made comfort
measures only, metoprolol was discontinued and patient was taken
off of telemetry monitoring.
#Anemia: Pt has known chronic GIB, and during hospitalization
had occasional BRBPR. His Hct steadily dropped during admission
and he received 3 units PRBC during this admission. Aspirin was
discontinued when patient was made comfort measures only.
#Nutrition- On physical exam, patient had e/o superficial
cellulitis with erythema and pus from insertion site of G-tube.
CT abdomen was negative for abscess or deeper infection. He
completed a 10 day course of clindamycin 300mg PO q8 hours. His
G-tube fell out on HD 13. IR was consulted for replacement
however given his allergy to dye, endoscopy was the only method
for replacing G-tube. After discussion with the family and
patient, the decision was made not to replace the tube.
Stable Issues:
.
# CAD: Pt has history of CAD status post CABG ([**2152**]: SVG-LAD,
SVG-rPDA, SVG-OM1-OM2), status post PCI ([**2171**]:SVG-LAD), ischemic
cardiomyopathy (LVEF 35-40%), status post inferior/inferolateral
myocardial infarction. He had no chest pain and r/o for MI on
admission. His ASA was discontinued due to decreasing Hct and
BRBPR (see above). His statin was discontinued.
.
# CKD: Creatinine improved to 1.4 with diuresis.
.
# Pulmonary Fibrosis: Stable. He was continued on his home
albuterol and atrovent nebs.
.
# Dysphagia: Attributed to a large osteophyte located at C3.
Initially hadG-tube and received bolus tube feeds with
isosource. However his G-tube fell out over the course of the
hospitalization. After discussion with the family it was
determined that replacement of the tube would not be in-line
with the goals of care. Therefore the patient was continued on
a full liquid diet PO with boost supplements.
.
# Transitional Issues:
- Patient maintained DNR/DNI code status throughout
hospitalization, confirmed with pt and family.
- Patient will be going to inpatient hospice hospice and should
not be readmitted to the hospital, based on the wishes of the
patient and his wife. IV lasix can be given at hospice to
improve patient symptoms. Hospice care will be followed by his
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], and [**Doctor First Name **] [**Doctor First Name 107826**], [**Name6 (MD) 2287**] cardiology NP.
Medications on Admission:
Codeine-Guaifenesin 10-100 mg/5 mL two tspns q4hr
Lansoprazole 30 mg daily
Simvastatin 10 mg QHS
Potassium Chloride 10 % Liquid 75ml daily
Metoprolol Succinate 12.5mg daily
Pramipexole 0.5 mg daily
Ipratropium-Albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL QID
Allopurinol 100 mg daily
Trazodone 25 mg QHS prn insomnia
Torsemide 60mg daily
Ipratropium Bromide 0.02 % neb TID
Betamethasone Dipropionate (DIPROSONE) 0.05 % Topical Cream [**Hospital1 **]
Ferumoxytol (FERAHEME) 510 mg/17 mL (30 mg/mL) IV
Ferrous Sulfate 325 mg (65 mg Iron) Oral Tablet 1 tablet qd
Fluocinolone 0.025 % TOPICAL CREAM [**Hospital1 **] to legs
Colase 100MG PO takes one [**Hospital1 **]
Metolazone 5mg daily
Discharge Medications:
1. hospice
please evaluate for hospice
2. Atropine-Care 1 % Drops [**Hospital1 **]: 1-4 drops Ophthalmic prn as
needed for increased secretions.
Disp:*QS * Refills:*2*
3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Hospital1 **]:
5-20 mg PO q2hrs:prn as needed for shortness of breath or
wheezing.
Disp:*30 mL* Refills:*0*
4. haloperidol lactate 2 mg/mL Concentrate [**Hospital1 **]: 2-4 mg PO Q2H as
needed for agitation.
Disp:*1 bottle* Refills:*0*
5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
8. allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. betamethasone dipropionate 0.05 % Cream [**Last Name (STitle) **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
10. fluocinolone 0.025 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
11. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
12. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 6.25 mg PO twice a
day.
Disp:*12 tablets* Refills:*2*
13. pramipexole 0.25 mg Tablet [**Hospital1 **]: 1-2 Tablets PO TID (3 times
a day) as needed for restless legs.
14. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
Disp:*1 bottle* Refills:*1*
15. trazodone 50 mg Tablet [**Age over 90 **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Age over 90 **]: One (1)
PO DAILY (Daily).
17. heparin, porcine (PF) 10 unit/mL Syringe [**Age over 90 **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*50 ML(s)* Refills:*2*
18. sodium chloride 0.9 % 0.9 % Solution [**Age over 90 **]: Three (3) mL
Injection every eight (8) hours: Q8H and PRN line flush.
Disp:*QS QS* Refills:*2*
19. home oxygen
home oxygen by nasal cannula
20. torsemide 20 mg Tablet [**Age over 90 **]: Three (3) Tablet PO once a day:
please start if weight increases by 3 lbs in one day, or if
increasing shortness of breath.
21. furosemide 10 mg/mL Solution [**Age over 90 **]: One [**Age over 90 **]y (120)
mg Injection PRN as needed for shortness of breath, weight gain.
Disp:*100 mL* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 656**] family hospice house
Discharge Diagnosis:
chronic systolic heart failure
anemia
chronic lower gastrointestinal bleed
chronic kidney disease, stage IV
atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were seen in the hospital for shortness of breath and weight
gain. This was most likely due to fluid overload from your
heart failure. While in the hospital, your symptoms improved
somewhat with fluid removal with IV lasix and dopamine. Hospice
was discussed with you and your wife and you will go to a
hospice facility with the goal of your care
WE have stopped giving you your diuretics and other cardiac
medicines but have started medicines that will keep you
comfortable. These include creams and benedryl for the itching,
morphine and lorazepam for pain and trouble breathing, bowel
medicines to prevent constipation, nebulizers to help your
breathing and allopurinol to prevent a gout flare.
Followup Instructions:
Please address any concerns with your hospice nurse.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
|
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icd9cm
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[
[
[]
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] |
[
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[
[
[]
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2339, 2628
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,788
| 144,980
|
44306
|
Discharge summary
|
report
|
Admission Date: [**2169-8-14**] Discharge Date: [**2169-9-1**]
Date of Birth: [**2093-10-8**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Bladder cancer.
Major Surgical or Invasive Procedure:
1. Radical cystoprostatectomy.
2. Ileal conduit.
3. Pelvic lymph node dissection
History of Present Illness:
Patient is a 75 year-old gentleman who has been followed for
nonmuscle invasive
bladder cancer for several years. He has received 2 rounds of
intravesical therapy including BCG, alpha interferon,
gemcitabine and Adriamycin. Most recent urine cytology in [**Month (only) 205**]
of [**2169**] was positive for malignant cells. Patient
subsequently underwent cystoscopy and bladder biopsy. Biopsy
revealed high grade urothelial carcinoma with lamina propria
invasion but without muscle invasive disease. However, there was
a significant degree of micropapillary invasion which was noted
to be high risk for invasion. Given that risk factor
the patient was counseled as to the risks and benefits of
surgery versus watchful waiting and the decided to opt for
surgical intervention prior to development of muscle invasive
disease.
Past Medical History:
1. Hypertension.
2. Elevated cholesterol (LDL 122).
3. Obstructive sleep apnea.
4. Degenerative joint disease.
5. Obesity.
6. Sciatica.
.
PSHx: TURBTx8, hemrrhoidectomy, Nasal septal surgery.
Social History:
SOCIAL HISTORY: The patient drinks approximately [**3-11**] alcohol
beverages a week, denies smoking tobacco.
Family History:
FAMILY HISTORY: Brother with hypertension, father with a
history of a myocardial infarction at the age of 75.
Physical Exam:
Patient resting comforable in bed.
VS: 99.7/71 174/68 94%RA
I/O: 640 PO/SL O: 700 urostomy/several bm.
HEENT: unshaven, soft/supple, PEERLA.
Chest: CTABL
CV: RRR S1S2
Abd: Midline incision with steri strips covering incision.
Minor erythema. Large abdomen: soft/nontender/no rebound/no
guarding/no rigidity. +BS. Urostomy tube in place.
Neuro: Grossly intact.
Extrm: +1 pitting ankle edema.
Pertinent Results:
[**2169-8-25**] 08:45AM BLOOD WBC-19.0* RBC-2.89* Hgb-8.6* Hct-26.1*
MCV-90 MCH-29.7 MCHC-32.9 RDW-15.5 Plt Ct-323
[**2169-8-24**] 03:30PM BLOOD WBC-16.6* RBC-3.07* Hgb-8.8* Hct-27.1*
MCV-88 MCH-28.7 MCHC-32.5 RDW-15.6* Plt Ct-318
[**2169-8-24**] 01:38AM BLOOD WBC-13.7* RBC-2.76* Hgb-8.3* Hct-24.5*
MCV-89 MCH-30.2 MCHC-33.9 RDW-15.3 Plt Ct-248
[**2169-8-23**] 02:11AM BLOOD Neuts-91.3* Lymphs-5.6* Monos-2.1 Eos-0.7
Baso-0.3
[**2169-8-25**] 08:45AM BLOOD Plt Ct-323
[**2169-8-25**] 08:45AM BLOOD PT-17.0* PTT-28.6 INR(PT)-1.6*
[**2169-8-24**] 03:30PM BLOOD Plt Ct-318
[**2169-8-25**] 08:45AM BLOOD Glucose-109* UreaN-67* Creat-2.7* Na-149*
K-3.1* Cl-117* HCO3-19* AnGap-16
[**2169-8-24**] 03:30PM BLOOD Glucose-133* UreaN-60* Creat-2.2* Na-146*
K-3.3 Cl-115* HCO3-20* AnGap-14
[**2169-8-24**] 01:38AM BLOOD Glucose-149* UreaN-56* Creat-2.1* Na-145
K-3.5 Cl-115* HCO3-19* AnGap-15
[**2169-8-23**] 04:59PM BLOOD Glucose-118* UreaN-55* Creat-2.1* Na-147*
K-3.4 Cl-115* HCO3-21* AnGap-14
[**2169-8-23**] 04:59PM BLOOD Glucose-113* UreaN-53* Creat-1.9* Na-141
K-GREATER TH Cl-126* HCO3-21*
[**2169-8-20**] 08:20AM BLOOD ALT-12 AST-31 AlkPhos-84 Amylase-107*
TotBili-1.2
[**2169-8-20**] 03:14AM BLOOD ALT-8 AST-30 AlkPhos-79 Amylase-104*
TotBili-1.3
[**2169-8-20**] 08:20AM BLOOD Lipase-107*
[**2169-8-25**] 08:45AM BLOOD Albumin-2.7* Calcium-7.3* Phos-2.5*
Mg-2.1
[**2169-8-24**] 03:30PM BLOOD Calcium-7.6* Phos-2.2* Mg-2.0 Iron-18*
[**2169-8-24**] 01:38AM BLOOD Calcium-7.2* Phos-2.4* Mg-2.1
[**2169-8-24**] 03:30PM BLOOD calTIBC-131* Ferritn-1155* TRF-101*
[**2169-8-25**] 08:45AM BLOOD Triglyc-163*
[**2169-8-24**] 03:30PM BLOOD PTH-107*
[**2169-8-25**] 08:45AM BLOOD CRP-226.0*
[**2169-8-22**] 04:09AM BLOOD Type-ART pO2-76* pCO2-42 pH-7.38
calTCO2-26 Base XS-0
[**2169-8-21**] 05:30PM BLOOD Type-ART pO2-178* pCO2-33* pH-7.44
calTCO2-23 Base XS-0
[**2169-8-21**] 05:30PM BLOOD Glucose-144*
[**2169-8-21**] 06:28AM BLOOD Glucose-112* Lactate-0.9
[**2169-8-15**] 03:32AM BLOOD Hgb-11.1* calcHCT-33
[**2169-8-14**] 06:07PM BLOOD Hgb-12.0* calcHCT-36 O2 Sat-98 COHgb-1
[**2169-8-21**] 06:28AM BLOOD freeCa-1.05*
[**2169-8-15**] 03:32AM BLOOD freeCa-1.29
[**2169-8-25**] 08:45AM BLOOD PREALBUMIN-PND
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2169-8-31**] 06:25AM 11.5* 2.92* 8.8* 25.1* 86 30.3 35.2*
16.0* 325
[**2169-8-30**] 06:40AM 12.3* 3.26* 9.2* 28.6* 88 28.2 32.1 16.2*
380
[**2169-8-29**] 05:20PM 13.2* 3.34* 9.9* 30.0* 90 29.5 32.9 15.9*
379
[**2169-8-29**] 05:50AM 13.3* 3.23* 9.2* 28.2* 87 28.4 32.6 16.1*
351
[**2169-8-28**] 04:55PM 12.9* 3.30* 9.7* 29.7* 90 29.4 32.6 16.0*
303
[**2169-8-28**] 07:25AM 13.4* 3.13* 9.1* 28.0* 89 29.2 32.7 16.2*
322
[**2169-8-27**] 05:40AM 17.5* 3.64* 10.1* 32.3* 89 27.6 31.2
16.3* 345
[**2169-8-26**] 05:55AM 19.5* 3.11* 9.3* 27.6* 89 29.9 33.7 15.8*
305
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2169-8-31**] 06:25AM 325
[**2169-8-30**] 06:40AM 380
[**2169-8-30**] 06:40AM 16.1* 28.3 1.5*
[**2169-8-29**] 05:20PM 379
[**2169-8-29**] 05:20PM 15.7* 1.4*
[**2169-8-29**] 05:50AM 351
[**2169-8-29**] 05:50AM 16.3* 29.2 1.5*
[**2169-8-28**] 04:55PM 303
[**2169-8-28**] 07:25AM 322
[**2169-8-28**] 07:25AM 16.2* 27.6 1.5*
[**2169-8-27**] 05:40AM 345
[**2169-8-27**] 05:40AM 16.0* 29.1 1.5*
[**2169-8-26**] 05:55AM 305
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2169-8-31**] 06:25AM 91 48* 2.0* 139 3.9 112* 19* 12
[**2169-8-30**] 06:40AM 135* 57* 2.3* 137 3.9 110* 18* 13
[**2169-8-29**] 05:20PM 112* 62* 2.3* 144 4.2 116* 17* 15
[**2169-8-29**] 05:50AM 107* 68* 2.5* 143 3.8 115* 19* 13
[**2169-8-28**] 04:55PM 118* 73* 2.5* 143 4.0 116* 15* 16
[**2169-8-28**] 07:25AM 101 74* 2.7* 144 3.9 116* 17* 15
[**2169-8-27**] 05:00PM 115* 79* 2.8* 143 3.6 114* 17* 16
[**2169-8-27**] 05:40AM 122* 79* 2.9* 144 3.3 111* 18* 18
[**2169-8-26**] 02:45PM 95 80* 3.1* 145 3.1* 113* 18* 17
[**2169-8-26**] 05:55AM 101 78* 2.9* 152*1 3.2* 119* 20* 16
[**2169-8-30**] 6:28 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2169-8-31**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2169-8-31**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
[**2169-8-22**] 11:19 pm URINE
**FINAL REPORT [**2169-8-24**]**
URINE CULTURE (Final [**2169-8-24**]): <10,000 organisms/ml.
.
[**2169-8-21**] 5:12 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2169-8-23**]**
MRSA SCREEN (Final [**2169-8-23**]): NO STAPHYLOCOCCUS AUREUS
ISOLATED.
.
[**2169-8-18**] 4:02 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2169-8-20**]**
GRAM STAIN (Final [**2169-8-18**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2169-8-20**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
.
[**2169-8-17**] 10:41 pm SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT [**2169-8-20**]**
GRAM STAIN (Final [**2169-8-18**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2169-8-20**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2169-8-15**] 3:27
AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] CC6B [**2169-8-15**]
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 94998**]
Reason: Eval ET position
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with bladder CA s/p cystectomy w/ ileoconduit
REASON FOR THIS EXAMINATION:
Eval ET position
Final Report
INDICATION: Evaluation of endotracheal tube.
Portable AP view of the chest.
Comparison is available from yesterday.
FINDINGS: Heart is mildly enlarged. Mediastinal contour is
widened and
stable and hilar contour is normal. left pleural effusion and
left basilar
atelectasis are unchanged . The remainder of both lungs is
clear. The
endotracheal tube is 4.3 cm above carina. NG tube has its tip
in the stomach.
IMPRESSION: Unchanged left basilar atelectasis and small
effusion.
Endotracheal tube stable in satisfactory position.
.
Radiology Report RENAL U.S. PORT Study Date of [**2169-8-15**] 10:56 AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] CC6B [**2169-8-15**]
RENAL U.S. PORT Clip # [**Clip Number (Radiology) 94999**]
Reason: ?ureteral obstruction
[**Hospital 93**] MEDICAL CONDITION:
75 year old man POD 1 s/p cystectomy & ileal conudit with low
urine output
REASON FOR THIS EXAMINATION:
?ureteral obstruction
Final Report
RENAL ULTRASOUND, PORTABLE
INDICATION: Low urine output. Rule out obstruction.
FINDINGS: The right kidney is normal in echotexture. There is
no evidence of
hydronephrosis, stones, or masses. A small simple cyst is
visualized in the
upper pole of the right kidney measuring 1.3 x 1.4 x 1.2 cm.
The right kidney
measures 10.0 cm in diameter. Limited views of the left kidney
show normal
echotexture. There is no hydronephrosis or stones present.
There is a
suspicious mass on the lateral aspect of the left kidney
measuring 1.6 x 2.4
cm. Comparison is made with the CT exam dated [**2169-7-8**]. This
density most
likely represents extension of the renal cortex, however, a
follow up
ultrasound at 6 months is recommended.
A small pleural effusion is noted on the left. There is no
evidence of
pleural effusion on the right.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Small, mildly suspicious area in the mid-left kidney noted,
probably a
pseudonodule since no lesion is seen on a recent single phase CT
scan, but
followup ultrasound recommended at 6 months.
.
Cardiology Report ECG Study Date of [**2169-8-20**] 10:18:10 AM
Sinus rhythm
Lead(s) unsuitable for analysis: V4
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] T.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 186 86 346/384.42 45 22 46
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2169-8-21**] 3:54
AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] CC6B [**2169-8-21**]
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 95000**]
Reason: tachypnea
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with bladder CA s/p cystectomy w/ ileoconduit.
n/w tachypnea
s/p extubation
REASON FOR THIS EXAMINATION:
tachypnea
Final Report
PORTABLE UPRIGHT CHEST on [**2169-8-21**].
INDICATION: Tachypnea.
COMPARISON: [**2169-8-20**] chest x-ray.
Left subclavian catheter remains in standard position. Cardiac
silhouette is
enlarged but stable. Multifocal areas of consolidation are
again demonstrated
with slight worsening in the right upper and left lower lobes,
concerning for
multifocal pneumonia, although a component of pulmonary edema is
also
possible.
.
Radiology Report VIDEO OROPHARYNGEAL SWA Study Date of [**2169-8-24**]
1:24 PM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-24**]
VIDEO OROPHARYNGEAL SWALLOW Clip # [**Clip Number (Radiology) 95001**]
Reason: Pt had a bedside evaluation, and was reccomended to have
a v
[**Hospital 93**] MEDICAL CONDITION:
75 year old man s/p cystectomy and ileal loop diversion.
REASON FOR THIS EXAMINATION:
Pt had a bedside evaluation, and was reccomended to have a video
eval. Pt has
been transfered from the [**Hospital Ward Name **] to [**Hospital Ward Name **]; would like
to start pt on
a regular diet, but would like to be cleared by Swallowing
study.
Final Report
INDICATION: Video assisted oropharyngeal fluoroscopic
evaluation was
performed. The patient was administered barium of various
consistencies
including thin liquid, nectar thick puree, and solid barium
coated cookie.
Oral phase was severely impaired with difficulty in bolus
formation and
manipulation. Swallow was associated with poor laryngeal
elevation and absent
epiglottic deflection resulting in moderate/significant
vallecular residue.
Thin liquid was accompanied by silent aspiration at which it
could not be
alleviated with chin tuck maneuvers.
IMPRESSION: Silent aspiration with thin liquids and valleculae
and piriform
sinus residue.
.
Radiology Report CHEST (PA & LAT) Study Date of [**2169-8-25**] 8:11 AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-25**]
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 95002**]
Reason: Signs of gastric aspiration/infection?
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with TCC s/p cystectomy, ileal loop diversion
REASON FOR THIS EXAMINATION:
Signs of gastric aspiration/infection? To be done STAT.
Final Report
CLINICAL INFORMATION: History of transitional cell carcinoma
status post
cystectomy and ileal loop diversion. Evaluate for gastric
aspiration versus
infection.
PA AND LATERAL CHEST RADIOGRAPH:
Comparison is made to chest radiographs obtained from [**8-20**]
through [**8-22**]. Multifocal pulmonary consolidation seen diffusely
throughout both lungs
appear more confluent compared to prior film. The cardiac
silhouette is
mildly enlarged but stable. There may be small bilateral
pleural effusions.
The left subclavian central line has been removed in the
interval time.
IMPRESSION: Multifocal pulmonary consolidation, appearing more
confluent
compared to last film, however, similar to appearance to [**8-22**] film
acquired at 05:28 hours, which is likely secondary to a
combination of
multifocal pneumonia and pulmonary edema.
.
[**Known lastname 7327**],[**Known firstname 54344**]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 95003**]
FINAL REPORT
INDICATION: 75-year-old male, postop day 13 status post
cystectomy with ileal
conduit with persistent elevated creatinine. Evaluate for
evidence of
ureteral obstruction.
COMPARISON: CT scan from [**2169-8-7**].
TECHNIQUE: Contiguous axial images were obtained from the lung
bases to the
pubic symphysis with coronal and sagittal reformatted images.
CONTRAST: No oral or intravenous contrast was administered.
CT OF THE ABDOMEN WITHOUT CONTRAST: There are bilateral
consolidative
opacities at the lung bases. There are small bilateral pleural
effusions,
greater on the right. There may be a small amount of pericardial
fluid.
There is limited evaluation of solid organs without intravenous
contrast,
however, the liver, spleen, stomach, pancreas, adrenal glands,
and gallbladder
appear stable in appearance. There is ascites, around the liver
and spleen.
No pathologically enlarged retroperitoneal or mesenteric
lymphadenopathy is
seen. There is limited evaluation of bowel without oral or IV
contrast,
however, there is no evidence of bowel dilatation.
There is no evidence of perinephric fluid. There may be mild
pelvic fullness,
however, there is no frank hydronephrosis or hydroureter. The
ileal conduit
is seen in the right lower quadrant and is not distended.
Post-surgical clips
are seen in the region of surgery and bladder resection.
Calcification is seen within the aortic wall, without any
evidence of
aneurysmal dilatation.
CT OF THE PELVIS WITHOUT CONTRAST: Post-surgical changes are
seen within the
pelvis, including clips and bladder resection. There is a small
amount of
free fluid. The rectum and distal colon are normal in
appearance. There are
multiple scattered colonic diverticula. There is a fluid
containing left
inguinal hernia.
BONE WINDOWS: There has been no interval change in comparison to
the prior
study. The previously noted sclerotic focus within the mid
sacrum is
unchanged. Degenerative changes are seen within the thoracic
spine.
IMPRESSION:
1. The patient is status post cystectomy. There is no
hydroureter or
dilatation of the ileal conduit, or perinephric fluid.
2. There are bilateral consolidative opacities at the lung
bases. This may
represent an infectious etiology, or aspiration.
3. Small bilateral pleural effusions, and a small amount of
pericardial
fluid. There is also ascites surrounding the liver and spleen.
These results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 95004**] at 12 pm
on [**8-27**]/6.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name8 (NamePattern2) 5650**] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: MON [**2169-8-28**] 3:03 PM
Procedure Date:[**2169-8-27**]
Radiology Report LUNG SCAN Study Date of [**2169-8-27**]
[**Last Name (LF) **], [**First Name3 (LF) 275**] C. [**2169-8-27**]
LUNG SCAN Clip # [**Clip Number (Radiology) 95005**]
Reason: 75M S/P RADICAL CYSTECTOMY W/PERSISTENT HYPOXEMIA AND
INCREASED TACHYPNEA. CXR DOES NOT SHOW WORSENED PULMONARY
Final Report
RADIOPHARMECEUTICAL DATA:
5.0 mCi Tc-[**Age over 90 **]m MAA;
40.0 mCi Tc-99m DTPA Aerosol;
HISTORY: 75 year old man post cystectomy with persistent hypoxia
and tachypnea.
Bilateral patchy infiltrates on chest radiograph. Patient is not
a candidate for
CTA given elevated creatinine.
INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol
in 8 views
demonstrate considerable central airway deposition of tracer
and several areas
of reduced tracer deposition within the parenchyma of both
lungs.
Perfusion images in the same 8 views show relatively preserved
perfusion
throughout the parenchyma of both lungs (compared to the
ventilation images).
There are subsegemental scattered areas of reduced tracer
activity.
Given the chest radiograph appearance, the above findings are
consistent with an
intermediate probability of pulmonary embolism. Central
deposition of tracer on
the ventilation study is suggestive of an airway turbulence.
IMPRESSION: Intermediate probability of pulmonary embolism.
Given the multiple
bilateral patchy infiltrates on chest radiograph and
corresponding areas of
reduced tracer deposition on the ventilation portion of the
study, perfusion
appears relatively preserved in comparison. Given the chest
X-ray findings,
pulmonary embolism cannot be ruled out; however, there are no
findings which a
particularly suggestive of that diagnosis.
[**First Name11 (Name Pattern1) 714**] [**Last Name (NamePattern4) 95006**], M.D.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D.
Approved: MON [**2169-8-28**] 2:24 PM
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of
[**2169-8-27**] 11:47 AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-27**]
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip #
[**Clip Number (Radiology) 95007**]
Reason: Please assess for evidence of ureteral obstruction
(although
Field of view: 44
[**Hospital 93**] MEDICAL CONDITION:
75M POD13 s/p cystectomy w/ ileal conduit with persistently
elevated creatinine
(currently 2.9).
REASON FOR THIS EXAMINATION:
Please assess for evidence of ureteral obstruction (although
some mild fullness
might be expected, given refluxing anastamoses) or fluid leak.
CONTRAINDICATIONS for IV CONTRAST:
elevated creatinine
Final Report
INDICATION: 75-year-old male, postop day 13 status post
cystectomy with ileal
conduit with persistent elevated creatinine. Evaluate for
evidence of
ureteral obstruction.
COMPARISON: CT scan from [**2169-8-7**].
TECHNIQUE: Contiguous axial images were obtained from the lung
bases to the
pubic symphysis with coronal and sagittal reformatted images.
CONTRAST: No oral or intravenous contrast was administered.
CT OF THE ABDOMEN WITHOUT CONTRAST: There are bilateral
consolidative
opacities at the lung bases. There are small bilateral pleural
effusions,
greater on the right. There may be a small amount of
pericardial fluid.
There is limited evaluation of solid organs without intravenous
contrast,
however, the liver, spleen, stomach, pancreas, adrenal glands,
and gallbladder
appear stable in appearance. There is ascites, around the liver
and spleen.
No pathologically enlarged retroperitoneal or mesenteric
lymphadenopathy is
seen. There is limited evaluation of bowel without oral or IV
contrast,
however, there is no evidence of bowel dilatation.
There is no evidence of perinephric fluid. There may be mild
pelvic fullness,
however, there is no frank hydronephrosis or hydroureter. The
ileal conduit
is seen in the right lower quadrant and is not distended.
Post-surgical clips
are seen in the region of surgery and bladder resection.
Calcification is seen within the aortic wall, without any
evidence of
aneurysmal dilatation.
CT OF THE PELVIS WITHOUT CONTRAST: Post-surgical changes are
seen within the
pelvis, including clips and bladder resection. There is a small
amount of
free fluid. The rectum and distal colon are normal in
appearance. There are
multiple scattered colonic diverticula. There is a fluid
containing left
inguinal hernia.
BONE WINDOWS: There has been no interval change in comparison
to the prior
study. The previously noted sclerotic focus within the mid
sacrum is
unchanged. Degenerative changes are seen within the thoracic
spine.
IMPRESSION:
1. The patient is status post cystectomy. There is no
hydroureter or
dilatation of the ileal conduit, or perinephric fluid.
2. There are bilateral consolidative opacities at the lung
bases. This may
represent an infectious etiology, or aspiration.
3. Small bilateral pleural effusions, and a small amount of
pericardial
fluid. There is also ascites surrounding the liver and spleen.
These results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 95004**] at 12 pm
on [**8-27**]/6.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 5650**] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: MON [**2169-8-28**] 3:03 PM
Radiology Report CHEST (PORTABLE AP) Study Date of [**2169-8-27**]
7:31 PM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-27**]
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 95008**]
Reason: ? cause
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with bladder CA s/p cystectomy w/ ileoconduit.
n/w
tachypnea s/p extubation with mild resp distress now with
increased RR to
36
REASON FOR THIS EXAMINATION:
? cause
Final Report
HISTORY: Bladder CA, increased respiratory rate, question
cause.
CHEST, SINGLE AP PORTABLE VIEW.
There are dense diffuse patchy bilateral alveolar opacities
throughout both
lungs, similar to the chest x-ray on [**2169-8-25**]. There is very
slight
obscuration of the right hemidiaphragm. No gross effusion.
IMPRESSION: Diffuse patchy alveolar opacities in both lungs
similar to
[**2169-8-25**], possibly minimally improved. Differential diagnoses
includes CHF,
multifocal pneumonia, or combination of the two. In the
appropriate clinical
setting, this could reflect the presence of ARDS.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: TUE [**2169-8-29**] 10:59 AM
Radiology Report UNILAT UP EXT VEINS US Study Date of
[**2169-8-28**] 9:52 AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-28**]
UNILAT UP EXT VEINS US LEFT Clip # [**Clip Number (Radiology) 95009**]
Reason: SWELLING ASSESS FOR CLOT IN LEFT CUBITAL FOSSA
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with 1 day hx. of shortness of breath and
metabolic acidosis.
REASON FOR THIS EXAMINATION:
r/o clot in left cubital fossa
Final Report
INDICATION: One-day history of shortness of breath, metabolic
acidosis.
COMPARISONS: None.
LEFT UPPER EXTREMITY ULTRASOUND: 2D, color, and Doppler
waveform imaging was
obtained of the left internal jugular, subclavian, axillary,
brachial, and
basilic veins. Normal compressibility, waveforms, and
augmentation were
demonstrated. No intraluminal thrombus was identified. Imaging
of the
cephalic vein in the upper arm showed an occlusive thrombus.
Thrombus was not
seen extending into the axillary vein.
IMPRESSION:
1. Occlusive thrombus identified within the left cephalic vein.
2. No evidence of deep venous thrombosis within the left upper
extremity.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: MON [**2169-8-28**] 4:47 PM
Radiology Report BILAT LOWER EXT VEINS Study Date of
[**2169-8-28**] 9:52 AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-28**]
BILAT LOWER EXT VEINS Clip # [**Clip Number (Radiology) 95010**]
Reason: POSSIBLE PE ASSESS FOR DVT
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with 1 day hx. of shortness of breath and
metabolic acidosis.
Patient has very poor renal fxn. and could not undergo CT angio.
V/Q done.
REASON FOR THIS EXAMINATION:
r/o dvt.
Final Report
INDICATION: Shortness of breath, metabolic acidosis.
COMPARISONS: None.
BILATERAL LOWER EXTREMITY ULTRASOUND: 2D, color, and Doppler
waveform imaging
was obtained of bilateral common femoral, superficial femoral,
and popliteal
veins. Normal compressibility, waveforms, and augmentation were
demonstrated.
No intraluminal thrombus is identified.
IMPRESSION: No evidence of lower extremity deep vein
thrombosis, bilaterally.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: MON [**2169-8-28**] 4:47 PM
Brief Hospital Course:
Mr [**Known lastname **] is a 74 year old man with a 3 year history of
transitional cell carcinoma. He was admitted to [**Hospital1 18**] on [**8-14**], [**2169**] for his procedure. He was prepared and consented as per
standard; all risks and benefits of his surgery were discussed
and it was ensured that he understood all potential
compolications.
In the operating room, the total estimated blood loss was
3500cc. The total procedure time was 12 hours. He received 10L
of crystaloid, 800 Hespan, and 6 Units of packed red blood
cells.
.
Mr [**Known lastname **] was sent to the Surgery ICU (SICU) upon completion of
his surgery. He had an NGT, CVL, urostomy, JP drain and ETT in
place. He was given a total of 3 doses of Ancef in the next 24
hours. His INR at this point was 1.2. His chest film on [**8-15**]
read as: "Heart is mildly enlarged. Mediastinal contour is
widened and
stable and hilar contour is normal. left pleural effusion and
left basilar
atelectasis are unchanged . The remainder of both lungs is
clear. The
endotracheal tube is 4.3 cm above carina. NG tube has its tip
in the stomach."
.
On [**8-16**], a chest film was read as: "There is a left lower lobe
retrocardiac atelectasis with large consolidation. ____ and NG
tube in standard positions." He had a sputum culture which was
also negative. His [**Location (un) 1661**]-[**Location (un) 1662**] drainage continued to be high,
and hence, a JP creatinine level and a Urine creatinine level
was sought in order to rule-out a urine leak within the abdomen.
The levels were repeated 3 times in the next 6 days, and on all
three occassions, it was determined that a urine leak was not
present.
.
On [**8-17**], Mr [**Known lastname **] was started on anticoagulation medications.
He received 5mg of coumadin this evening. A chst film was read
as: "An ET tube is seen with the tip in the mid trachea. There
is a left subclavian line, with the tip in the lower SVC.
There is an NG tube, with the tip in the stomach. Again seen is
left
retrocardiac opacity, which is unchanged. The right lung is
clear. Pulmonary
vasculature is within normal limits." He also had a urine
culture today, for febrile episodes during the day, which was
negative. His sputum culture was also negative on this day.
.
On [**8-18**], Mr [**Known lastname **] had a BAL, whose result is as follows:
[**2169-8-18**] 4:02 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2169-8-20**]**
GRAM STAIN (Final [**2169-8-18**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2169-8-20**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
He received 5mg of coumadin this evening.
.
.
On [**8-19**], Mr [**Known lastname **] was extuabted. His NGT was removed later in
the evening. He received 1mg of coumadin this morning. He was
also started on levofloxacin. A chest film was read as: "A
single AP view of the chest is obtained on [**2169-8-19**] at 0534 hours
and compared with the prior radiograph of [**2169-8-17**]. Tubes and
lines appear
unchanged in position. Retrocardiac opacity consistent with
airspace disease
is unchanged. There does, however, now appear to be increased
opacity in the
left mid lung zone and the right lower lung zone consistent with
worsening
airspace disease." Mr [**Known lastname **] was in distress overnight, and
required a dose of Haldol. He was restless and agitated. He was
able to tolerate sips, as he bad started to pass flatus earlier
in the day. Dr [**Last Name (STitle) 261**] spoke with the family over the phone in
the afternoon; there was discussion about determining whether Mr
[**Known lastname **] sister would be able to care for her brother at home.
In addition, the ostomy nurse [**First Name (Titles) **] [**Name (NI) 653**] in order to teach Mr
[**Name (NI) **] regarding ostomy care once he is transfered to the floor.
.
On [**8-20**], Mr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain was removed. He
received 1mg of coumadin this morning. At midnight, his fluids
were stopped. A morning chest film was read as: "A single AP
view of the chest is obtained on [**2169-8-20**] at 05:42 hours and
compared with the prior day's radiograph. Again is seen patchy
multifocal
airspace disease which appears unchanged on the left side but it
is worse on
the right side. The patient has been extubated. A left-sided
subclavian line
is unchanged in position. No large pleural effusion is
present."
.
On [**8-21**], Mr [**Known lastname **] INR was 3.6. His coumadin was held this
evening. A repeat chest xray this morning read as: "Left
subclavian catheter remains in standard position. Cardiac
silhouette is enlarged but stable. Multifocal areas of
consolidation are again demonstrated with slight worsening in
the right upper and left lower lobes, concerning for multifocal
pneumonia, although a component of pulmonary edema is also
possible." He continued to require oxygen at 12L. LAter in the
day, he was switched to CPAP. He was also started on a Lasix IV
drip, and given albumin 25% to help with diuresis. His
antibiotic (Levo) was stopped.
.
On [**8-22**], the Lasix drip continued, as did the 25% albumin. Mr
[**Known lastname **] started to tolerate oral intake. It was decided Mr [**Known lastname **]
was able to be transfered to the floor (his orders were put in
and he was awaiting a bed). A cardiology consult was called, and
en echo done which showed:
"The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). 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 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. There is mild pulmonary artery systolic
hypertension. There is
an anterior space which most likely represents a fat pad.
Compared with the report of the prior study (images unavailable
for review) of [**2163-12-20**], mild pulmonary artery systolic
hypertension is now suggested. Biventricular systolic function
appears similar." Overnight, Mr [**Known lastname **] had some episodes of
respiratory distress. He also had episodes of chest pain - a
12-lead EKG was done which did not show any abnormalities. He
also spiked a temperature of 101.5, and was pancultured. Mr
[**Known lastname **] was given 2.5mg of Vitamin K overnight due to his INR
level.
.
On [**8-23**], Mr [**Known lastname **] was given another 2.5mg PO of Vitamin K. His
chest pain had resolved and he was no longer having breathing
difficulties. His Lasix drip was continued at 5mg/hr. Overnight,
he had some episodes of respiratory distress for which his
oxygen level was increased.
.
On [**8-24**], Mr [**Known lastname **] was transfered to the floor (12 [**Hospital Ward Name 1827**]). He
had a video surveillance study to assess his risk for gastric
aspiration, and it was determined he would require a thickened
diet due to some risk of aspiration. In addition, it was advised
to keep him off whole pills. Mr [**Known lastname **] had no other complaints
and was seen by a physical therapist. He was given a bolus of
Lasix on the floor, and another unit of blood. His central
venous line was removed. In the evening, Mr [**Known lastname **] was given 1
unit of packed red blood cells. After starting administration,
he had an allergic reaction to the product and his blood
pressure elevated and his temperature went up to 103. This
product was stopped, and his temperature and blood pressure came
down. Overnight, he had no other issues.
.
On [**8-25**], Mr [**Known lastname **] was seen for a rehabilitation screening. He
was also visited by the physical therapist, who stated he would
need some physical therapy in order to regain his strength. He
had no new medical issues today.
.
On [**8-26**],
On [**8-27**], the patient underwent a trigger event.
Neuro: Off all pain meds. On home seroquel.
CV: Intermittently hypertensive over weekend (SBP 130-180).
Increased lopressor
to 62.5 tid (along w/ PRN hydralazine). Still off home
nifedipine b/c can't
crush the pill. Consider touching base w/ cardiology about
recommended
alternative [**Doctor Last Name 360**] if still intermittently hypertensive.
PULM: Was on RA by Saturday PM. Then increasingly tachypnic
today PM (rate
25-40). ABG and PM lytes c/w metabolic acidosis w/ respiratory
compensation as
well as some degree of primary respiratory hypoxemia. CXR
stable from 2 days
prior. Pulmonary previously consulted and felt hypoxemia likely
due to
multifocal aspiration PNA (no ABx treatment if no fever spikes).
Renal and pulm
felt that fluid overload from IVF over weekend might have helped
trigger events
today PM. Plan to observe off IVF and on O2. Consider repeat
ABG in AM. Will
also obtain VQ Scan overnight per Dr. [**Last Name (STitle) **] to assess for PE
(although
radiologist states that utility w/ inderlying parenchymal
disease is minimal).
Pulmonary following.
GI: Currently on limited diet per speech/swallow. Albumin
Sunday 2.5. On
calorie counts and followed by nutrition. Must get
speech/swallow reassessment
(specifically about prognosis for return to full swallowing
function) Monday.
If poor prognosis for PO intake ability, we should consider PICC
for peripheral
nutrition/boluses or J-tube for feeds. Protonix [**Hospital1 **] via IV
until can tolerate
pills.
GU: Severely hypernatremic and intravascularly contracted
Saturday AM. Renal
reconsulted. Presumed ATN and intravascular depletion from poor
oncotic
pressure with low albumin (secondary to poor nutrition) and
previous lasix for
days while in SICU. Recommended 24h of D5W at 150 cc/h. Today
they recommended
HLIV and observation, but we elected to continue IVF at 150 cc/h
(until they
were HLIV when tachypnea presented). Renal following. Even
with everything
today PM, Dr. [**Last Name (STitle) **] would like to restart IVF at 75 cc/h Monday
PM if it
appears patient can tolerate. CT A/P Sunday w/o evidence of
obstruction.
ID: WBC peaked at 19.5, currently 17.5. Afebrile. No ABx. F/U
Cx (just about
everything is NGF). CT A/P Sunday shows evidence of known PNA.
H: On coumadin 1hs [**First Name8 (NamePattern2) **] [**Doctor Last Name **]. INR 1.5-1.6 over weekend.
E: Blessedly, no issues.
T/L/D: PIV (maybe). Ureteral stent removed Saturday AM. [**Month (only) 116**]
need PICC stat in
AM for access (PIV blew just now).
OTHER: Labs to check in AM. PT/OT following. Currently being
screened for
rehab. Ostomy nurse needs to come by on Monday (ostomy
appliance leaking like a
seive all weekend).
On [**8-28**], the patient was still on the the floor (12 [**Hospital Ward Name 1827**]) on
2L of oxygen. He wife comment that his breathing was no
different since he left the ICU. The V/Q scan from the previous
day did not show a pulmonary embolism, but it was indeterminant.
The doppler of the lower extremities did not show any DVT
either and respiratory had now new recs. Speech and swallow
were consulted again about his swallowing status. An solid
answer was not obtained and they will be [**Hospital Ward Name 653**] again on
Tuesday. The nutrition team also made some recs about inserting
a Dobhoff tube and feeding the patient at night, but with his
reflux, this is not a good idea. His urostomy appliance leaked
over the weekend and it continued to do so today despite the
nurse fixing it. Cardiology was also [**Name (NI) 653**] about his
hypertenstion and they recommended going up on the lopressor to
75-100 mg TID with prn hydralazine. His pain is well
controlled. His IV fluids were restarted originally with D5 [**1-9**]
NS with 1 amp of bicarb. This was changed to D5W with 1 amp of
bicarb. His coumadin was also increased to 2 mg this eveing.
He had no pain and has no other major issues.
On [**8-29**], patient still on floor (12 [**Hospital Ward Name 1827**]) off of oxygen.
Overnight, the patient had some difficulty sleeping and was very
frustrated with his current situation at hand. Speech and
swallow were [**Hospital Ward Name 653**] again and asked specifically when his
swallowing would recover. Therapist believes that it will
recover, but it may take several weeks for this to happen. In
the mean time, aspiration precautions should not preven the
patient from going to rehab. Recommends pureed diet so that it
takes less energy to eat which has been ordered. He also got
1,200 calories and 47 grams of protein. With the concerns about
ascietes, liver enzymes were drawn and gastroenterology was
curbsided. They were unimpressed by his current enzyme levels
and recommended a right upper quadrant ultrasound if concerned.
Additionally, patient's appliance continued to leak last night
and the stoma nurse came by today and changed it again.
On [**8-30**], patient still on the floor (12 [**Hospital Ward Name 1827**]) off oxygen.
Overnight, the patient did better and got some rest. The
hospitalist does not recommend anticoagulating this patient for
the clot in his left arm. They do not want any blood draws from
that arm. The Gastroenterologists commented that the ascites
has not contributed to the difficult fluid management. The
renal team is signing off and they recommend that he stay on
Bicitra 30mg PO BID for the indefinate future. He tolerated
clear fluids very well with no coughing. He continues to
dislike the food and his wife was encouraged to bring in food
for the patient. The dischage coordinator was [**Hospital Ward Name 653**] and
several care facilites are reviewing his chart for admission.
Dr. [**Last Name (STitle) 261**] saw the patient and agress with the current plan of
care. Staples to come out tomorrow am and due for dischgare if
things are well.
On [**8-31**], patient still on the floor (12 [**Hospital Ward Name 1827**]) off oxygen.
Overnight, there were no issues. He recieved his dose of
coumadin last night and it was d/c today. The staples were
removed and steri strips were applied to the wound. The nurse
communicated her concern about the lower part of the wound as it
maybe infected. The intern communicated this to the resident
and he came to look at it. The wound is erythematous, but there
was no purulent discharge or tenderness. Keflex was prescribed
at 500 mg QID x7 days. Awaiting to hear from discharge
planners. Patient will need to f/u with all consult teams that
saw him. Patient due for discharge back to [**State 1727**] this afternoon.
He will recive 1 unit of blood for low hematocrit this
afternoon.
Medications on Admission:
Nolol,nifedipine, flonase, lovastatin, zoloft, asprin,
rabeprazole, nitrostat prn
ALLERGIES: The patient has no known drug allergies.
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: 3.5 Tablets PO TID (3
times a day).
10. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO BID (2 times a day).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day. Capsule, Delayed
Release(E.C.)(s)
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-13**]
hours as needed for pain: hold if O2 sat less than 93% or
oversedated.
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO every twelve
(12) hours for 2 days.
15. Outpatient Lab Work
Please recheck chem 7 as patient was put on new renal
medication.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 24402**], ME
Discharge Diagnosis:
Bladder cancer.
Discharge Condition:
Stable.
Discharge Instructions:
You are being prescribed a narcotic pain medication. DO NOT
DRIVE OR OPERATE HEAVY MACHINERY WHILE TAKING THIS MEDICATION.
IT [**Month (only) **] MAKE YOU DROWSY.
Contact a physician for fever >100.5, bleeding or increasing
redness from incisions, difficulty swallowing or breathing,
headache, nausea or vomiting, double or blurry vision, or any
other concerns.
Please continue all home medications and those given to you by
your surgeon.
Followup Instructions:
Please arrange a follow-up appointment with Dr. [**Last Name (STitle) 261**] by
calling ([**Telephone/Fax (1) 4276**]. The rehab facility needs to call on
Friday ([**2169-9-1**]) to arrange for follow up.
Please arrange for follow up with your cardiologist at home in
[**State 1727**] as you need to go back on your Nifedipine. Please have
the rehab facility arrange this for you. You can also contact
one of our cardiologists here at ([**Telephone/Fax (1) 2037**].
Please arrange a follow up with the nephrology team by calling
them at([**Telephone/Fax (1) 773**]. You can also have your primary care
doctor arrange an appointment for you with a nephrologist up in
[**State 1727**].
Please arrange to have an ultrasound scan done on your left arm
in 7 days to make sure the blood clot has resolved.
Completed by:[**2169-8-31**]
|
[
"188.8",
"285.9",
"789.5",
"V45.82",
"999.8",
"278.00",
"327.23",
"584.5",
"518.5",
"403.90",
"276.4",
"585.9",
"530.81",
"428.31",
"453.8",
"511.9",
"276.0",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"96.6",
"38.93",
"56.51",
"33.24",
"57.71",
"96.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
43674, 43752
|
27275, 42120
|
329, 412
|
43812, 43822
|
2185, 8195
|
44311, 45149
|
1657, 1753
|
42306, 43651
|
26341, 26497
|
43773, 43791
|
42146, 42283
|
43846, 44288
|
1768, 2166
|
274, 291
|
26526, 27252
|
441, 1267
|
1289, 1495
|
1528, 1624
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,214
| 177,340
|
19966+57100
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-10-21**] Discharge Date: [**2112-10-27**]
Date of Birth: [**2045-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
adhesive tape / Latex
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2112-10-21**] Coronary artery bypass graft x 4 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
ramus, saphenous vein graft to obtuse marginal, saphenous vein
graft to posterior descending artery)
History of Present Illness:
66 year old male with PCIx3 (RCA, LAD, OM2) in [**2103**] who states
that he has been experiencing intermittent exertional chest pain
relieved with rest or NTG (NTG use is 2-3 times per week). He
states that the chest pain may have been more progressive over
the past few weeks. Stress test today at [**Hospital3 4107**] showed
ST depressions along with prolonged chest pain. Transferred for
cardiac catheterization. He was found to have three vessel
disease that was poorly suitable for stenting and is now being
referred to cardiac surgery for revascularization.
Past Medical History:
Hypertension
Dyslipidemia
Borderline diabetes
Coronary artery disease s/p PCI in [**2103**]
Pacreatitis (gallstone)
tremor hands (neurology appt. [**2112-10-13**])
s/p appendectomy
s/p partial colectomy
Social History:
Race:Caucasian
Last Dental Exam:many years ago
Lives with:wife
Occupation:accountant
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-11**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Mother passed away MI age 54,
Father dies age 77 from diabetes/CAD, 2 children A&W
Father MI < 55 [] Mother < 65 [x]
Physical Exam:
Pulse:66 Resp:16 O2 sat:98/2L
B/P Right:180/82 Left:162/88
Height:5'6" Weight:190 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses: all palpable
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2112-10-21**] Echo: PRE-BYPASS: The left atrium is elongated. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). 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. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. Physiologic mitral
regurgitation is seen (within normal limits). There is no
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results prior to incision.
POST-BYPASS: The patient is in sinus rhythm. The patient is on
no inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged. Aortic regurgitation is unchanged.
Tricuspid regurgitation is mild (1+). The aorta is intact
post-decannulation.
[**2112-10-27**] 08:50AM BLOOD Hct-35.4*
[**2112-10-26**] 07:13AM BLOOD WBC-9.5 RBC-3.78* Hgb-11.6* Hct-33.8*
MCV-89 MCH-30.8 MCHC-34.5 RDW-14.1 Plt Ct-272
[**2112-10-25**] 08:44AM BLOOD WBC-11.2* RBC-4.02* Hgb-12.5* Hct-36.1*
MCV-90 MCH-31.1 MCHC-34.6 RDW-14.5 Plt Ct-246#
[**2112-10-27**] 08:50AM BLOOD UreaN-29* Creat-1.4* Na-143 K-4.6 Cl-106
[**2112-10-26**] 07:13AM BLOOD Glucose-107* UreaN-30* Creat-1.2 Na-139
K-4.2 Cl-102 HCO3-28 AnGap-13
[**2112-10-25**] 08:44AM BLOOD Glucose-135* UreaN-28* Creat-1.3* Na-142
K-4.4 Cl-105 HCO3-30 AnGap-11
[**2112-10-24**] 05:50AM BLOOD Glucose-157* UreaN-28* Creat-1.4* Na-139
K-4.3 Cl-105 HCO3-26 AnGap-12
[**2112-10-23**] 02:53AM BLOOD Glucose-186* UreaN-21* Creat-1.1 Na-135
K-4.0 Cl-106 HCO3-22 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 656**] was a same day admit and on [**10-21**] was brought to the
operating room where he underwent a coronary artery bypass graft
x 4 with left internal mammary artery to left anterior
descending coronary; reverse saphenous vein single graft from
the aorta to first obtuse marginal coronary artery; reverse
saphenous vein single graft from the aorta to the second obtuse
marginal coronary artery; as well as reverse saphenous vein
single graft from the aorta to posterior descending coronary
artery.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. On
postoperative day one, he developed atrial fibrillation which
was treated with amiodarone. On postoperative day two, he was
transferred to the step down unit for further recovery. He was
gently diuresed towards his preoperative weight. Chest tubes and
epicardial pacing wires were removed per protocol. Coumadin was
started with 3 doeses given but then stopped with INR 3.9 at
discharge and patient in sinus rhythm for greater than 48 hours.
[**Last Name (un) **] was consulted due to a preop HBA1C 9.0% preop. They
added Lispro sliding scale and Lantus pen to his regimen. He
underwent diabetes/insulin teaching and was discharged home with
instructions. His Lasix was decreased on the day of discharge
with creatinine increased to 1.4 (baseline 0.8). The physical
therapy service was consulted for assistance with his
postoperative strength and recovery. Mr. [**Known lastname 656**] continued to
make steady progress and was discharged home on postoperative
day 6 with VNA and home PT services. VNA instructed to check
INR, BUN, Creatinine and K on [**10-28**] and call CT surgery office
with results. All follow-up appointments were instructed.
Medications on Admission:
CLOPIDOGREL 75 mg Daily (last dose 11/9)
LISINOPRIL 2.5 mg Daily
METOPROLOL TARTRATE 50 mg Daily
ROSUVASTATIN [CRESTOR] 40 mg Daily
ASPIRIN 81 mg DAily
NIACIN 500 mg Daily
OMEGA-3 FATTY ACIDS [FISH OIL] 500 mg Daily
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO DAILY (Daily).
4. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or temp >38.4.
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 2 weeks then 200 mg [**Hospital1 **] x 2 weeks then 200 mg daily x
1 month.
Disp:*100 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Humalog KwikPen 100 unit/mL Insulin Pen Sig: Six (6) units
Subcutaneous before meals: follow sliding scale .
Disp:*QS 1 month 1* Refills:*0*
14. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Thirty
(30) units Subcutaneous once a day: 30 Subcutaneous q hs glc
control
.
Disp:*QS 1 month 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 4
Past medical history:
Hypertension
Dyslipidemia
Borderline diabetes
s/p PCI in [**2103**]
Pacreatitis (gallstone)
tremor hands (neurology appt. [**2112-10-13**])
s/p appendectomy
s/p partial colectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with: Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
Edema- 1+ bilat edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2112-12-12**] at 1:00PM
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] on [**11-23**] at 3:00pm
Wound check on [**11-3**] at 11:15am in [**Hospital Unit Name **], [**Hospital Unit Name **]
Please call [**Hospital **] [**Hospital 982**] Clinic [**Telephone/Fax (1) 3402**] at for follow up
appointment within 1 week
***VNA to draw INR, BUN/Crea/K on [**10-28**] and call results to
[**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**
Completed by:[**2112-10-27**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 9995**]
Admission Date: [**2112-10-21**] Discharge Date: [**2112-10-27**]
Date of Birth: [**2045-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
adhesive tape / Latex
Attending:[**First Name3 (LF) 1543**]
Addendum:
[**First Name8 (NamePattern2) **] [**Last Name (un) 616**], Lantus changed to 18 units Q hs and Lispro SS
adjusted. Follow up in 1 week with [**Last Name (un) 616**] outpatient clinic
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2112-10-27**]
|
[
"333.1",
"411.1",
"997.1",
"V17.3",
"414.01",
"V45.82",
"250.00",
"401.9",
"427.31",
"E878.2",
"272.4",
"V45.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
11077, 11291
|
4290, 6202
|
301, 536
|
8576, 8808
|
2337, 4267
|
9731, 11054
|
1626, 1787
|
6468, 8193
|
8292, 8353
|
6228, 6445
|
8832, 9708
|
1802, 2318
|
251, 263
|
564, 1130
|
8375, 8555
|
1372, 1610
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,798
| 130,543
|
22823
|
Discharge summary
|
report
|
Admission Date: [**2177-1-13**] Discharge Date: [**2177-1-19**]
Date of Birth: [**2100-8-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Lethargy and Dizziness
Major Surgical or Invasive Procedure:
[**2176-1-14**] Drainage of pericardial effusion
[**Last Name (NamePattern4) 15255**] of Present Illness:
Mr. [**Known lastname 58995**] is a 76 year old gentleman status post AVR/CABGx3
[**2176-12-31**] by Dr. [**Last Name (Prefixes) **]. He was discharged home on [**2177-1-6**] on
coumadin for atrial fibrillation. He was also on plavix and
amiodarone. Roughly a day after discharge, Mr, [**Known lastname 58995**] began
to feel progressively tired. He denies any chest pain, syncope
or palpitations however did experience dysnea with laying flat.
On [**2177-1-10**], he noticed that he passed bloody urine. Incidently
he had fallen on his rightside two days prior. He presented to
an outside emergency room where a CT scan of his pelvis and
kidneys was unremarkable. His INR was 6.4 and a chest x-ray
revealed cardiomegally with a left sided pleural effusion. He
was diuresed and claims to have felt better. The urology service
saw him and was planning lithotripsy as an outpatient for
nephrolithiasis given his past history. Mr. [**Known lastname 58995**] was
subsequently transferred back to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **]
Medical Center given his hematuria, congestive heart failure,
anemia and supratherapeutic INR.
Past Medical History:
CABGx3/AVR [**2176-12-31**]
Atrial Fibrillation
Nephrolithiasis s/p stent
Skin cancer
Gout
Knee arthroscopy
Hyperlipidemia
Social History:
18 pack years of smoking, past alcohol abuse. Lives with wife.
Family History:
Father died of CAD at age 56
Mother died of lung cancer
Physical Exam:
Gen: Well developed man in no acute distress
VS: 116/58 64 SR Afebrile
HEENT: Anicteric sclera, PERRL, EOMI, Oropharynx benign
NECK: Supple
LUNGS: Few scattered rales
CARDIAC: RRR, III/VI systolic murmur
ABDOMEN: Soft, nontender, nondistended
EXT: 2+ lower extremity edema
DERM: small rash on back
NEURO: Nonfocal
Pertinent Results:
[**2177-1-13**] 10:04PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2177-1-13**] 10:04PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2177-1-13**] 10:04PM URINE RBC-97* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2177-1-13**] 10:04PM URINE MUCOUS-RARE
[**2177-1-13**] - CXR
Status post CABG/AVR. There is cardiomegaly but no evidence for
CHF. There are small bilateral pleural effusions with associated
atelectasis in the left lower lobe. No pneumothorax.
[**2177-1-13**] - EKG
Sinus bradycardia. Left atrial abnormality. Modest non-specific
intraventricular conduction delay. Diffuse ST-T wave
abnormalities with
prolonged QTc interval. Clinical correlation is suggested for
metabolic/drug effect. Since the previous tracing of [**2176-12-31**]
sinus bradycardia rate has increased. No pacer activity is seen
and further ST-T wave changes are present
[**2177-1-14**] ECHO
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function cannot be reliably assessed.
3. The aortic root is mildly dilated.
4. A prosthetic aortic valve is present.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6. There is a moderate sized (1-2 cm) pericardial effusion with
fibrin
deposits on the surface of the heart. Right ventricular
compression is
present, which suggests the presence of some tamponade.
7. Compared with the findings of the prior study (tape reviewed)
of [**2176-12-24**], the pericardial effusion is new.
[**2177-1-15**] CYTOLOGY
Blood and rare reactive mesothelial cells
[**2177-1-15**] ECHO
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Segmental
wall motion was not fully assessed. Right ventricular chamber
size is normal. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade. Compared with the prior
study (tape reviewed) of [**2177-1-14**], the pericardial effusion is
now much smaller.
[**2177-1-14**] PERICARDIOCENTESIS
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 6 French pulmonary wedge pressure
catheter,
advanced to the PCW position through a 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Pericardiocentesis: was performed via the subxyphoid approach,
using an
18 gauge thin-wall needle, a guide wire, and a drainage
catheter.
Right femoral artery was accessed with a 4 French catheter from
arterial
hemodynamic monitoring.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 58995**] was admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2177-1-13**] for further management of his hematuria and
congestive heart failure. An echocardiogram was performed which
noted signs of tamponade. Given his elevated INR, fresh frozen
plasma and vitamin K were given for reversal. On [**2177-1-14**], Mr.
[**Known lastname 58995**] was taken to the cardiac catheterization lab where he
underwent pericardiocentesis with drainage of 350cc's of blood
fluid. He was transferred to the cardiac surgical intensive care
unit for monitoring. The urology service was consulted for
hematuria however as Mr. [**Known lastname 58995**] was already under the care
of an outside urologist, he elected to have follow-up with his
outpatient urologist. Hie foley catheter drianage cleared from
pink to yellow. On [**2177-1-16**], his pericardial drain was removed
without issue. A repeat echocardiogram showed a significant
improvement in his pericardial effusion. Anticoagulation was
resumed for his paroxysmal atrial fibrillation. Mr. [**Known lastname **]
was transferred to the cardiac surgical step down unit for
further recovery. Gentle diuresis continued. The
electrophysiology service was consulted for assistance with his
atrial fibrillation. His amiodarone dose was decreased and it
was elected to wait one week prior to resuming his coumadin. On
[**2177-1-17**], Mr. [**Known lastname 58995**] was discharged home. He will follow-up
with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary care
physician as instructed.
Medications on Admission:
MEDS ON TRANSFER:
Lopressor 12.5mg twice daily
Lasix 40mg twice daily
Protonix 40mg once daily
Alopurinol 150mg once daily
2% nitropaste
Pravachol 20mg once daily
Cephalexin 250mg four time daily
Iron and folic acid
Coumadin(on hold)
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. 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*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
10. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day: RESTART ON TUESDAY.
Disp:*30 Tablet(s)* Refills:*2*
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. 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*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
10. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day: RESTART ON TUESDAY.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
vna of [**Location (un) **]
Discharge Diagnosis:
pericardial effusion
AFib
Discharge Condition:
good
Discharge Instructions:
no lifting > 10 # for 1 month
no creams or lotions to incisions
may shower, no bathing or swimming for 1 month
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (STitle) **] in [**12-15**] weeks
with Dr. [**Last Name (Prefixes) **] in [**2-14**] weeks
with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 22784**] in [**2-14**] weeks
Completed by:[**2177-2-7**]
|
[
"V45.81",
"423.0",
"272.0",
"428.0",
"427.31",
"592.0",
"286.9",
"274.9",
"V42.2",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
9383, 9441
|
301, 1603
|
9511, 9517
|
2254, 4887
|
1846, 1903
|
6877, 9360
|
9462, 9490
|
6617, 6617
|
9541, 9653
|
9704, 9933
|
1918, 2235
|
4938, 6591
|
239, 263
|
1625, 1750
|
1766, 1830
|
6635, 6854
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,081
| 120,983
|
47400
|
Discharge summary
|
report
|
Admission Date: [**2198-5-7**] Discharge Date: [**2198-5-10**]
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
pericardial effusion with cardiac tamponade
Major Surgical or Invasive Procedure:
pericardiocentesis and drain placement
History of Present Illness:
Ms. [**Known lastname 38807**] is a [**Age over 90 **] F with a distant PMH of breast cancer who
was transferred to [**Hospital1 18**] [**2198-5-7**] from [**Hospital6 3872**]
where she had presented from her rehab with progressive dyspnea
x 2 weeks. At MWH, she was seen by pulmonary for a large left
sided pleural effusion found on chest radiograph. CT scan of
the chest showed large left pleural effusion and a moderate to
large right pleural effusion w/o lymphadenopathy. There were
diffuse interstital abnormalities of the left lung concerning
for lymphangitic spread of tumor. She underwent a thoracentesis
which showed a pH 7.4, LDH 248, c/w exudative effusion, with
gram stain negative and NGTD on culture and pending cytology.
She was treated with a 5 day course of ceftriaxone. A TTE showed
a moderate sized paricardial effusion with no signs of
tamponade. The patient was transferred here at the family's
request.
.
Upon arrival to [**Hospital1 18**], she underwent repeat transthoracic echo
on [**5-8**] which revealed preserved EF of 55% but also showed a
pericardial effusion with sustained RA collapse and right
ventricular diastolic collapse, consistent with cardiac
tamponade. She was taken to the cath lab for pericardiocentesis.
.
Prior to her admission, she denied fevers, chills, or any viral
syndrome, but endorsed nausea and constipation for several
months. However, she did move her bowels this AM prior to going
for echo. She denies chest pain. She reports decreased energy
since her pelvic fracture in [**2198-2-25**], for which she was at
rehab prior to MWH presentation. She reports increased thirst
and some increased "thickness" of her legs since her pelvic
fracture. At rehab, she was most recently walking with the
assistance of a walker. Othewise, otherwise all other ROS were
negative in detail.
Past Medical History:
# Breast Cancer:
# s/p lumpectomy of left breast, XRT and tamoxifen
# s/p lumpectomy of right breast
# Afib: diagnosed [**4-5**], not on anticoagulation
# s/p Pelvic fracture
# frequent UTIs
# hypertension
# h/o cholecystitis
# osteoporosis
Social History:
Prior to pelvic fracture, pt had been living independently in
her home in [**Location (un) 745**]. Lifelong non-smoker, no EtOH use. Widowed,
has 3 children and is expecting a great-grandchild in [**Month (only) **].
Family History:
Per transfer record, Mother and father possibly died of stroke.
No history of lung cancer.
Physical Exam:
On admission -
VITAL SIGNS: afebrile 119/54 86 20 95-98% 3L NC
GENERAL: elderly woman, no acute distress, c/o mild chest pain.
HEENT: Normocephalic, atraumatic. + mild pallor. No scleral
icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD.
NECK: No carotid bruits. JVP not grossly distended, prominant
EJs
CARDIAC: Irregularly irregular. S1/S2. No murmurs appreciated.
LUNGS: Decreased air movement overall, with diminished breath
sounds at bases bilaterally. No appreciable
consolidation/dullness to percussion.
ABDOMEN: Moderately distended, tympanic to percussion.
Non-tender. No HSM appreciated. NABS.
GROIN: R groin femoral arterial and venous sheaths removed, no
oozing or hematoma noted.
EXTREMITIES: cool extremities with 2+ LE edema bilaterally, no
calf pain, 1+ DP pulses.
SKIN: No rashes/lesions/ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation to LT, moves all extremities equally. Gait assessment
deferred.
PSYCH: Listens and responds to questions appropriately
Pertinent Results:
==========
Labs
==========
[**2198-5-8**] 06:35AM BLOOD WBC-13.6*# RBC-4.81 Hgb-13.7 Hct-42.6
MCV-89 MCH-28.4 MCHC-32.1 RDW-16.1* Plt Ct-493*#
[**2198-5-8**] 01:30PM BLOOD WBC-14.5* RBC-4.41 Hgb-12.6 Hct-38.3
MCV-87 MCH-28.5 MCHC-32.8 RDW-16.1* Plt Ct-457*
[**2198-5-9**] 05:33AM BLOOD WBC-11.7* RBC-4.34 Hgb-12.2 Hct-37.6
MCV-87 MCH-28.0 MCHC-32.3 RDW-16.3* Plt Ct-371
[**2198-5-10**] 06:40AM BLOOD WBC-12.4* RBC-4.26 Hgb-12.0 Hct-37.2
MCV-87 MCH-28.3 MCHC-32.4 RDW-16.2* Plt Ct-359
[**2198-5-8**] 06:35AM BLOOD Glucose-136* UreaN-31* Creat-1.0 Na-133
K-5.2* Cl-96 HCO3-24 AnGap-18
[**2198-5-8**] 01:30PM BLOOD Glucose-159* UreaN-29* Creat-1.0 Na-129*
K-5.0 Cl-95* HCO3-23 AnGap-16
[**2198-5-9**] 05:33AM BLOOD Glucose-119* UreaN-27* Creat-0.8 Na-131*
K-5.3* Cl-98 HCO3-26 AnGap-12
[**2198-5-10**] 06:40AM BLOOD Glucose-111* UreaN-27* Creat-0.9 Na-132*
K-5.3* Cl-97 HCO3-25 AnGap-15
[**2198-5-8**] 06:35AM BLOOD ALT-44* AST-47* LD(LDH)-375* AlkPhos-190*
TotBili-0.7
[**2198-5-8**] 06:35AM BLOOD Albumin-3.6 Calcium-8.3* Phos-3.2 Mg-3.0*
[**2198-5-8**] 06:35AM BLOOD Digoxin-1.8
.
Pericardial Fluid
Cytology - NEGATIVE FOR CARCINOMA.
[**2198-5-8**] 07:16PM OTHER BODY FLUID WBC-500* RBC-[**Numeric Identifier 30493**]* Polys-5*
Lymphs-87* Monos-0 Macro-8*
[**2198-5-8**] 07:16PM OTHER BODY FLUID TotProt-4.3 Glucose-137
LD(LDH)-[**2114**] Amylase-28 Albumin-2.6
[**2198-5-8**] 1:00 pm FLUID,OTHER PERICARDIAL.
GRAM STAIN (Final [**2198-5-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2198-5-9**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
.
=============
Cardiology
=============
TTE [**2198-5-8**]
Overall left ventricular systolic function is normal (LVEF>55%).
There is a moderate sized pericardial effusion. There is
sustained right atrial collapse, consistent with low filling
pressures or early tamponade. There is right ventricular
diastolic collapse, consistent with impaired fillling/tamponade
physiology.
.
TTE [**2198-5-9**]
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Significant aortic
regurgitation is present, but cannot be quantified. Mitral
regurgitation is present but cannot be quantified. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed from post tap) of
[**2198-5-8**], no change.
.
Cardiac Cath [**2198-5-8**]
1. Emergent pericardiocentesis for pericardial tamponade with
removal of
380 cc of bloody fluids.
2. Persistent elevation of pericardial pressure indicative of
constrictive effusive etiology.
3. Pericardial drain left in place.
4. Repeat 2D echocardiogram in AM.
.
============
Radiology
============
Chest X ray [**5-10**]
Bilateral pleural effusions have not significantly changed in
the interim and the slightly better aeration of the right lung
base may be due to
redistribution of the fluid. The pericardial drainage has been
removed. There is no pneumothorax. There is no evidence of
pneumomediastinum.
.
Chest X ray [**5-9**]
Bilateral pleural effusions, larger on the left. No
pneumothorax.
Brief Hospital Course:
[**Age over 90 **] yo woman with a history of breast cancer who is transferred
to the CCU after TTE revealed pericardial effusion cuasing
tamponade physiology, s/p pericardiocentesis and drain
placement.
.
# Pericardial effusion with tamponade - Had pericardiocentesis
and drain placement [**5-8**] with subsequent removal the following
day. Given persistently elevated pericardial pressures after
drainage, this is likely constrictive disease. Etiology thought
to be likely malignant given history of BrCA and coincident
pleural effusions with CT chest showing suspicion of
lymphangitic spread of CA, but cytology was negative. However,
sensitivity for cytology is only between 67 and 92 percent.
Cultures from pericardial fluid no growth to date at time of
discharge. Repeat TTE showed no signs of tamponade. Patient was
started on indocin for pain. She was monitored for 24 hours in
the CCU before transfer to the floor. Plan for patient to have
cardiology follow up with repeat TTE next week.
.
#. Pleural effusions - these were most suspicious for malignancy
given that OSH CT scan also with interstial process of the left
lung. Has large right pleural effusion that has not been tapped.
There was no evidence of empyema or parapneumonic effusion. Pt
now s/p 5 day course of ceftriaxone at OSH. No current evidence
of pneumonia. CXR over 2 days showed stability. Cytology will
need to be followed up from [**Hospital1 **] ([**Telephone/Fax (1) 54722**]). Patient
was maintained on oxygen while in house to keep peripheral
saturations greater than 90.
.
#. Afib: Recently diagnosed. On diltiazem and digoxin for rate
control. Not currently anticoagulated given fall risk and
possible procedures. Dig level ok at 1.8. Continued on diltiazem
and digoxin for rate control, but digoxin changed to 0.125 mg
daily. Discharged without anticoagulation pending followup with
cardiology next week. Please hold all anticoagulation until
after patient is seen in follow-up.
.
#. Failed voiding trial: Foley removed 1 day prior to discharge
but did not void. Foley was replaced on the day of dicharge with
appropriate urine output.
.
# CODE STATUS:
-- After discussion with patient and family, she is DNR/DNI
.
# EMERGENCY CONTACT:
-- HCP [**Name (NI) **] ([**Name2 (NI) **]) [**Name (NI) **] [**Telephone/Fax (1) 100301**]
.
# DISPOSITION:
-- D/c back to Nursing Home
Medications on Admission:
REHAB MEDICATIONS:
Lasix 60mg
Digoxin
DuoNeb
Cardizem CD 360mg daily
MV with minerals
Vitamin D 100u Daily
ASA 325 daily
calcium 500mg [**Hospital1 **]
Fosamax 70mg weekly
Florastor 250mg [**Hospital1 **]
oxycodone PRN
Colace 100mg [**Hospital1 **]
fondaparinux 2.5mg sc daily
Trazodone 25mg QHS PRN insomnia
Acetaminophen PRN
Discharge Medications:
1. Cardizem SR 120 mg Capsule, Sust. Release 12 hr Sig: Three
(3) Capsule, Sust. Release 12 hr PO once a day.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17)
grams PO DAILY (Daily) as needed for constipation.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation.
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day.
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO WEEKLY ():
Give on Saturday.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Indomethacin 25 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day) as needed for pain.
13. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: While pt taking
indomethecin only.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
Bilateral Pleural Effusions
Pericardial Effusion
Atrial Fibrillation: currently not on anticoagulation
Discharge Condition:
stable
Discharge Instructions:
You had trouble breathing and was admitted to [**Hospital3 **] where some fluid was taken out of your lungs and did not
show signs of infection or cancer. They also found some fluid
around your heart and you were admitted to [**Hospital3 **]. The
fluid was drained off and a repeat ECHO does not show
reaccumulation of the fluid. The culture and cytology tests are
pending on that fluid. You will need another ECHO in 3 weeks to
check to see if the fluid reaccumulates.
Medication changes:
1. Your digoxin was decreased to 0.125mg daily
2. Indomethecin: to take for chest pain
3. Omeprazole: to protect your stomach from Indomethecin.
4. Please hold comadin for now
.
Please call Dr. [**Last Name (STitle) 39606**] or Dr. [**Last Name (STitle) **] if your breathing or chest
pain worsens, if you have vomiting or fevers or if you have any
other unusual symptoms.
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) 507**] [**Doctor First Name 508**] Phone: [**Telephone/Fax (1) 133**] Date/time: Thursday
[**5-17**] at 10:15am.
.
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39606**] Phone: ([**Telephone/Fax (1) 100302**] Date/Time: please call to
make an appt in [**12-29**] weeks. an ultrasound should be repeated at
that time as well if appropriate.
Completed by:[**2198-5-10**]
|
[
"564.09",
"733.00",
"401.9",
"276.7",
"511.9",
"276.1",
"420.99",
"423.3",
"427.31",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
11309, 11399
|
7173, 9535
|
296, 336
|
11546, 11555
|
3853, 5408
|
12466, 12925
|
2710, 2802
|
9912, 11286
|
11420, 11525
|
9561, 9889
|
11579, 12049
|
2817, 3834
|
12069, 12443
|
213, 258
|
364, 2196
|
5491, 7150
|
2218, 2460
|
2476, 2694
|
5440, 5455
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,583
| 199,500
|
53992
|
Discharge summary
|
report
|
Admission Date: [**2118-6-4**] Discharge Date: [**2118-6-9**]
Date of Birth: [**2050-3-31**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Code stroke for left sided weakness and dysarthria
Major Surgical or Invasive Procedure:
[**2118-6-4**] - Cerebral Angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery
History of Present Illness:
68RHM with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 AM after
taking
a shower. Code stroke called given his significant acute
deficits.
The patient had been previously fit and well until 7:50 AM. Upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. He fell backward, hitting his
back and right elbow. During this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. He was initially reluctant
to call EMS, but his son did. [**Name2 (NI) **] was transferred to the [**Hospital1 18**]
ED.
Of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
"something was grabbing hold of me". He attributed these to his
heart and they eased after he took a deep breath. These lessened
in frequency over the past 1 month but were still frequent. He
did however note that he had been very stressed over this period
as he has family and financial worries. He denies any prior
weakness or numbness or vision loss. No neck pain or trauma in
recent past. No stroke-like symptoms.
At [**Hospital1 18**] ED, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. There was evidence of a right MCA and ICA occlusion
on
CTA. CTP shows right MCA hypoperfusion. He was given IV tPA at
9:12 AM. After this, his symptoms significantly improved by
assessment at 10:45 AM, with NIHSS then 3. However, by 11:30
after his blood pressure dipped to SBP 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. Due to his initial improvement, Neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.
Past Medical History:
No known issues but has not seen a doctor in 10 years; possible
remote history of hypertension
Social History:
Lives with son.
Retired systems worker for a publishing company. In process of
selling his house.
Mobilises unaided.
Never smoked, no ETOH or illicit drug use.
Family History:
Mother - breast ca
Father - blocked neck arteries per patient ahd had ? CEA, no
strokes, prostate ca
Sibs - sisters - breast ca
Children - 5 well 1 with soem learning difficulties
.
There is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.
Physical Exam:
At admission:
Vitals: T:Afebrile P:70 SR R:14 BP:156/77 SaO2: 100%RA
General: Awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT.
Skin: Large hematoma right olecranon following fall and bruises
on back.
Neurologic:
NIH Stroke Scale score at 10:45 was 2 and 11:30 was 10
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0 at 11:30 1
3. Visual fields: 0
4. Facial palsy: 1 at 11:30 1
5a. Motor arm, left: 1 at 11:30 3
5b. Motor arm, right: 0
6a. Motor leg, left: 0 at 11:30 3
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0 at 11:30 1
9. Language: 0
10. Dysarthria: 0 at 11:30 1
11. Extinction and Neglect: 0
-Mental Status:
ORIENTATION - Alert, oriented x 3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric initially then mild dysarthria.
NAMING Pt. was able to name both high and low frequency objects.
[**Location (un) **] - Able to read without difficulty
ATTENTION - Attentive, able to name [**Doctor Last Name 1841**] backward without
difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall 3/ 3 at 5
minutes.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
V: Facial sensation intact to light touch.
VII: Mild left facial weakness.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally initially then
considerable weakness on left.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Initial assessment mild
left pronator drift then dens left hemiparesis.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Initial assessment post tPA.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 5 4+ 4+ 5 4- 5 5 4 4+ 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
Following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. On left
decreased temperature whole left side, decreased pinprick to
knee
in LE and whole of left UE, decreased vibration to ankle on
leftLE and sme decreased proprioception in left foot to ankle.
No
extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 1 1
R 2 2 2 2 1
Plantar response was flexor bilaterally with contraction of TFL
on left.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally but some difficulty with weakness on initail
assessment.
-Gait: Deferred
At transfer from NeuroICU to stroke floor:
normal mental status, improved right gaze preference and no
longer has L neglect. Mild DSS extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in LUE, joint position sense impairment in
LUE, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
At Discharge:
Neurological Exam Prior to Discharge:
Mental Status: Awake, Alert, Oriented to person, place, month,
day year, able to name months of year backwards
Cranial Nerves: Notable for Left Facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal V1-V3 bilaterally, tongue midline,
unable to raise Left shoulder (CN [**Doctor First Name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
Motor: 0/5 in left upper and left lower extremity
Reflexes: unable to elicit reflexes on the L, right biceps and
right patella 2; upgoing toe on right
Sensory: No extinguishing to double simultaneous tactile
stimulation (using face and arm)
Pertinent Results:
LABS ON ADMISSION:
[**2118-6-4**] 08:50AM BLOOD WBC-9.0 RBC-5.11 Hgb-14.4 Hct-42.6 MCV-83
MCH-28.2 MCHC-33.9 RDW-13.5 Plt Ct-249
[**2118-6-4**] 08:50AM BLOOD PT-12.7* PTT-33.6 INR(PT)-1.2*
[**2118-6-4**] 08:50AM BLOOD Plt Ct-249
[**2118-6-4**] 05:14PM BLOOD Fibrino-330
[**2118-6-4**] 08:50AM BLOOD UreaN-16
[**2118-6-4**] 08:51AM BLOOD Creat-1.0
[**2118-6-4**] 05:14PM BLOOD Glucose-104* UreaN-12 Creat-0.8 Na-140
K-3.8 Cl-108 HCO3-25 AnGap-11
[**2118-6-4**] 05:14PM BLOOD CK(CPK)-149
[**2118-6-5**] 01:17AM BLOOD ALT-15 AST-25 CK(CPK)-273 AlkPhos-76
TotBili-0.7
[**2118-6-4**] 05:14PM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8
[**2118-6-5**] 01:17AM BLOOD Albumin-4.0 Calcium-8.0* Phos-2.5* Mg-1.8
Cholest-175
[**2118-6-4**] 05:14PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2118-6-4**] 08:58AM BLOOD Glucose-107* Na-141 K-3.5 Cl-101
calHCO3-26
.
CARDIAC ENZYMES:
[**2118-6-4**] 05:14PM BLOOD CK-MB-3 cTropnT-<0.01
[**2118-6-5**] 01:17AM BLOOD CK-MB-5 cTropnT-<0.01
.
STROKE RISK FACTORS:
[**2118-6-5**] 01:17AM BLOOD %HbA1c-5.4 eAG-108
[**2118-6-5**] 01:17AM BLOOD Triglyc-76 HDL-47 CHOL/HD-3.7 LDLcalc-113
[**2118-6-5**] 01:17AM BLOOD TSH-0.44
.
[**2118-6-6**] 10:34 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2118-6-8**]**
MRSA SCREEN (Final [**2118-6-8**]): No MRSA isolated.
CTA/CTP brain:
Final Report
INDICATION: Stroke, question fall.
COMPARISON: Retrieved on the OMR.
TECHNIQUE: CT head without contrast; CT angiogram of the head
and neck with
IV contrast; CT cerebral perfusion study. With reformations of
the arteries
and _____ color maps.
FINDINGS:
NON-CONTRAST CT HEAD: There is dense appearance of the right
middle cerebral
artery, representing thrombus within. There is a hypodense area
noted in the
right corona radiata, which is likely chronic.
There is no acute intracranial hemorrhage or mass effect at this
point. There
is mild prominence of the ventricles and extra-axial CSF spaces
related to
volume loss.
No suspicious osseous lesions are noted. Moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.
The cerebral perfusion study: There is a large area of increased
MTT with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right MCA territory. Associated small
acute infarct
is possible in addition with a large penumbra.
CT ANGIOGRAM OF THE HEAD AND NECK: The origins of the arch
vessels are
patent. On the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. Except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. In
the petrous
and the cavernous carotid segments, there is no flow noted. As
also in the
supraclinoid segment. There is no flow noted in the right middle
cerebral
artery. A few peripheral collaterals are noted.
The right A1 segment is partially occluded. There is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.
The left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. Mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
No flow
limitation is noted distally. There are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
There is no flow limitation. The left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.
The vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. Scattered
calcifications are
noted in the distal vertebral arteries and the V4 segments,
predominantly on
the left side with moderate short segment stenosis. The major
branches of the
vertebral and basilar arteries are patent. The basilar artery is
diminutive
in size with fetal PCA pattern, with prominent posterior
communicating
arteries and diminutive P1 segments.
The thyroid is unremarkable. A few small scattered nodes are
noted in both
sides of the neck, not enlarged by CT size criteria. Mild
fullness is noted
in the left pyriform sinus.
A small subpleural based focus is noted in the right lung. In
the apex, which
can be correlated with dedicated CT chest imaging.
Mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent CT C-spine study.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Large area of perfusion abnormality in the right middle
cerebral artery
territory.
3. The large area of ischemia along with a possible small area
of acute
infarction. If there is continued concern, for the extent of
infarction, MRI
can be considered.
4. New total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
Possibilities include
dissections/thrombosis. Partial occlusion of the right A1
segment.
Please see the subsequent conventional angiogram study.
Short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.
CT C-spine without contrast:
Final Report
INDICATION: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for C-spine fracture.
COMPARISON: None available.
TECHNIQUE: MDCT images were acquired through the cervical spine
without
intravenous contrast. Sagittal and coronal reformats were
generated and
reviewed.
FINDINGS: No acute cervical spine fracture or malalignment is
detected. The
prevertebral soft tissues are normal. The vertebral body heights
are normal.
There is mild reduction of the intervertebral disc height at
C5-C6, C6-C7 and
C7-T1 levels. Mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. Some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. No significant spinal
canal stenosis
is seen in the cervical level. There is some degree of rotation
at C1 and C2-
correlate clinically-? positional. The imaged portion of the
thyroid gland
is normal. A subpleural nodular focus is noted in the right lung
apex.
Vascular calcifications and scattered nodes are noted. Fullness
in the
piriform sinuses-correlate clinically.
IMPRESSION: No acute cervical spine fracture or malalignment.
Multilevel
degenerative changes with foraminal narrowing. Correlate
clinically to decide
on the need for further workup.
Cerebral angiogram:
Final Report
CLINICAL HISTORY:
68-year-old male with history of sudden onset of left
hemiplegia. CT
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.
Informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. Risks and indications
were also
discussed with the patient's son.
The patient was brought to the neurointerventional suite and
prepared for
General Anesthesia and was ready for puncture at 2:20 p.m.
Access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. A 4 French Berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:
RIGHT COMMON CAROTID ARTERY:
LEFT COMMON CAROTID ARTERY:
RIGHT COMMON CAROTID ARTERY FINDINGS:
There is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. There is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and M2
segment of
the middle cerebral artery on the right.
Later the catheter was withdrawn and the left common carotid
artery was
catheterized.
LEFT COMMON CAROTID ARTERY FINDINGS:
There is moderate irregular plaque noted in the proximal left
internal carotid
artery. There is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. There is
cross flow noted
across the anterior communicating artery into the A2 branch of
the anterior
cerebral artery on the right.
The system was upgraded to a 9 French system and Merci balloon
catheter was
introduced into the right common carotid artery. A rapid transit
catheter and
a gold tip Glidewire was introduced to catheterize the right
internal carotid
artery. Multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. At this
point, findings
were discussed with Dr. [**First Name (STitle) **], who suggested to abort the
procedure. 2
milligrams of TPA was introduced into the proximal right
internal carotid
artery.
IMPRESSION:
1. Unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of TPA was introduced into the proximal right internal
carotid
artery.
ECG:
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 188 86 [**Telephone/Fax (2) 110698**]5
MRA Brain without contrast:
Final Report
INDICATION: Right ICA and MCA occlusion with attempted
thrombolysis. MRI to
evaluate for stroke.
COMPARISON: CTA head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].
TECHNIQUE: MRI and MRA of the brain was performed without
contrast per
departmental protocol.
FINDINGS:
MRI HEAD: There is an area of slow diffusion with accompanying
FLAIR signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. A small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. Multiple tiny scattered
foci of slow
diffusion are also seen in the distal right MCA territory. There
is no mass
effect, or edema seen. A chronic lacunar infarct is seen in the
right centrum
semiovale.
There is no hydrocephalus or midline shift. Visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.
MRA OF THE BRAIN: As seen on the prior CTA and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. There is
filling of the right ACA and MCA via collaterals from the circle
of [**Location (un) 431**].
The right MCA, however, appears attenuated. There is an overall
paucity of
the peripheral cortical branches of the right MCA. The left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
Bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.
IMPRESSION:
1. Early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. Multiple small scattered foci of slow diffusion in the right
MCA
distribution, concerning for acute embolic infarcts.
3. Chronic lacunar infarct in the right centrum semiovale.
4. Persistent right ICA occlusion with reconstitution of the
right ACA and
MCA. However, the right MCA appears attenuated with an overall
paucity of
distal cortical branches.
R groin vascular U/S:
Final Report
INDICATION: Patient with recent diagnostic angiogram. Assess for
aneurysm
formation in the right groin.
COMPARISONS: None available.
FINDINGS:
Grayscale and color Doppler images of common femoral artery and
vein
demonstrate patent vessels. There is no evidence of
pseudoaneurysm or AV
fistula. Appropriate arterial and venous waveforms are
demonstrated. No focal hematoma in this region is seen.
IMPRESSION:
No evidence of pseudoaneurysm, AV fistula, or adjacent hematoma
involving
right common femoral vessels.
TTE:
Conclusions
The left atrium and right atrium are normal in cavity size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is an
apically displaced muscle band. Right ventricular chamber size
and free wall motion are normal. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Dilated aortic arch. No definite cardiac source of embolism
identified.
CLINICAL IMPLICATIONS:
Based on [**2113**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Ankle Xray:
FINDINGS: The mortise is congruent. No fractures or dislocations
are
observed. No significant soft tissue swelling is observed. The
soft tissue
is unremarkable. There is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
IMPRESSION: No fractures or dislocations. Mild degenerative
changes seen in the ankle and tarsal joints.
CXR:
FINDINGS: There is no evidence of rib fractures. Both lungs are
clear.
Heart size is normal. Mediastinal and hilar contours are
unremarkable. There is no pleural abnormality.
IMPRESSION: No evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
LABS AT TIME OF DISCHARGE:
[**2118-6-8**] 05:00AM BLOOD WBC-6.8 RBC-4.37* Hgb-12.3* Hct-36.4*
MCV-83 MCH-28.0 MCHC-33.7 RDW-13.2 Plt Ct-244
[**2118-6-9**] 05:35AM BLOOD PT-23.5* PTT-83.7* INR(PT)-2.2*
[**2118-6-9**] 05:35AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname **] is a 68 RHM with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 AM ([**6-4**])
after taking a shower. He presented to the [**Hospital1 18**] [**2118-6-4**] and was
admitted to the Stroke Service for further evaluation and care.
He was discharged on [**2118-6-4**] to rehabilitation.
.
#Right Basal Ganglia Infract from Right Internal Carotid Artery
Occlusion (and Right Middle Cerebral Artery Occlusion - since
recanalized): Initially on admission a code stroke called given
his significant acute deficits. At [**Hospital1 18**] ED, the patient was
hypertensive to 190s and initial NIHSS was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. There was evidence of a right MCA and ICA occlusion
on CTA concerning for dissection. CTP showed a large area of
right MCA hypoperfusion. He was administered IV tPA at 9:12 AM.
After this, his symptoms initially significantly improved with
good antigravity on the left with NIHSS then 3. However, as his
blood pressure dipped to SBP 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. Accordingly, the Neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits. Unfortunately, the ICA could not be opened. (The
difficulty passing the catheter through the ICA was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
The patient was started on heparin gtt. A subsequent MRI showed
patent R MCA later that night. His goal PTT was 50-70, and was
checked every 6 hours. Dosing adjustments were made accordingly.
In the acute setting the patient required a nicardipine gtt with
goal SBP 140-190's, he eventually did not require this anymore.
After his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg QD with a goal SBP of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent R ICA occlusion). He was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
His stroke risk factors were assessed: FLP 175, TG 76, HDL 47,
LDL 113, A1C 5.4. As his LDL was not at goal <70 the patient was
started on high dose Atorvastatin 80mg QD. A TTE was obtained
(see full report above) which did not show an ASD/PFO/thrombus,
and the patient had a preserved EF. A Speech and Swallow
evaluation was obtained, and the patient was cleared for a
regular diet. The patient was evaluated by Physical Therapy and
Occupational Therapy, and has been recommended for inpatient
rehab. Also, the patient will have a follow-up CTA in 3 months,
to be reviewed at his follow-up appointment with Dr. [**First Name (STitle) **] in
Neurology (scheduled prior to discharge).
.
#Hypertension: Patient has had goal SBP 140's-180's, he
previously was not on any anti-HTN medications. We started the
patient on lisinopril and uptitrated to 20mg QD. We have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. In about 2 days post discharge ([**2118-6-11**]) his
SBP range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#Left Rib Pain, Left Ankle Pain s/p fall: Patient had a CXR and
a Left Ankle Xray without evidence of fracture. He was treated
with acetaminophen for pain and tolerated this well.
.
#Antiocoagulation: Patient will need anticoagulation for his
occlusion for at least 3 months. His goal INR is [**3-18**]. His INR
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
TRANSITIONAL ISSUES:
1) D/c to rehab
2) Follow up CTA at 3 months (scheduled prior to discharge)
3) Anticoagulation with goal INR [**3-18**] on coumadin
4) Follow up with Dr. [**First Name (STitle) **] (Neurology)
5) Follow up with Primary Care Physian - who could potentially
follow the INR or help facilitate monitoring with the coumadin
clinic.
Medications on Admission:
Aspirin 325mg qd
Nil OTC
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right MCA distribution
in the setting of Right Internal Carotid Artery Occlusion,
Right Middle Cerebral Artery Occlusion (since recanalized)
Secondaty Diagnoses: Hypertension, Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
.
Neurological Exam Prior to Discharge:
Mental Status: Awake, Alert, Oriented to person, place, month,
day year, able to name months of year backwards
Cranial Nerves: Notable for Left Facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal V1-V3 bilaterally, tongue midline,
unable to raise Left shoulder (CN [**Doctor First Name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
Motor: 0/5 in left upper and left lower extremity
Reflexes: unable to elicit reflexes on the L, right biceps and
right patella 2; upgoing toe on right
Sensory: No extinguishing to double simultaneous tactile
stimulation (using face and arm)
Discharge Instructions:
Dear Mr. [**Known lastname **],
.
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. We performed inital
imaging of your head and found out that you had a clot in
several of the arteries (Right Internal Carotid and Middle
Cerebral Arteries) that supply the right side of the brain.
There was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. You
were given an IV medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
To treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). Your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an INR.
Your goal INR range is [**3-18**]. This will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
Your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. For this reason we recommended
starting a cholesterol medication (Atorvastatin). Plesae take
this as prescribed. Please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this. Your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
You have appoinmtents scheduled for follow-up with a primary
care provider, [**Name10 (NameIs) 3**] well as Dr. [**First Name (STitle) **] of Neurology. Please see
below.
We made the following changes to your medications:
START Atorvastatin 80mg take one tablet by mouth daily
START Warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as INR with a goal INR of [**3-18**])
START Lisinopril 20mg tablet take one tablet by mouth daily
START Docusate 100mg take one tablet by mouth two times a day
STOP Aspirin 325
START Acetaminophen 650mg take one tablet by mouth every 6
hours as needed for pain
Followup Instructions:
We coordinated an appointment with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 110520**], MD and Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (the PCP for purposes of insurance)
Phone:[**Telephone/Fax (1) 2010**] on [**2118-6-23**] at 1:45 pm. Please call your
insurance company in advance of the appointment to notify them
that Dr. [**First Name (STitle) **] is your primary care doctor.
.
Neurologist [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD (Phone:[**Telephone/Fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm. The office is located on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building on the [**Hospital Ward Name 516**].
.
CTA
Wednesday [**2117-9-6**]:15 AM
NPO 3 hours prior
Medications okay with water
performed on the [**Hospital Ward Name 517**] in the Clinical Center Building
[**Location (un) **] Radiology
[**Hospital1 32464**] (off [**Location (un) 71679**])
[**Location (un) 86**], MA
.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"784.51",
"434.11",
"E879.8",
"342.90",
"342.92",
"401.9",
"786.50",
"719.47",
"433.11",
"V45.88",
"272.4",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"88.41",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
27806, 27876
|
23129, 26984
|
355, 492
|
28351, 28351
|
8157, 8162
|
31536, 32633
|
2988, 3321
|
27409, 27783
|
27897, 28330
|
27359, 27386
|
29271, 31027
|
5202, 7379
|
3336, 4454
|
21741, 23106
|
7394, 7432
|
27005, 27333
|
31056, 31513
|
9039, 9805
|
264, 317
|
520, 2675
|
28668, 29247
|
9814, 21718
|
8176, 9022
|
28556, 28652
|
2697, 2794
|
2810, 2972
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,533
| 173,026
|
33137
|
Discharge summary
|
report
|
Admission Date: [**2170-1-13**] Discharge Date: [**2170-1-25**]
Date of Birth: [**2101-8-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
found down, s/p fall from ladder, transferred from OSH
Major Surgical or Invasive Procedure:
PEG placement
IVC filter placement
History of Present Illness:
The patient is a 68M who was apparently taking down [**Holiday **]
decorations when he had an unwitnessed fall in his garage. The
patient was not seen until approximately 3hours later when he
was found standing by his family. He was
alert and speaking but confused per family report. The family
brought him to an OSH where he found to be disoriented and
confused with a body temperature of 88F. The patient was
sedatedand intubated and transferred to [**Hospital1 18**] after CT Head
revealed bifrontal contusions and 2.5mm SDH in middle cranial
fossa.
Past Medical History:
1. COPD
2. HTN
3. hypercholesterolemia
4. hiatal hernia
5. lower esophageal ring s/p dilitation [**12-15**]
6. BPH, prostate nodule
7. colonic polyps last colonoscopy [**1-13**]
Social History:
lives with spouse, has large family support system. Denies
ETOH, tobacco, or recreational drug use. Wife [**Name (NI) **] [**Telephone/Fax (1) 77024**]
Family History:
noncontributory
Physical Exam:
On admission:
99.8 R 92 156/88 16 100% (vent)
Gen: intubated, sedated
Eyes: PERLA 4-->3, R periorbital echymosis
ENT: TM clear, intubated, good condensation
Respiratory: breath sounds equal bilaterally
Cardiovascular: normal rate, regular rhtm
Abdomen: soft, non-tender, pelvis stable
Skin: posterior head lac
.
On discharge pertinent changes:
98.2 Ax 79 114/74 20 95% 2L
Gen:NAD
Resp: BS equal bilaterally
Cardiovascular: nl rate, reg. rhythm
Abd: soft, PEG in place, dressings covering superficial
abdominal scars
Skin: legs in sheepskin
Neuro: not following commands, not moving LE
Pertinent Results:
on admission:
[**2170-1-13**] 10:47PM GLUCOSE-174* LACTATE-2.9* NA+-145 K+-3.5
CL--102 TCO2-23
[**2170-1-13**] 10:40PM WBC-21.4* RBC-4.49* HGB-14.7 HCT-41.7 MCV-93
MCH-32.7* MCHC-35.2* RDW-12.5
[**2170-1-13**] 10:40PM UREA N-13 CREAT-1.0
[**2170-1-13**] 10:40PM ALT(SGPT)-18 AST(SGOT)-31 ALK PHOS-87 TOT
BILI-0.9
[**2170-1-13**] 10:40PM ALT(SGPT)-20 AST(SGOT)-30 CK(CPK)-184* ALK
PHOS-89 AMYLASE-60 TOT BILI-1.1
[**2170-1-13**] 10:40PM cTropnT-<0.01
[**2170-1-13**] 10:40PM CK-MB-5
[**2170-1-13**] 10:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-1-13**] 10:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-1-13**] 10:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-8.0
LEUK-NEG
pertinent imaging:
CT C-spine [**1-13**]: neg
CT torso [**1-13**]: neg
CT head [**1-13**]: mod R frontal subgaleal hematoma, R frontal bone fx
c sup sag sutural diastasis & ext into occipital bone, b/l
frontal hemoarrhagic contusions, sm SDH along falx/tentorium,
?mild intravent ext of hemorrhage s hydroceph, no herniation
CT head [**1-14**]: no change
MRI head [**1-14**]: b/l frontal hemorrhagic contusions c edema,
smaller hemorrhagic contusions in R vertex & b/l temp lobes, bld
in post horns of lat vent, 4th vent, interpeduncular fossa, sm L
parasag SDH, b/l parietal SAH, no hydroceph/midline
shift/infarction
MRI TL spine [**1-14**]: no cord compression/spinal stenosis.
subarachnoid blood in spinal canal
MRI C spine [**1-14**]: No fx or cord compression, mild [**Last Name (un) **] dz
CT head [**1-16**]: no significant change. R temporal contusion
slightly more conspicuous.
CT head [**1-17**]: no interval change in contusions, subarachnoid,
subdural hemorrhages. unchanged mass effect.
MR L spine [**2170-1-22**]: Evolution of the stable volume of blood
within the thecal sac. No evidence of new canal or foraminal
stenoses.
Brief Hospital Course:
The patient was brought to the [**Hospital1 18**] emergency department as a
basic trauma on [**2170-1-13**], and had CT head, C-spine, chest,
abdomen, and pelvis as detailed above. He was admitted to the
TICU, with Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**], Attending Physician. [**Name10 (NameIs) **]
Neurosurgery team was immediately consulted regarding his
subdural hematoma. He was loaded with dilantin, and a repeat
head CT was performed the subsequent day, [**2170-1-14**], which did not
demonstrate any change. On [**2170-1-14**] he remained intubated on
propofol gtt in the TICU. He continued to have q1hour neuro
checks, but his neuro exam was inconsistent. There was question
whether he was moving his lower extremities at all. A MRI Head,
T and L spine was performed at night. Subarachnoid blood was
seen in the spinal canal, but it was not felt to be impinging on
the cord. On [**2170-1-15**] he was extubated, and neurology was
consulted due to concern for lower extremity weakness.
Recommendations by neurology were to continue dilantin and to
start manitol to reduce ICP. On [**2170-1-16**], he was found to be A&O
x1 only and a repeat head CT showed no significant change. On
[**2170-1-17**] patient was taken to the OR for IVC and PEG tube
placement which was performed without complication however
postoperative the patient developed anisocoria with dilation of
the right pupil which resolved spontaneously. Another repeat
head CT was negative. TF were also started on [**2170-1-17**] and were
advanced to goal on [**2170-1-19**]. Patient was extubated on [**2170-1-19**]
and the mannitol was discontinued. Was transfered to the floor
on [**2170-1-20**] and screening for rehab was undertaken. Patient had
physical therapy work with him allowing him to be able to go
from the bed to the chair. On [**2170-1-22**] the neurology team felt as
though his reflexes were decreased in his right leg and an MRI
was done which showed no acute processes. Per neurology, his
dilantin may be weaned at rehab. Patient will need to schedule
an appointment with neurology to be followed as an outpatient.
On [**2170-1-23**] patient was deemed stable for discharge. Upon
discharge patient was tolerated tube feeds at goal, was able to
tolerate being transferred from the bed to chair, continued to
have decreased movement in his lower extremities and had no
other acute surgical issues. He is oriented x1 when awake. He
is incontinent of bladder and bowels, and requires a diaper. On
discharge his SaO2 was 100% on 2L. This may be weaned as
tolerated. Patient will be transferred to a rehabilitation
facility and will follow up in clinic in [**1-10**] weeks.
Medications on Admission:
ASA 81', terazosin 5', Lipitor 10', Advair 250/50, Salmeterol,
Cardizem 180'
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: One (1) PO BID (2
times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Phenytoin 100 mg/4 mL Suspension [**Last Name (STitle) **]: One Hundred (100) mg PO
Q8H (every 8 hours).
4. Warfarin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily) as
needed for dvt prophylaxis.
5. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO DAILY (Daily).
6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
7. Insulin Sliding Scale
Please see attached sheet for insulin sliding scale
8. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation. Suppository(s)
9. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Last Name (STitle) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) nebulizer Inhalation Q6H (every 6 hours). nebulizer
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Multiple hemorrhagic contusions & Subdural hematoma
Discharge Condition:
Stable
Discharge Instructions:
Please [**Name8 (MD) 138**] MD or visit ER if you experience any of the
following: Temp>101.5, chest pain, shortness of breath, severe
nausea/vomiting, severe abdominal pain, redness or drainage from
around the PEG site or any other concerning symptoms.
You may shower however keep all incisions clean and dry.
Followup Instructions:
Please follow up in clinic with Dr. [**Last Name (STitle) 519**] in approximately [**1-10**]
weeks. You have been arranged to see him on [**2170-2-5**] at 8:30 on
the [**Location (un) 470**] of [**Hospital Ward Name 23**] Clinical Center.
You will also need to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
Behavioral Neurology. Please call ([**Telephone/Fax (1) 1703**] to arrange for
an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2170-1-25**]
|
[
"E881.0",
"991.6",
"V12.72",
"272.0",
"496",
"263.9",
"800.10",
"E901.0",
"600.00",
"401.9",
"729.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.33",
"96.6",
"38.93",
"96.71",
"38.7",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
8134, 8204
|
4013, 6720
|
369, 405
|
8300, 8309
|
2013, 2013
|
8669, 9271
|
1376, 1393
|
6847, 8111
|
8225, 8279
|
6746, 6824
|
8333, 8646
|
1408, 1408
|
275, 331
|
433, 988
|
2027, 3990
|
1010, 1189
|
1205, 1360
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,362
| 184,179
|
34702+57937+57939
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2162-7-13**] Discharge Date: [**2162-7-18**]
Date of Birth: [**2084-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
pericardiocentesis
right heart catheterization
History of Present Illness:
The patient is a 77 year old man with history of CHB s/p ppm,
and hypertension p/w chest pain and dyspnea. On [**2162-7-1**] he
presented to [**Hospital **] Hosp with pleuritic chest pain radiating
to his shoulder and back. There was no change in the sensation
with position. He states that prior to the chest pain starting,
he had ~2 weeks of bronchitis which was slow to clear. On that
presentation he was given the clinical diagnosis of
pericarditis. A TTE at that time showed a small pericardial
effusion but otherwise no change from [**2-11**]. He also had a
negative V/Q scan and lower extremity u/s to rule out
thromboembolic disease. He was prescribed a course of NSAIDS. On
[**2162-7-9**] he developed progressive dyspnea on exertion and
occasional lightheadedness and re-presented to [**Hospital **]
Hospital. A TTE showed moderate to large pericardial effusion
with signs of early tamponade. His Cr was noted to be mildly
above his baseline of 1.79 to 1.86. He was taken for right heart
cath and pericardiocentesis. Multiple attempts at the
pericardiocentesis were performed under ultrasound guidance
without fluid aspiration. He received 1 dose of Kefzol post
procedure. He was transfered to [**Hospital1 18**] for further care.
.
He currently denies chest pain or shortness of breath. He has
mild discomfort from the attempted pericardiocentesis sites.
.
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.
.
*** Cardiac review of systems is notable for absence of
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
complete heart block s/p ppm [**2160**] c/b RV lead dislodgement
requiring pacer revision further complicated by subclavian DVT
hypertension
hyperlipidemia
BPH
CKD (baseline Cr 1.7)
s/p right THA (with revision)
Pacemaker/ICD placed in [**2160**]. [**Company 1543**] DDD
Social History:
Social history is significant for the distant (>30 years ago)
tobacco use. There is no history of alcohol abuse. He is a
retired engineer for Polaroid. He lives with his second wife. [**Name (NI) **]
works part-time in machine shop
Family History:
There is no family history of premature coronary artery disease
or sudden death. Multiple uncles/aunts with [**Name2 (NI) 499**] cancer
Physical Exam:
VS: T 99.6, BP 133/79, HR 104, RR 13, O2 97% on 3L
pulsus parodoxus 5
Gen: WDWN elderly male in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP flat.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. no pericardial rub
Chest: bandages from attempted pericardiocenteses. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use. No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: alert and oriented x3. CN grossly intact. moving all 4
extremities symmetrically.
Pertinent Results:
EKG demonstrated [**2162-7-13**] with sinus @102 v-paced PR prolongation,
LAFB, IVCD, Q II,III,avF no significant change compared with
prior dated [**2162-7-13**] 829am (at [**Hospital1 **]) on [**2162-7-13**] demonstrated:
LVEF 65-70% with mild impaired relaxation. septal dysynchrony.
mild concentric LVH. moderate circumferential pericardial
effusion with diastolic invagination of RV free wall suggestive
of increased intra-pericardial pressurw but no clear signs of
frank tamponade. normal valves. trace TR normal est PA systolic
pressure
right heart cath:
[**2162-7-13**]
RA mean 19
RV 44/15/20
PA 38/19/27
PCW 27
CO/CI 4.43/2.08
LABORATORY DATA: [**2162-7-13**] 850am
CBC 9.4> 32.8< 347 MCV 91.3 RDW 15.6 80%pmn 12%lymp 0 band
Na 136 K 4.4 Cl 103 CO2 22 BUN 30 Cr 1.85 Glu 108 AG 11
tpro 6.8 Ca 9.5 alb 4.1 tbil 0.4 ast 25 alt 32 alkp 123
INR 1.18 CK 126 BNP 139 Troponin 0.029
Pericardiocentesis- cytology negative
Brief Hospital Course:
Mr. [**Known lastname 79556**] is a 77 year-old man with history of hypertension,
complete heart block who was admitted with shortness of breath
and pleuritic chest pain. He was found to have pericarditis and
a pericardial effusion. On [**2162-7-14**] he underwent a pericardial
window performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]. He tolerated the
procedure well and was able to be transferred to the surgical
intensive care unit in critical but stable condition. On
post-operative day one a left pleural chest tube was placed and
the fluid was sent to the lab for cytology. He was extubated
and transferred to the surgical step-down floor. His chest
tubes were removed. He was seen in consultation by physical
therapy. By post-operative day 3 he was ready for discharge to
home. Pericariocentesis cytology was negative, although pleural
fluid cytology was pending at the time of discharge.
Medications on Admission:
Cardura 2 mg daily
Zocor 10 mg daily
ASA 81 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cardura 2 mg Tablet Sig: One (1) Tablet PO once a day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking pain medication for constipation.
Disp:*60 Capsule(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Location (un) 5871**]/[**Location (un) 6159**]
Discharge Diagnosis:
Primary:
Pericardial effusion with tamponade
Pericarditis
Secondary:
hypertension
complete heart block
Discharge Condition:
good.
Discharge Instructions:
Please take your medications as prescribed.
If you develop any concerning symptoms such as chest pain,
worsening shortness of breath, fainting, or fever to >101F;
please seek medical attention.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 70216**] (PCP) in 2 weeks [**Telephone/Fax (1) 72189**].
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] (Cardiology) in 2 weeks.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in 4 weeks.
Completed by:[**2162-7-18**] Name: [**Known lastname 12778**],[**Known firstname **] Unit No: [**Numeric Identifier 12779**]
Admission Date: [**2162-7-13**] Discharge Date: [**2162-7-18**]
Date of Birth: [**2084-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1543**]
Addendum:
Recurrent pericardial effusions were determined to be of unknown
etiology after pericardiocentesis cytology was returned
negative.
Major Surgical or Invasive Procedure:
pericardiocentesis
right heart catheterization
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Location (un) 745**]/[**Location (un) 746**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2162-7-18**] Name: [**Known lastname 12778**],[**Known firstname **] Unit No: [**Numeric Identifier 12779**]
Admission Date: [**2162-7-13**] Discharge Date: [**2162-7-18**]
Date of Birth: [**2084-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1543**]
Addendum:
Pleural fluid cytology final results returned with no malignant
cells.
Major Surgical or Invasive Procedure:
pericardiocentesis
right heart catheterization
Past Medical History:
complete heart block s/p ppm [**2160**] c/b RV lead dislodgement
requiring pacer revision further complicated by subclavian DVT
hypertension
hyperlipidemia
BPH
CKD (baseline Cr 1.7)
s/p right THA (with revision)
Pacemaker/ICD placed in [**2160**]. [**Company 1331**] DDD
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Location (un) 745**]/[**Location (un) 746**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2162-7-19**]
|
[
"403.90",
"285.21",
"272.4",
"585.9",
"423.3",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"97.29",
"37.0",
"34.04",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
9055, 9307
|
4895, 5838
|
8688, 8737
|
6800, 6808
|
3943, 4872
|
7050, 7868
|
2790, 2927
|
5942, 6534
|
6673, 6779
|
5864, 5919
|
6832, 7027
|
2942, 3924
|
237, 270
|
385, 2230
|
8759, 9032
|
2541, 2774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,304
| 178,394
|
51894
|
Discharge summary
|
report
|
Admission Date: [**2184-3-11**] Discharge Date: [**2184-3-14**]
Date of Birth: [**2134-11-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
49 yoF w/ metastatic breast cancer (brain, spine, bone, liver)
presents from OSH s/p seizure. According to her ex-husband, her
sx began at ~ 4 p.m., when she developed worsening HA, N/V, and
increased lethargy; she received Decadron 4 mg PO X1 at home in
addition to 2 mg IV morphine. There was no witnessed seizure
activity, bowel/bladder incontinence at home. She was
transported to OSH, where she was noted to be lethargic w/ ~ 2
min sz activity (exact character not recorded). She was
intubated for airway protection and received Ativan 1 mg IV X 2,
Decadron 10 mg IV X 1, Fosphenytoin 16 mg IV X 1 and transported
to [**Hospital1 18**] for further management. Of note, at her last visit w/
her neuro-oncologist Dr. [**Last Name (STitle) 724**] [**2184-3-9**], she received 5th
induction dose of DepoCyte.
Past Medical History:
1) Metastatic breast cancer diagnosed in [**2172**].
- s/p lympectomy [**2172**], right mastectomy [**2175**]
- arimide [**6-/2179**] for bone mets
- s/p adriamycin X 2 cycles [**3-14**]
- taxotere, zometa, neulasta
- whole braine irradiation [**Date range (2) 107438**] to [**2178**] cGY
- s/p ventricular access devise placement [**2183-12-17**]
- s/p lumbar spine and cervical spine irradiation
- receiving DepoCyst and Navelbine. She was last seen by her
oncologist [**2184-3-9**]
2) s/p appy
3) shingles
Social History:
divorced w/ 3 children; lives in [**Hospital1 107439**] with ex-husband.
[**Name (NI) **] tobacco, alcohol, or other drug use. Uses walker at home
Family History:
Paternal aunt died of breast cancer.
Physical Exam:
Gen: chronically-ill appearing middle-aged female, intubated,
sedated
HEENT: Pupils equal and minimally reactive to light, (+)
papilledema bilaterally, (+) corneal reflex, (+) gag, ETT tube
in place, neck supple, no JVD
Cardiac: RRR, no M/R/G appreciated
Chest: Left SC portocath site C/D/I
Pulm: Coarse BS throughout
Abd: hypoactive BS, soft, ND, liver edge 3 cm below RCM
Ext: No C/C/E, warm with good cap refull bilaterally
Neuro: Pupils equal and minimally reactive to light, (+) corneal
reflex, (+) gag, small movements of all 4 extremities to painful
stimuli, 1+ DTR [**Name (NI) **] and [**Name2 (NI) **] bilaterally, toes upgoing right,
equivocal left
Pertinent Results:
[**2184-3-13**] 04:18AM BLOOD WBC-1.3*# RBC-3.21* Hgb-10.5* Hct-29.4*
MCV-92 MCH-32.9* MCHC-35.9* RDW-17.1* Plt Ct-105*
[**2184-3-13**] 04:18AM BLOOD Plt Ct-105*
[**2184-3-13**] 04:18AM BLOOD Glucose-106* UreaN-9 Creat-0.3* Na-137
K-3.1* Cl-103 HCO3-27 AnGap-10
[**2184-3-11**] 11:30AM BLOOD ALT-319* AST-68* LD(LDH)-533* CK(CPK)-53
AlkPhos-389* Amylase-26 TotBili-1.3
[**2184-3-13**] 04:18AM BLOOD Calcium-7.2* Phos-1.8* Mg-2.5
[**2184-3-11**] 09:24AM BLOOD Type-ART Rates-18/ Tidal V-500 FiO2-100
pO2-529* pCO2-29* pH-7.43 calHCO3-20* Base XS--3 AADO2-177 REQ
O2-38 Intubat-INTUBATED
CT Head:
1. Numerous extra- and intra-axial lesions scattered throughout
the brain, with associated edema. When compared to [**2183-10-10**]
the amount of surrounding edema may be slightly decreased. Many
of these lesions now are partially calcified, a finding which
may reflect the patient's whole-brain radiation therapy. No
evidence of shift of normally midline structures or increased
mass effect.
EKG:
Sinus rhythm. Inferolateral ST-T wave changes. No previous
tracing available for comparison.
Brief Hospital Course:
Ms. [**Known lastname **] is a 49 yo female with metastatic breast cancer
presenting with headache, nausea, vomiting, atypical movements
thought due to posturing or ?seizure. These symptoms occured 2
days after receiving her fifth dose of intrathecal chemotherapy.
She was intubated for airway protection.
Mental status change/?seizure: Most likely cause of mental
status changes and posturing/?seizure due to increased
intracranial pressure secondary to inflammation from DepCoyte.
Head CT largely unchanged. LP on [**3-11**] noted elevated opening
pressure of 30cm. LP removed 40cc of clear CSF, that was not
infected (note: liposomal prepartion of Depcyte will
artificially elevate wbc count). She was maintained on Decadron
4mg q6hr and Keppra 250mg [**Hospital1 **]. Pt became less stuperous after
her LP and was extubated on HD#2. Neuro exam s/p extubation
was relatively normal except for weakness R ([**3-16**]) and L(4+/5)
weakness. Pt notes she had a stroke and has R sided weakenss as
a result. Pt felt her overall condition has continued to
worsen, with persistent malignant cells in her CSF, and pt
elected to go home with hospice.
Medications on Admission:
1) Decadron 4 mg PO TID
2) Zofran prn
3) Keppra 250 mg PO BID
4) Depcyt
5) Navelberine
6) Ativan
Discharge Medications:
1. lorazepam
as directed
2. morphine
as directed
3. Keppra
as directed
4. Decadron
as directed
5. oxygen
as directed
6. heparin flush
7. sodium chloride flush
Discharge Disposition:
Home With Service
Facility:
Hospice of [**Hospital3 **]
Discharge Diagnosis:
Primary:
1. Elevated intracranial pressure and inflammation s/p lumbar
puncture of 40cc CSF
2. Metastatic breast cancer
Discharge Condition:
poor
Discharge Instructions:
--take all medications as prescribed
--call physician for uncontrolled pain
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9 Where: [**Hospital 4054**] [**Hospital **]/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-3-16**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**]
[**Hospital6 **]/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-3-16**] 11:00
Provider: [**Name10 (NameIs) 17246**] [**Name11 (NameIs) **], RN Where: [**Hospital6 29**]
[**Hospital6 **]/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-3-16**] 11:30
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 5799**]
|
[
"198.3",
"780.39",
"V10.3",
"197.7",
"599.0",
"198.4",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5225, 5283
|
3735, 4894
|
324, 337
|
5447, 5453
|
2622, 3209
|
5577, 6309
|
1889, 1927
|
5041, 5202
|
5304, 5426
|
4920, 5018
|
5477, 5554
|
1942, 2603
|
277, 286
|
365, 1176
|
3218, 3712
|
1198, 1709
|
1725, 1873
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,147
| 176,557
|
10031
|
Discharge summary
|
report
|
Admission Date: [**2155-2-10**] Discharge Date: [**2155-2-19**]
Date of Birth: [**2127-1-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
This is a 28 year old male admitted with a BMI of 60 for weight
reduction surgery.
Major Surgical or Invasive Procedure:
Status post Open Gastric Bypass
History of Present Illness:
[**Known firstname 333**] has class III extreme morbid obesity with weight of
459.0 lbs as of [**2154-12-26**] (initial screen weight was 456.1 lbs),
height of 73 inches and BMI of 60.7. His previous weight loss
efforts have included The [**Doctor Last Name 1729**] ([**2152**]) and South Beach diets
([**2151**]), Weight Watchers ([**2153**]), as [**Street Address(1) 33553**] counseling for 6
months in [**2154**] without results. He stated that his birth weight
was 11 lbs and that he has always had a significant [**Last Name 4977**]
problem. Factors contributing to his excess weight include large
portions, inconsistent meal schedules, too many carbohydrates
and
fats as well as lack of exercise although he has been trying to
use treadmill daily for 15-20 minutes. He denied history of
eating disorders or depression.
Past Medical History:
Asthma
OSA on CPAP [**10-29**]
Dyslipidemia
Hypertension
Cholelithiasis
back pain
Knee pain
Lactose intolerance
h/o Rt arm fracture
Social History:
He has no known food or drug allergies. He
denied tobacco, recreational drugs, has [**1-15**] alcoholic drinks
socially and drinks 2 cans of soda daily. He is currently
unemployed on disability. He is single and has 2 children. he
has a girlfriend who had
[**Name (NI) 33554**] gastric bypass surgery and is doing very well.
Family History:
Family history is noted
for mother living with diabetes, asthma, arthritis and obesity;
siblings with obesity.
Physical Exam:
His medical history is noted for asthma on inhalers with no
recent exacerbations, hospitalizations or steroid tapers,
obstructive sleep apnea on CPAP diagnosed 7 years ago at
[**Hospital3 1810**] and repeated recently with confirmation of a
moderate sleep disorder breathing and recommendation of CPAP at
10-15 cm, and dyslipidemia (elevated triglycerides) by recent
blood work. His blood pressure has recently been elevated but is
not on medication for hypertension. Recent ultrasound study
noted
gallbladder disease with multiple gallstones. He also has
weight-related back and right knee pain. Review of systems
includes shortness of breath with stairs/hills and occasionally
with exertion. He denied chest pain, headaches, palpitations,
dizziness or lightheadedness, abdominal pain, nausea/vomiting,
fever/chills or diarrhea/constipation. He denied heart disease,
hypertension, diabetes, GERD, thromboembolism, or thyroid
disease. He has no surgical history.
Pertinent Results:
[**2155-2-11**] 02:11AM BLOOD WBC-16.2*# RBC-4.26* Hgb-13.0* Hct-38.2*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.6 Plt Ct-342
[**2155-2-14**] 05:10AM BLOOD WBC-17.8* RBC-3.47* Hgb-10.8* Hct-31.8*
MCV-92 MCH-31.1 MCHC-33.9 RDW-13.4 Plt Ct-327
[**2155-2-14**] 05:10AM BLOOD Neuts-77.4* Lymphs-12.1* Monos-10.1
Eos-0.2 Baso-0.1
[**2155-2-14**] 05:10AM BLOOD Glucose-96 UreaN-13 Creat-0.7 Na-140
K-4.3 Cl-103 HCO3-31 AnGap-10
[**2155-2-13**] 02:06AM BLOOD Glucose-117* UreaN-15 Creat-0.7 Na-141
K-4.2 Cl-105 HCO3-29 AnGap-11
[**2155-2-10**] 01:11PM BLOOD Glucose-132* UreaN-22* Creat-1.1 Na-144
K-4.7 Cl-108 HCO3-24 AnGap-17
[**2155-2-11**] 02:11AM BLOOD ALT-254* AST-525* AlkPhos-59 Amylase-98
TotBili-0.2
[**2155-2-14**] 05:10AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.4
[**2155-2-10**] 01:11PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
[**2155-2-12**] 03:04AM BLOOD Type-ART Temp-38.6 pO2-75* pCO2-48*
pH-7.41 calTCO2-31* Base XS-4
[**2155-2-11**] 04:37PM BLOOD Type-ART Temp-38.2 pO2-94 pCO2-47*
pH-7.37 calTCO2-28 Base XS-0 Intubat-NOT INTUBA Comment-O2
DELIVER
[**2155-2-10**] 02:15PM BLOOD Type-ART pO2-58* pCO2-58* pH-7.25*
calTCO2-27 Base XS--2 Intubat-INTUBATED Vent-IMV
[**2155-2-10**] CTA Chest
1. No central or segmental pulmonary artery filling defects are
detected, within the limits of this examination.
2. Moderate atelectasis in bilateral lower lobes.
[**2155-2-12**] UGI
Limited examination secondary to patient body habitus and
clinical status . No definite evidence of leak at the
gastrojejunal anastomosis. Slight irregularity along the
inferior margin of the gastric remnant could be post- surgical
change.
[**2155-2-12**] Chest X-ray
IMPRESSION: Interval improvement in parenchymal aeration. Mild
basilar atelectasis.
[**2155-2-14**] Abd/Pelvis CT with contrast
Significantly limited study due to patient's large habitus. Free
passage of oral contrast through to the rectum without
obstruction. No definite pneumoperitoneum or extravasation of
orally administered contrast.
Brief Hospital Course:
This is a 28 year old morbidly obese male who had open gastric
bypass with cholecystectomy on [**2155-2-10**]. Postoperatively he was
difficult to extubate. Transferred to the surgical intensive
care unit. Febrile and tachycardic. He was extubated on [**2155-2-11**].
Postoperative Issues;
1. Febrile, Tachycardia and increased white count
A. R/O Leak - On [**2155-2-12**] he had a methylene blue study that was
negative for leak.
On [**2155-2-13**] Upper GI study completed, negative for leak or
obstruction. Transferred to regular floor. [**2155-2-14**] Abdominal CT -
Free passage of oral contrast through to the rectum without
obstruction. No definite pneumoperitoneum or extravasation of
orally administered contrast.
B. Pancultured for infection - blood, urine, stool and sputum.
All negative to date.
Incisional site dry and intact, no erythema or redness. Stool
negative times three for C.difficile. Chest x-ray - on [**2155-2-12**]
Mild basilar atelectasis.
C. Blood work - WBC - Peaked on [**2155-2-15**] at 19.2. Today ([**2155-2-18**])
WBC 16.4. LFT's elevated.
2. Bariatric diet - Patient started on Bariatric stage one diet
and progressed to stage 3 over several days without nausea or
feeling of fullness. Patient has had various discussions with
staff and dietician regarding stage 3 diet.
3. Mobility - Physical therapy has been working with patient. He
currently is independently ambulating with a rolling walker.
4. Hypertension/Tachycardia - Has been recieving beta blocker
while in house. Will have patient follow up with his primary
care provider regarding use of this.
5. Discharge Plans - patient plans to go to mother's house. He
will have VNA as well as Physical therapy. Rolling walker and
raised toilet seat have been obtained. He will continue
cipro/flagyl for 7 more days and lovenox sq q 12 hours for 14
days. He will see his primary care (Dr. [**Last Name (STitle) **] early next week
and Dr. [**Last Name (STitle) **] on [**2155-3-6**].
Medications on Admission:
flovent 44'
MVI
Vitamin D
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*600 ML(s)* Refills:*0*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*14 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*21 Tablet(s)* Refills:*0*
4. Equipment Needed
Bariatric Rolling Walker
and
Bedside Commode
5. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) .4 Subcutaneous
every twelve (12) hours: for 14 days.
Disp:*qs 14 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Status post Open Gastric Bypass
Discharge Condition:
Stable
Discharge Instructions:
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. 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.
2. You should begin taking a Flintstones chewable complete
multivitamin. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
Activity:
No heavy lifting of items [**10-29**] 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 steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
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) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2155-3-6**] 10:15
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2155-3-6**] 10:30
Please call your primary care provider to make an appointment in
one week to follow up on hypertension and hyperglycemia.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33555**] & DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2155-4-9**] 9:30
Completed by:[**2155-2-19**]
|
[
"271.3",
"574.20",
"401.9",
"719.46",
"780.57",
"V85.4",
"493.90",
"518.0",
"278.01",
"338.29",
"576.8",
"785.0",
"288.60",
"780.6",
"998.89",
"724.2",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.31",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
7543, 7601
|
4911, 6892
|
397, 431
|
7677, 7686
|
2912, 4888
|
9509, 10168
|
1801, 1913
|
6968, 7520
|
7622, 7656
|
6918, 6945
|
7710, 8276
|
1928, 2893
|
275, 359
|
9151, 9486
|
459, 1287
|
8301, 9139
|
1309, 1442
|
1458, 1785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,627
| 120,605
|
8665
|
Discharge summary
|
report
|
Admission Date: [**2200-5-16**] Discharge Date: [**2200-5-27**]
Date of Birth: [**2122-4-2**] Sex: M
Service: SURGERY
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media /
lovastatin / Atorvastatin / Dilaudid / morphine
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Trauma: MVC
Injuries:
L 4-8th rib fx
R 6-8th rib fx
splenic hemorrhage
Major Surgical or Invasive Procedure:
Epidural catheter placement [**2200-5-20**]
Epidural catheter d/c on [**5-23**]
History of Present Illness:
78 M s/p MVC, unrestrained driver, head on collision, +LOC,
positive FAST with large perisplenic hematoma, bilateral rib
fractures and RLL/LLL contusions
Past Medical History:
PMH: Hypercholesterolemia, CAD, DVT, Ischemic cardiomyopathy EF
20%, CRI baseline Cr 1.8
.
PSH: cardiac cath s/p coronary stent x3, left pointer finger tip
amputation, ICD auto implant cardio/defib
Social History:
nc
Family History:
nc
Physical Exam:
PHYSICAL EXAMINATION
Temp:97.9 HR:80 BP:120/80 Resp:20 O(2)Sat:99 Normal
Constitutional: Uncomfortable, vomiting
HEENT: Normocephalic, atraumatic
Neck nontender
Chest: Clear to auscultation, very sore bilateral ribs no
crepitus splinting respirations, no flail chest
Cardiovascular: Normal first and second heart sounds,
Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Physical examination upon discharge: [**2200-5-26**]:
Vital signs: t= 95.4, bp=148/62, hr=75, resp. rate 18, oxygen
sat. RA 97%
General: Pleasant, conversant, alert and oriented
CV: occasional irreg., ns1, s2, -s3, -s4]
LUNGS: Diminshed BS left side, clear right side
ABDOMEN: soft, non-tender
EXT: no pedal edema bil., + dp bil.
Pertinent Results:
- [**5-16**]: CT [**Last Name (un) 103**]/pelvis - multiple bilateral mostly non-displaced
rib fractures with bilateral atelectatic change in ground glass
changes of the right upper lobe. No pneumothorax.
- [**5-16**]: CT chest - c/w prior ct from 5 hrs earlier. Interval
development of large perisplenic hematoma - tracks along the
LUQ, subdiaphragmatic space and along the stomach. smaller
subcapsular splenic hematoma.
- [**5-16**]: CT head (OSH) - negative
- [**5-16**]: CT C-spine (OSH) - negative
- [**5-16**]: CXR - no significant change, though rib fractures and
known lung contusion is better assessed on the corresponding CT
scan.
- [**5-17**]: CT [**Last Name (un) 103**]/pelvis - enlarging perisplenic hematoma with
expansion of collection around liver
- [**5-19**]: CXR - stable pulmonary edema
- [**5-20**]: CXR - stable pulmonary edema
- [**5-21**]: CXR - moderate cardiomegaly and evidence of minimal
pulmonary edema, unchanged retrocardiac atelectasis
[**2200-5-23**] 06:10AM BLOOD WBC-8.5 RBC-3.08* Hgb-9.5* Hct-27.6*
MCV-90 MCH-30.8 MCHC-34.3 RDW-17.3* Plt Ct-255
[**2200-5-22**] 01:43AM BLOOD WBC-8.2 RBC-3.10* Hgb-9.3* Hct-27.5*
MCV-89 MCH-29.9 MCHC-33.7 RDW-16.7* Plt Ct-198
[**2200-5-21**] 12:00AM BLOOD WBC-8.2 RBC-2.91* Hgb-8.6* Hct-25.8*
MCV-89 MCH-29.6 MCHC-33.4 RDW-16.6* Plt Ct-166
[**2200-5-20**] 02:06AM BLOOD WBC-8.8 RBC-3.12* Hgb-9.3* Hct-28.1*
MCV-90 MCH-29.8 MCHC-33.0 RDW-17.1* Plt Ct-160
[**2200-5-16**] 06:45PM BLOOD Neuts-92.2* Lymphs-4.4* Monos-3.0 Eos-0.3
Baso-0.1
[**2200-5-23**] 06:10AM BLOOD Plt Ct-255
[**2200-5-22**] 01:43AM BLOOD Plt Ct-198
[**2200-5-21**] 12:00AM BLOOD Plt Ct-166
[**2200-5-20**] 02:06AM BLOOD PT-13.5* PTT-25.4 INR(PT)-1.1
[**2200-5-19**] 01:53AM BLOOD Plt Ct-151
[**2200-5-19**] 01:53AM BLOOD PT-13.6* PTT-25.2 INR(PT)-1.2*
[**2200-5-23**] 06:10AM BLOOD Glucose-114* UreaN-43* Creat-2.1* Na-140
K-3.8 Cl-97 HCO3-32 AnGap-15
[**2200-5-22**] 01:43AM BLOOD Glucose-99 UreaN-40* Creat-2.0* Na-142
K-3.5 Cl-98 HCO3-33* AnGap-15
[**2200-5-21**] 01:32PM BLOOD Glucose-99 UreaN-37* Creat-1.8* Na-142
K-3.9 Cl-99 HCO3-32 AnGap-15
[**2200-5-19**] 05:55PM BLOOD proBNP-8967*
[**2200-5-23**] 06:10AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.0
[**2200-5-22**] 01:43AM BLOOD Calcium-9.2 Phos-2.2* Mg-1.9
[**2200-5-21**] 01:32PM BLOOD Calcium-9.4 Phos-2.3* Mg-2.1
[**2200-5-16**] 06:54PM BLOOD freeCa-1.16
Brief Hospital Course:
Due to his large perisplenic hematoma, Mr [**Known lastname 30362**] was admitted
to the Trauma SICU for close hemodynamic monitoring. On HD #1,
his serial HCTs were [**Last Name (LF) 30363**], [**First Name3 (LF) **] a repeat CT AP was
obtained which showed extension of hematoma. He was transfused 1
unit PRBC + 1U FFP. In addition, his home digoxin restarted. On
HD #2, his diet was advanced to regular. Due to fluid overload,
he was started on a lasix drip with improvement in his
respiratory status. For pain control, an epidural was attempted
but could not be placed. On [**5-20**], however, a repeat attempt at
placement was successful with marked improvement in his pain.
Over the previous days he was quite delirious which greatly
improved with placement of the epidural, improved pain control
and cessation of narcotics. Heparin sc was started. EP
interrogated his pacemaker and discovered no fires or
arrhythmias. On [**5-21**], his lasix changed from drip to home PO
dose. Mental status continued to improve but he was kept in the
ICU as he had been so recently delirious. On [**5-22**], the patient
had continued stable hematocrit checks, was tolerating a regular
diet and A&O x2-3, so he was transferred to the surgical floor.
Note completed by [**Last Name (NamePattern4) 30364**], NP:
Transferred to the surgical floor on [**5-22**]. Epidural infusing
bupivicaine only, no narcotic related to prior confusion. His
epidural infusion was stopped on [**5-23**] in preparation for
removal. Foley replaced [**5-22**] after inability to void after
foley removed. Evaluated by occupational therapy to determine
need for rehabilitation and to assess his cognitive ability. He
was re-evaluated on [**5-26**] and it was determined at that time that
he was safe to go home. He will still need cognitive evaluation
in 1 month related to his head injury.
His atrial fibrillation has been controlled with medications.
He is tolerating a regular diet without complaints of nausea or
vomitting. He is afebrile and his vital signs are stable. He is
alert, oriented, and conversant. His home medications have been
resumed except for his coumadin. He has resumed his diuretics,
last creatinine 1.7. He is voiding without difficulty.
He is preparing for discharge home with instructions to
follow-up with the acute care service in 2 weeks and cognitive
neurology in 1 month. It is recommended that he follow-up with
his primary care provider [**Last Name (NamePattern4) **] [**3-28**] days to discuss resumption of
his coumadin and to check electrolytes.
Of note: his coumadin has been on hold related to his splenic
hematoma. Will need to be addressed by his primary care
provider [**Last Name (NamePattern4) **] [**3-28**] days.
Medications on Admission:
Carvedilol 3.123 mg PO bid, Digoxin 0.125 PO QD, Doxazosin 4mg
PO QD, Lasix 60 mg PO bid, Metolazone 2.5 mg PO QD, Rosuvastatin
5 mg PO Qhs, Coumadin 5mg PO Daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): prn pain.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. Crestor 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. coumadin
Daily coumadin ( coumadin has been on hold related to splenic
hematoma...pt to follow-up with Primary care provider [**Last Name (NamePattern4) **] [**3-28**]
days)
8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a
day: hold for systolic blood pressure <100.
9. doxazosin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
11. furosemide 40 mg Tablet Sig: 1.5 Tablets PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
L 4-8th rib fx
R 6-8th rib fx
splenic hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
You were admitted to the hospital after you were involved in a
motor vehicle accident in which you sustained rib fractures,
bleeding around your spleen, and loss of consciousness. You
were intially admitted to the intensive care unit for
monitoring, but have been managed on the general surgical floor.
Your rib pain had been controlled with an epidural catheter.
Your pain has diminished and you are now on oral analgesics.
You are preparing for discharge home with the following
instructions:
Your injury caused bilatgeral rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
You also had bleeding around your spleen, here are additional
instructions;
If you suddenly become dizzy, lightheaded, feeling as if you are
going to pass out go to the nearest Emergency Room as this could
be a sign that you are having inernal bleeding from your liver
or spleen injury.
Please follow up with your primary care provider [**Last Name (NamePattern4) **] 1 week about
resuming your coumadin and follow-up lab work
Followup Instructions:
Please follow up with the acute care service in 2 weeks. You
can schedule this appointment by calling # [**Telephone/Fax (1) 600**].
Please follow up with your Primary care provider [**Last Name (NamePattern4) **] [**3-28**] days
regarding resuming your coumadin.
Please follow up with Dr. [**First Name (STitle) **], cognitive neurology, in 1
month. The telephone number is [**Telephone/Fax (1) 6335**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2200-5-27**]
|
[
"V12.51",
"E812.0",
"V45.82",
"V12.54",
"868.03",
"428.23",
"428.0",
"788.21",
"V49.62",
"807.06",
"427.31",
"V58.61",
"V45.02",
"865.02",
"414.01",
"850.5",
"585.9",
"338.11",
"440.20",
"292.81",
"861.21",
"E937.8",
"272.0",
"414.8",
"790.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
8241, 8247
|
4318, 7064
|
436, 519
|
8340, 8340
|
1941, 4295
|
10618, 11164
|
959, 963
|
7277, 8218
|
8268, 8319
|
7090, 7254
|
8476, 10595
|
978, 1602
|
323, 398
|
1619, 1922
|
547, 702
|
8355, 8452
|
724, 923
|
939, 943
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,895
| 159,113
|
39494
|
Discharge summary
|
report
|
Admission Date: [**2185-2-24**] Discharge Date: [**2185-3-2**]
Date of Birth: [**2127-10-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Augmentin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic stenosis,mitral regurgitation, ascending aortic aneursym
Major Surgical or Invasive Procedure:
aortic valve replacement(23mm St. [**Male First Name (un) 923**] mechanical),Mitral valve
repair(32mm [**Doctor Last Name **] Annuloplasty ring),replacement of ascending
aorta(30mm Gelweave) [**2185-2-25**]
History of Present Illness:
This is a 57 year old male with known
aortic stenosis and possible rheumatic heart disease. He is
followed very closely with serial echocardiograms by Dr. [**Last Name (STitle) **].
In [**2185-1-26**], he was admitted to [**Hospital1 882**] with congestive
heart failure. Repeat echocardiogram at that time was notable
worsening mitral regurgitation and worsening left ventricular
function with LVEF dropping from 50-55% to approximately 30%.
Given the above findings, he was referred to Dr. [**Last Name (STitle) **] for
cardiac surgical evaluation. Currently his symptoms have
improved, and is able to perform routine ADL without difficulty.
He currently denies shortness of breath, chest pain, syncope,
pre-syncope, orthopnea, PND and pedal edema. He does admit to
decreased energy, easy fatiguability, and poor sleep. He is very
anxious about the possibilty of heart surgery.
Past Medical History:
Rheumatic Heart Disease, rheumatic fever at age 5
- Chronic Systolic Congestive Heart Failure
- Aortic Stenosis, Mitral Regurgitation
- History of Endocarditis [**2147**] c/b seizure
- Hypertension
- Asthma(exercise induced)
- History of Kidney Stones
- Chronic Low Back Pain, Lumbar strain
- History of Gilberts Hyperbilirubinemia
Past Surgical History: s/p Tonsillectomy
Social History:
Race: Caucasian
Last Dental Exam: 8 months ago, needs bridge work
Lives with: Wife
Occupation: Attorney
Cigarettes: Never
ETOH: 2 bottles of wine per week
Illicit drug use: Denies
Family History:
Family History: Denies premature coronary artery disease
Physical Exam:
Pulse: Resp:14 O2 sat:98%
B/P Right:110/70 Left:106/68
Height:72" Weight:181#
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade 3-4/6sem bases to
neck______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [n] _____
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
Pertinent Results:
[**2185-3-2**] 05:35AM BLOOD WBC-6.1# RBC-3.09* Hgb-9.7* Hct-27.8*
MCV-90 MCH-31.3 MCHC-34.8 RDW-12.7 Plt Ct-176
[**2185-2-24**] 07:37AM BLOOD WBC-5.7 RBC-4.55* Hgb-14.2 Hct-40.7
MCV-90 MCH-31.2 MCHC-34.9 RDW-12.5 Plt Ct-137*
[**2185-3-1**] 07:35PM BLOOD PT-25.5* INR(PT)-2.4*
[**2185-3-1**] 04:55AM BLOOD PT-21.7* PTT-33.2 INR(PT)-2.1*
[**2185-2-28**] 04:45AM BLOOD PT-11.6 PTT-27.0 INR(PT)-1.1
[**2185-2-27**] 02:29AM BLOOD PT-14.0* INR(PT)-1.3*
[**2185-3-2**] 05:35AM BLOOD UreaN-29* Creat-1.0 Na-137 K-4.6 Cl-101
[**2185-2-24**] 07:37AM BLOOD Glucose-101* UreaN-21* Creat-1.1 Na-141
K-3.9 Cl-104 HCO3-28 AnGap-13
[**2185-2-24**] 07:37AM BLOOD ALT-18 AST-15 AlkPhos-35* TotBili-1.7*
PRE-BYPASS:
The left atrium is moderately dilated. Mild spontaneous echo
contrast is present in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 25
%).
Right ventricular chamber size is normal with mild global free
wall hypokinesis.
The ascending aorta is mildly dilated. The descending thoracic
aorta is mildly dilated.
The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Mild to moderate ([**12-27**]+) aortic
regurgitation is seen.
The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at
time of surgery.
POST-BYPASS:
The patient is A paced. The patient is on norepinephine and
epinephrine infusions.
Left ventricular function is unchanged, estimated EF is 25%.
Right ventricular function is mildly improved.
There is a well-seated mechanical prosthetic valve in the aortic
position. Characteristic washing jets are seen. The leaflets are
normally mobile. The peak gradient across the aortic valve is
18mmHg, the mean gradient is 9mmHg with CO of 4L/min.
There is a mitral annuloplasty ring in place. There is a mean
gradient of 2 mmHg across the mitral valve at a cardiac output
of 4L/min. No mitral regurgitation is seen.
There is a tube graft in the ascending aortic position. The
aortic arch and descending aorta are intact post-decannulation.
Brief Hospital Course:
He was taken to the Operating Room on [**2-25**] where surgery was
performed as noted. See operative note for details. He weaned
from bypass on Epinephrine, Propofol and Levophed. He remained
stable, was extubated and over 48 hours weaned from pressors.
He transferred to the floor on POD 2 and Physical Therapy worked
with him. Coumadin was begun and Heparin started on POD 3. He
was diuresed towards his preoperative weight and Coreg was
started and titrated as BP allowed. No ACE_I was given as BP was
too low to allow it.
Mediastinal CTs were removed per protocol, as were pacing wires,
however, pleural CTs remained in until [**3-2**] due to drainage. At
discharge he was ambulatory , follow up appointments were
arranged and Coumadin follow up by Dr. [**Last Name (STitle) 35888**] arranged as well.
Medications on Admission:
Lasix 20mg daily, Toprol XL 25mg daily,
Flovent 50mcg 2puffs twice daily, Albuterol MDI prn, Amoxicillin
prn dental prophylaxis
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 400mg(2tablets)twice daily for two weeks, then
200mg(one tablet) twice daily for two weeks then, 200mg daily
until directed to stop.
Disp:*120 Tablet(s)* Refills:*2*
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
9. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
12. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: goal INR 2.5-3.5.
Disp:*100 Tablet(s)* Refills:*2*
13. Outpatient Lab Work
INR/PT on [**3-3**] then prn.
Please FAX results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35888**] at [**Telephone/Fax (1) 11145**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
aortic stenosis
mitral regurgitation
ascending aortic aneurysm
Rheumatic Heart Disease
Chronic Systolic Congestive Heart Failure
h/o Endocarditis [**2147**]
Hypertension
Asthma(exercise induced)
h/o Kidney Stones
Chronic Low Back Pain
Gilberts Hyperbilirubinemia
s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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:
Surgeon:Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2185-3-30**] at 1:15 pm
Cardiologist:Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2185-3-16**] at 10:00am
Wound check in [**Last Name (un) 6752**] 2A on [**2185-3-10**] at 10:15 am
Please call to schedule appointments with:
Primary Care: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35888**] ([**Telephone/Fax (1) 11144**]) in [**3-31**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: mechanical aortic valve
Goal INR 2.5-3.5
First draw [**2185-3-3**]
Results to fax [**Telephone/Fax (1) 11145**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35888**])
Completed by:[**2185-3-2**]
|
[
"416.0",
"277.4",
"493.90",
"724.2",
"396.2",
"441.2",
"398.91",
"401.9",
"746.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"88.56",
"37.23",
"35.22",
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
8026, 8083
|
5256, 6072
|
339, 548
|
8408, 8587
|
2832, 5233
|
9427, 10324
|
2085, 2128
|
6251, 8003
|
8104, 8387
|
6098, 6228
|
8611, 9404
|
1835, 1855
|
2143, 2813
|
236, 301
|
576, 1458
|
1480, 1812
|
1871, 2053
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,894
| 130,001
|
16731+16732
|
Discharge summary
|
report+report
|
Admission Date: [**2194-1-23**] Discharge Date: [**2194-2-4**]
Date of Birth: [**2138-4-23**] Sex: M
Service: VASCULAR SERVICE
CHIEF COMPLAINT: Disabling claudication bilaterally, right
greater than left.
HISTORY OF PRESENT ILLNESS: This is a 55 year old
non-diabetic white male with known coronary artery disease
status post coronary artery bypass graft times three in
[**Month (only) 404**] of this year, which was complicated by a
postoperative myocardial infarction and congestive failure.
The patient has a history of alcohol abuse and delirium
tremens occurred after the patient's carotid endarterectomy
at [**Hospital6 **].
The patient was referred to Dr. [**Last Name (STitle) 1391**] for evaluation of
his calf claudication. Symptoms started one year ago on the
right and the left symptoms now are almost as severe. He can
only walk plus/minus 20 feet comfortably. He also has had
rest pain on the right which improved with dependency. He
denies any ulcerations of his skin or feet.
PAST MEDICAL HISTORY:
1. No known drug allergies.
2. Coronary artery disease, non-Q wave myocardial
infarction, congestive heart failure.
3. Carotid disease, left greater than right, status post
left carotid endarterectomy in 10/[**2192**]. Right carotid showed
70 to 80% stenosis.
4. History of alcohol abuse.
5. History of chronic obstructive pulmonary disease.
6. History of coronary artery disease with ejection fraction
of 40%.
PAST SURGICAL HISTORY:
1. Left carotid endarterectomy in [**2193-9-17**].
2. Coronary artery bypass graft using left saphenous vein on
[**2193-12-23**] with re-open for bleeding on [**2193-12-23**].
MEDICATIONS ON ADMISSION:
1. Pletal 100 mg twice a day.
2. Lopressor 12.5 mg twice a day.
3. Lipitor 20 mg q. day.
4. Zantac 150 mg twice a day.
5. Folic acid 1 mg q. day.
6. Multivitamin tablet one q. day.
7. Motrin 325 mg q. day.
8. Trazodone 50 mg at h.s.
9. Vitamin B.
10. Thiamine.
11. Nitroglycerin sublingual p.r.n.
12. Combivent inhaler q. six hours p.r.n.
ALLERGIES: He has no drug allergies.
SOCIAL HISTORY: 55 year old male, married, lives with his
wife. Uses a cane to ambulate. He is a retired iron worker.
He is a former smoker, three packs per year times 30 years.
He drinks three to four beers per day.
PHYSICAL EXAMINATION: Vital signs were blood pressure
112/58; pulse rate 70; respirations 20, O2 saturation 92% on
room air. General appearance: Alert cooperative white male
in no acute distress. HEENT examination is unremarkable.
Pulse examination shows palpable carotids bilaterally. The
right radial is Dopplerable. The left radial is palpable one
plus. Femorals are palpable bilaterally. Popliteals are
absent bilaterally. The right dorsalis pedis and posterior
tibials are without Doppler signals. The left dorsalis pedis
is monophasic and the left posterior tibial is absent. Lungs
are clear to auscultation bilaterally. Heart is regular rate
and rhythm without murmur. The abdominal examination is
benign. Bone and joint examination shows both groins with no
bleeding, ecchymosis or hematoma. Feet are equally cool with
prominent rubor of the forefoot when patient is supine, right
greater than left. There are no ulcerations. The left leg
saphectomy is well healed with extensive eschar. The
neurological examination was unremarkable.
LABORATORY: Included a CBC with white count 7.2, platelets
466, BUN 10, creatinine 0.7. Potassium 4.7. PT and INR were
normal.
Chest x-ray shows a right apex opacity, lobulated opacity in
the upper retrosternal region. Chest CT scan is chronic
obstructive pulmonary disease with calcified granulomas of
the right apex. Left upper lobe calcification.
EKG is normal sinus rhythm with a rate of 79; no acute
changes.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area. He underwent a right femoral AP
bypass graft with [**Doctor Last Name 4726**]-Tex. He tolerated the procedure well.
He was transferred to the Post Anesthesia Care Unit and
extubated. His postoperative hematocrit was 31.8. His BUN
and creatinine were stable. His phosphorus was 1.6.
Arterial blood gases was 7.38/44/136.
The patient remained hemodynamically stable and was
transferred to the Vascular Intensive Care Unit for continued
care.
Overnight events were noted on postoperative day one:
Increased bleeding from the wound with a drop in hematocrit
to 23. Heparin was held, the leg was wrapped with
compression dressings and the patient was transfused with two
units of packed red blood cells. Post-transfusion hematocrit
was 27.9.
Other than that, the patient remained in the Vascular
Intensive Care Unit for continued monitoring and care. The
patient continued to demonstrate oozing of the wound with a
dropping of his hematocrit requiring transfusion, but he was
hemodynamically stable and the patient was delined and
transferred to the regular nursing floor.
Postoperative day four, he continued to do well. Physical
Therapy was requested to see the patient in anticipation for
discharge planning. On postoperative day five, he had
tachycardia with fever and tremors.
The patient required transfer to the Surgical Intensive Care
Unit for continued monitoring and care. The patient's
temperature maximum was 102.0 F. He required transfusion for
his hematocrit of 25.1. His electrolytes remained stable.
His blood gas was 7.45, 35, 90, 25 and zero. Lactate was
1.1.
Chest x-ray showed chronic obstructive pulmonary disease
without failure or infiltrate. Blood cultures were drawn
times two which were Gram positive cocci, two out of two.
The patient was begun on Vancomycin. The patient's central
line was removed and a new line was placed.
Infectious Disease was consulted regarding antibiotic therapy
for positive blood cultures. Recommendations were
pan-culture, discontinue Levofloxacin and Flagyl; continue
with Vancomycin as we were doing, and monitor patient.
The patient continued to run moderate grade temperatures.
The patient never melted a white count. His temperature
finally defervesced to normal on postoperative day number
seven. A PICC line was placed for long term antibiotic
treatment. Infectious Disease felt that he would require a
total of six weeks of therapy, given that the patient was
septic and had a Dacron graft.
Cardiothoracic Surgery was consulted regarding the patient
secondary to the development of erythema and swelling of the
upper superior portion of the median sternotomy incision.
Recommendations was that there was no purulence and no
fluctuants and they felt that it was superficial. There was
no sternum click and recommendations were just good skin care
wit4h dry dressing q. day and follow-up with Dr.[**Name (NI) 9920**]
office at the time of follow-up with Dr. [**Last Name (STitle) 1391**].
The remaining hospital course was unremarkable.
DISPOSITION: The patient was discharged home with Visiting
Nurses Association Services.
DISCHARGE INSTRUCTIONS:
1. The skin clips will be removed on post visit with Dr.
[**Last Name (STitle) 1391**].
2. The patient should follow-up with Dr. [**Last Name (STitle) **] at the same
time.
3. He will continue on his intravenous Vancomycin for a
total of six weeks of start of therapy.
4. He will receive weekly CBCs, random Vancomycin; BUN and
creatinine should be drawn to monitor drug therapeutics and
renal function.
DISCHARGE MEDICATIONS:
1. Vancomycin 250 mg q. 12 hours with random trough.
2. Metoprolol 12.5 mg twice a day.
3. Ipratropium bromide plus two four times a day.
4. Acetaminophen 325 to 650 mg q. four to six hours.
5. Percocet tablets one to two q. four to six hours p.r.n.
for pain.
6. Protonix 40 mg q. day.
7. Aspirin 325 mg q. day.
DISCHARGE DIAGNOSES:
1. Disabling claudication status post right external iliac
to right femoral profundus bypass graft using an 8 millimeter
Dacron graft, then a jump graft to the right posterior
tibial, using non-reversed saphenous vein and sight tube with
angioscopy.
2. Methicillin resistant Staphylococcus aureus sepsis
secondary to line infection, being treated.
3. Coronary artery disease status post coronary artery
bypass graft of [**2193-12-23**].
4. Stable mediastinotomy incision with cellulitis of the
superior portion, being treated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2194-2-4**] 10:05
T: [**2194-2-4**] 10:29
JOB#: [**Job Number 24917**]
Admission Date: [**2194-1-23**] Discharge Date: [**2194-2-4**]
Date of Birth: [**2138-4-23**] Sex: M
Service: VASCULAR
ADDENDUM/CORRECTION: The patient is a 55-year-old
nondiabetic white male with known coronary artery disease who
underwent coronary artery bypass surgery in [**Month (only) 404**] of this
year, and was referred to us for treatment of his leg
claudication afterward. He was transferred initially from [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 86**] outside hospital, status post carotid endarterectomy
which was complicated by an MI, congestive heart failure, and
failure to wean, but this did not require a tracheostomy. He
is also known to have a history of alcohol abuse and delirium
tremors which did occur after his carotid endarterectomy at
the outside hospital. The patient now is admitted for
revascularization of his extremity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2194-3-18**] 13:06
T: [**2194-3-18**] 12:46
JOB#: [**Job Number 47322**]
|
[
"440.22",
"496",
"998.11",
"996.62",
"682.2",
"038.11",
"412",
"E878.8",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.22",
"38.93",
"39.57",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
7778, 9754
|
7437, 7757
|
1694, 2083
|
3808, 6981
|
7005, 7414
|
1488, 1668
|
2329, 3789
|
167, 229
|
259, 1024
|
1046, 1465
|
2101, 2305
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,690
| 163,969
|
27294
|
Discharge summary
|
report
|
Admission Date: [**2192-10-18**] Discharge Date: [**2192-10-21**]
Date of Birth: [**2124-11-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
hematuria and suprapubic / vaginal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 yo russian only speaking F w/ a [**First Name3 (LF) 18048**], presents with a 1 week
history of suprapubic pain and symptoms of uterine prolapse.
She has had these symptoms once in the past about a year ago.
She states that she feels vaginal tissue protrude from her
vagina when she is walking and she has a suprapubic and vaginal
pain when this happens. She states that there is a recession
back into her vaginal canal when she lies down and this relieves
the symptoms. She has had a history of [**First Name3 (LF) 18048**] c/b HTN, anemia,
and recently (x3 days) hematuria. She has had hematuria x 3
days, light pink urine, no dysuria, no suprapubic pain when she
is urinating, no incrase in urinary frequency, no change in
urinary urgency. No fevers or night sweats, chronic history of
chills which she attributes to her anemia, no weight changes.
She recieves her care at home in [**Location (un) 3156**], visting family here in
[**Location (un) 745**]. Has refused prospect of HD in past adamantly and today
discusses that she realizes the risk of refusing HD when it may
become a necessity, risks including death.
No HA, no visual changes, weakness or numbness.
Past Medical History:
Polycystic Kidney Disease, Cr 5.5 on [**5-20**], eval by renal at that
time, started on phos binder, followed in [**Location (un) 3156**] w/ reportedlly
worsening renal function but cr unknown
HTN (on unk russian med "dormatec?")
Hematuria in past (1 year ago) attributed to cyst rupture
Social History:
Lives in [**Country 532**] in the [**Location (un) 3156**]. currently not working.
Non-smoker (never did) and Occ EtOH.
Family Contacts: Children: phone: [**0-0-**]
Family History:
Uncle w/ [**Name (NI) 18048**], father deceased in [**Name (NI) **], maternal aunt w/ CVA
Physical Exam:
VS: 96.1 BP 180/90 HR 68 RR 18 98% RA
GEN: NAD, AOX3
HEENT: JVP roughly 8cm, MMM, OP clear
Cardiac: [**3-20**] harsh holosystolic murmur @ apex radiates to
axilla, RRR
PULM: slight rales in LLL, otherwise clear
Abd: soft, bulging flanks, BS+, bilateral large palpable
kidneys, no hepatomegaly or splenomegaly, mild distention
GU: external genetalia normal, no prolapsed tissue on external
exam, bimanual exam reveals no adnexal masses and normal uterus
Ext: 1+ pedal edema to mid shins
Neuro: CN2-12 intact, normal distal motor in all 4 extremities,
PERRL
Pertinent Results:
Renal u/s: Innumerable renal cysts consistent with polycystic
kidney
disease.
Admission Labs: WBC 12.8 (0 bands, 82.3 PMNs, 14 Lymphs), Hct
24.3, Plt 274, PTT 32.6, INR 1.1, Lactate 0.4, Glucose 106, BUN
141, Cr 13.5, Na 140, K 5.0, Cl 109, Bicarb 7,
Discharge Labs: Na 141, K 3.7, Cl 101, Bicarb 24, BUN 100, Cr
10.4, glucose 121, Ca 6.7, Mg 2.1, Phos 4.9, WBC 9.4, Hct 27.3,
Plt 267. ALT 5, AST 11, AP 105, LDH 172, T bili 0.2, Alb 3.0.
U/A spec [**Last Name (un) **] 1.008, Lg blood, 500 protein, trace glucose and
mod leuks. >1000 RBC, >1000 WBC, many bacteria, no yeast. Urine
Cr 32, Urine Na 94, T prot 284, Urine Prot/Cr 8.9.
Brief Hospital Course:
CKD: secondary to [**Last Name (un) 18048**]. Patient has a history of worsening
renal function and does not have renal follow up. She was seen
by renal inpatient who initially recommended treating her
acidosis with a bicarb drip and then transitioning to PO bicarb
(discharged on 1 level teaspoon of baking soda per day). She
had no indication for emergent dialysis. She had some signs of
uremia including insomnia and decreased appetite but was not
encephalopathic and had no uncontrolled bleeding. She was close
to euvolemic, possibly slightly volume overloaded. She had a
good urine output and had some light pink urine likely due to
her baseline [**Last Name (un) 18048**]- possibly related to a cyst rupture. She had
some recent NSAID use, we had her hold her NSAIDs and
recommended that she not use them as an outpatient. She was set
up with follow up for Renal and should be closely monitored.
Multiple physicians had repeated conversations with the patient
through a translator regarding the issue of dialysis for the
long term, the patient was adamantly against dialysis at this
time even though there was the possibility that she could die if
she denied dialysis when she emergently needed it. She
understood these risks. Upon discharge she seemed to be more
amenable to conversation regarding dialysis and has been having
much encouragement from her daughter in this issue.
Hypocalcemia- secondary hypoparathyroidism. Has renal follow
up.
Anemia- Normocytic, not iron deficient, TIBC decreased, ferritin
elevated. Likely EPO deficiency, per Renal they will follow in
clinic and initiate erythropoeitin injections.
HTN: started on Norvasc and lopressor for HTN control.
Medications on Admission:
Iron supplements [**Hospital1 **]
calcium daily
ibuprofen
"russian antihypertensive [**Doctor Last Name 360**]" which she uses prn when home BP
is elevated (ends up being qod dosing)
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Sodium Bicarbonate 100 % Powder Sig: as directed PO once a
day: please take baking soda, 1 level teaspoon (fill heaping
teaspoon then run your finger over the top to level the powder
off). Take with 1 glass of water.
Disp:*qs * Refills:*2*
7. Trazodone 50 mg Tablet Sig: [**1-17**] Tablet PO at bedtime as
needed for insomnia for 2 weeks.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Polycystic Kidney disease with Chronic renal failure
Uterine prolapse
Discharge Condition:
stable, acidemia resolved.
Discharge Instructions:
You have been admitted for uterine prolapse as well as acidic
blood as a result of your polycystic kidney disease which has
caused your kidney failure.
The acidity was corrected and you are being sent out on
something to control it, you should take 1 teaspoon of baking
soda (sodium bicarbonate) per day, fill up the tea spoon and
then run your finger over it so the teaspoon is "level" at the
top.
Please continue your other medications that you have been
prescribed and please follow up with nephrology (kidney doctors)
and gynecology.
You should return to the emergency room if you have chest pain,
shortness of breath, palpitations, increased blood in your
urine, fevers or chills or any other symptoms that concern you.
As far as diet: avoid bananas, oranges, and tomatoes. Please
also note the potassium content of your meals and do not eat
foods that have a lot of potassium such as the three listed
above. Please limit protein intake to 60 grams daily.
Followup Instructions:
Please call the following numbers to make follow-up
appointments.
Kidney doctors, please make an appointment for within 2 weeks of
your discharge from the hospital. Ask for an appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**] at [**Telephone/Fax (1) 60**]. You need to have an
appointment within 2 weeks.
Gynecologist, for uterine prolapse. Please schedule an
appointment with gynecology outpatient within 4-6 weeks of your
discharge from the hospital. [**Telephone/Fax (1) 2664**]
|
[
"584.9",
"588.89",
"753.12",
"252.1",
"618.1",
"780.52",
"599.0",
"285.9",
"403.90",
"599.7",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6379, 6385
|
3429, 5126
|
356, 363
|
6518, 6547
|
2768, 2847
|
7562, 8093
|
2081, 2172
|
5359, 6356
|
6406, 6406
|
5152, 5336
|
6571, 7539
|
3037, 3406
|
2187, 2749
|
277, 318
|
391, 1570
|
2863, 3021
|
6425, 6497
|
1592, 1882
|
1898, 2065
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,741
| 142,887
|
51250
|
Discharge summary
|
report
|
Admission Date: [**2172-7-22**] Discharge Date: [**2172-8-3**]
Service: MEDICINE
Allergies:
Penicillins / lisinopril
Attending:[**First Name3 (LF) 89334**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
central line/a-line in ICU
History of Present Illness:
85 yo male with history of CAD s/p CABG, HTN, and diastolic
dysfunction, chronic dyspneic, found to have altered mental
status at rehab today. In addition, he was noted to have fever,
respiratory distress, and hypotension.
.
In the ED, initial vs were: T 103 P 120 BP 88/43 R 29 (29-40)
with FSG: 192. He was tachypneic with hypoxemia so he was
placed on a NRB. He was not oriented in the ED and pulling at
lines. He was altered so it was felt he would not tolerated
BiPap. EKG, CXR, and UA were done. Blood cultures were sent
prior to antibiotics. Labs revealed elevated white count with
bandemia, and elevated creatinine at 2 from 0.7. He was started
on vancomycin and cefepime for broad spectrum antibiotics for
presumed sepsis. He was given 3-4L of IVF prior to R-IJ central
line placment. He was started on peripheral levophed prior
without effect. Central levophed was initiated and pressures
stablized for a half hour prior to transfer. The patient was
confirmed DNR/DNI but okay for line placement and
hospitalization. VS prior to transfer to the MICU were VS:
113/45, 109, 29, 100% 15L NRB.
.
On the floor, he was initially oriented x3. He notes SOB but
couldn't find comfortable position, tired, constipation, pn,
uncomfortable. but denied CP, neck pain, headache, visual,
n/v/d, no leg pain, dysuria.
Past Medical History:
1. CAD status post CABG in [**2162**] with a LIMA to the LAD and SVG
to the PDA, SVG to the OM.
2. Subsequent cardiac catheterization in [**2164-5-24**] with
Hepacoat stent of the SVG-OM. The SVG to the PDA was noted to be
occluded at this time.
3. Most recent Persantine MIBI in [**2170-2-25**]
demonstrating a mild inferior fixed defect with an ejection
fraction of approx 61%.
4. Peripheral neuropathy
5. Diastolic dysfunction
6. Chronic exertional shortness of breath
7. Hyperlipidemia
8. HTN
9. BPH s/p TURP in '[**53**]
10. Cataracts s/p surgery
Social History:
Lives at home with his wife, daughter and son. 60 pack-year
smoking hx. Quit in [**2133**]. Previous social alcohol use. No
illicits.
Family History:
Non-contributory.
Physical Exam:
Adm PE:
Vitals: 99.1 117/83 100 92-96% on 4L 32
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMdry, oropharynx clear
Neck: supple, JVP not elevated, no LAD, no meningismus
Lungs: crackles at left base
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: +BS, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact, 5/5 strength in UE, no gag reflex, unable
to do DOWb
Discharge PE:
...
Pertinent Results:
Adm labs:
[**2172-7-22**] 11:45AM BLOOD WBC-3.3* RBC-1.13* Hgb-3.6* Hct-11.3*
MCV-100* MCH-32.3* MCHC-32.2 RDW-14.0 Plt Ct-51*
[**2172-7-22**] 12:24PM BLOOD Neuts-60 Bands-37* Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2172-7-22**] 12:24PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2172-7-22**] 11:45AM BLOOD Plt Smr-VERY LOW Plt Ct-51*
[**2172-7-22**] 11:45AM BLOOD Fibrino-142*
[**2172-7-22**] 11:45AM BLOOD UreaN-14 Creat-0.7
[**2172-7-22**] 10:35PM BLOOD ALT-916* AST-655* AlkPhos-148*
TotBili-4.9*
[**2172-7-22**] 11:45AM BLOOD Lipase-53
[**2172-7-22**] 12:24PM BLOOD cTropnT-0.03*
[**2172-7-22**] 12:24PM BLOOD Albumin-3.0* Calcium-7.2* Phos-1.4*
Mg-1.5*
[**2172-7-22**] 10:35PM BLOOD Hapto-193
[**2172-7-22**] 05:37PM BLOOD Type-ART Temp-38.4 Rates-/40 O2 Flow-4
pO2-95 pCO2-39 pH-7.29* calTCO2-20* Base XS--6 Intubat-NOT
INTUBA
[**2172-7-22**] 11:58AM BLOOD Glucose-42* Lactate-1.2
[**2172-7-22**] 11:58AM BLOOD Hgb-3.5* calcHCT-11
[**2172-7-23**] 03:25AM BLOOD freeCa-1.05*
Micro:
[**2172-7-22**] 12:05 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final [**2172-7-24**]):
GRAM POSITIVE ROD(S).
CONSISTENT WITH CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
Legionella Urinary Antigen (Final [**2172-7-23**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
URINE CULTURE (Final [**2172-7-24**]): NO GROWTH.
Imaging:
[**7-23**] RUQ U/S: 1. Increased liver echogenicity, compatible with
fatty infiltration. 2. Nondistended gallbladder with small
amount of intraluminal sludge, and marked gallbladder wall edema
measuring 7 mm. These findings are most compatible with low
protein state, third spacing due to liver disease or heart
failure. No definite evidence of acute cholecystitis. 3. Left
renal cyst.
[**7-27**] KUB: No evidence of obstruction; limited assessment for free
air.
[**7-25**] CXR: IMPRESSION: Pulmonary congestion with left effusion.
Brief Hospital Course:
MICU course
85 yo male with history of CAD s/p CABG, HTN, and diastolic
dysfunction presented with altered mental status, fever,
hypotension, and respiratory distress, found to have septic
shock with unclear etiology of infection (? biliary source)
.
# Septic shock: Patient presented with fevers, hypotension,
tachycardia with leukocytosis and bandemia. Hypotension and
tachycardia refractory to IV fluids and peripheral pressors
requiring central pressor support. Differential for source
included bacterial v. viral pneumonia, biliary source,
aspiration, meningitis, and prostatitis. Possibilities
including biliary source that improved with supportive care vs.
bacterial pneumonia though initial cxr in ed was clear. He was
stabilized in the ICU with IVF. He required levophed and
vasopressin, which was weaned off after pressures had
stabilized. He was treated with IV vancomycin and cefepime
started on [**7-22**]. His white count improved, he became afebrile,
and his blood cultures were negative, with the exception of an
isolated bottle positive for corynebacterium (a likely
contaminant). Ended vanc/cefepime on [**7-31**] and remained afebrile
following this.
.
# Hypoxemia: Differential included infection, volume overload
from CHF, and PE but most likely was a result of pneumonia. ABG
showed patient was ventilating well on 4L NC. His hypoxemia
improved in the ICU with antibiotics, and at the time of
transfer he was satting 93 on RA. weight 166.7 as of [**8-2**], down
from 180 in the ICU, no systolic CHF, but rather LVH and
resolving pulm edema and likely atelectasis. no SOB, CP to
suggest PE. O2 sat on morning of discharge was 97% on room air.
#Gallstones and transaminitis: LFTs improving following
admission to the ICU when they were ALT/AST in range 600-800 and
now 70, 40s as of [**2172-8-1**] and T bili normalized from [**4-28**] to
<1.0. Alk phos remained slightly high in low 200s from peak in
300s. Repeat ruq u/s showed distended gallbladder, gallstones,
but no ductal dilatation. He also has fatty liver. His
simvastatin was held in the setting of elevated LFTs but should
be re-started once LFTs have normalized.
--recommend repeat LFTs and outpatient repeat RUQ u/s and GI or
surgical evaluation for consideration of elective
cholecystectomy.
# ARF: Differential includes prerenal given insensible losses
from infection, poor perfusion from hypotension. Obstruction
was ruled out clinically. Most likely prerenal from infection,
and his creatinine improved with fluid rehydration.
# CAD s/p CABG: Patient reports that his anginal equivalent is
chest pain with shortness of breath. Patient remained chest
pain free. Troponin mildly elevated on initial labs, but
without EKG changes. His aspirin/plavix were continued and
simvastatin was held due to elevated LFTs--this can be
re-started once LFTs have normalized. aspirin dose decreased to
81mg from 325 given no recent stents.
.
# HTN: His metoprolol was held initially given hypotension but
then restarted.
# BPH: held detrol la initially while delirious given its
anticholinergic properties. continued finasteride.
.
# Peripheral neuropathy: Decreased sensation symmetrically to
mid calf, unchanged from prior per patient. His gabapentin was
restarted after his hypotension and infection improved. lumbar
xray showed : Moderate lumbar degenerative disease as detailed.
No compression fx detected in the lumbar spine.
#Anxiety/agitation: Pt frequently cried out regarding pain,
however he was unable to describe what was bothering him. He
was worked up for liver/gallbladder, abdominal, chest, back, and
bladder sources. When his hypotension and infection were
stabilized, geriatrics was consulted and recommended a trial of
zyprexa and initiation of ssri, which slowly helped. He was
aox3, conversant and pleasant as of time of discharge. He would
benefit from geriatric follow up.
#Speech/Swallow: Evaluated by speech and swallow on [**2172-7-28**] for
dysphagia. He had no overt signs of aspiration but had
significant burping with PO intake. Suggested PO diet of think
liquids and regular consistency solids, meds whole with water.
[**Month (only) 116**] need nutrition follow up for poor PO intake.
ITEMS TO F/U
--recommend repeat LFTs and outpatient GI/surgery evaluation
along with repeat RUQ u/s. Can re-start simvastatin once LFTs
normalize.
Medications on Admission:
HOME MEDICATIONS: (Last d/c summary)
1. clopidogrel 75 mg Tablet daily
2. finasteride 5 mg Tablet daily
3. gabapentin 100 mg q8h
4. metoprolol tartrate 25 mg Tablet PO BID
5. simvastatin 80 mg Tablet qhs.
6. Detrol LA 4 mg Capsule, ER daily.
7. Vitamin B-12 1,000 mcg PO once a day.
8. aspirin 325 mg Tablet DAILY
9. docusate sodium 100 mg Capsule PO BID
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-26**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
5. oxybutynin chloride 5 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
6. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic [**Hospital1 **] (2 times a day) as needed for dry eyes.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
9. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation,
anxiety.
11. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
15. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
16. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (SA) for 7 weeks.
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
19. nystatin 100,000 unit/mL Suspension Sig: One (1) PO Q8H
(every 8 hours).
20. senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
sepsis, unknown source, possible biliary
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:
Follow up with Dr. [**Last Name (STitle) 2903**] [**Telephone/Fax (1) 2205**] in 2 weeks
Follow up with Geriatrics at rehab and upon discharge from rehab
Followup Instructions:
Call PCP to arrange [**Name Initial (PRE) **]/u
--discuss LFTs and gallstones and fatty liver
Department: CARDIAC SERVICES
When: FRIDAY [**2172-11-13**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**] MD, [**MD Number(3) 89336**]
Completed by:[**2172-8-3**]
|
[
"038.9",
"787.21",
"584.9",
"E849.9",
"403.90",
"790.4",
"428.32",
"785.52",
"486",
"564.00",
"995.92",
"276.2",
"414.00",
"V49.86",
"E928.8",
"585.9",
"356.9",
"428.0",
"309.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11763, 11853
|
5149, 9523
|
239, 268
|
11938, 11938
|
3011, 4120
|
12293, 12870
|
2376, 2395
|
9929, 11740
|
11874, 11917
|
9549, 9549
|
12114, 12270
|
2410, 2973
|
9567, 9906
|
4164, 5126
|
2987, 2992
|
193, 201
|
296, 1624
|
11953, 12090
|
1646, 2208
|
2224, 2360
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,469
| 149,014
|
41194
|
Discharge summary
|
report
|
Admission Date: [**2151-1-7**] Discharge Date: [**2151-1-13**]
Date of Birth: [**2105-10-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
bright red blood per rectum, bilateral leg edema, general
weakness
Major Surgical or Invasive Procedure:
Endoscopy and Colonoscopy
History of Present Illness:
45 yo Mandarin speaking female with history of hemorrhoids and
rectal prolapse presents to ED with complaints of [**1-28**] weeks of
BRBPR, as well as swelling in her face, arms, and legs for the
last 10 days. Patient has had episodes of blood in her stool in
the past, usually they resolve on their own. There has been one
or two times where the bleeding has been more persistent, where
she went to see a traditional Chinese doctor [**First Name (Titles) 1023**] [**Last Name (Titles) 2875**] her
herbal medicine. The bleeding had responded to the herbal
medications on those instances. She had also taken the herbal
medication this time around for a week, but the bleeding
continued, so she decided to present to the emergency room for
further evaluation. She reports that the bleeding tends to be
intermittent, but when it comes it is around 2 or 3 times a day.
She has no abdominal pain or pain on defecation, but feels that
she is more bloated that she usually is. Had some mild nausea
for a couple of days, but no vomiting. Patient also endorses
fatigue, slight headache, slight shortness of breath,
lightheadedness, and some palpitations.
She also reports that she has swelling of her face, arms, and
legs from time to time. This has also occurred in the past
episodically. The last time it happened was about 2 years ago.
She had seen the traditional medicine doctor at that time as
well, took a week's course of herbal medication which seemed to
help it. Recently, for the last 10 days, she's noticed that her
legs are more swollen, although not painful.
In the ED, patient's initial vitals were: 96.8, 73, 120/60, 16,
100% RA. She was noted to be pale on examination. Had some
mild tenderness to LLQ. She had no stool in her rectal vault to
be guaiaced. Noted to have 2+ pitting edema to knees
bilaterally. Labs notable for hct of 18.1. GI was consulted
over the phone in the ED who recommended checking for hemolysis
labs, iron studies, and evaluating for signs of heart failure
prior to giving blood. If stable, can prep tonight for scope
tomorrow. Patient was also noted to be transiently bradycardic
to the 30's briefly, was asymptomatic during this episode.
Vitals on transfer were: 99, 60, 108/64, 16, 100% RA.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, or wheezing. Denies chest pain, chest pressure. Denies
vomiting, diarrhea, constipation. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
h/o hemorrhoids
h/o rectal prolapse
Social History:
Immigrated to the US 6 years ago. No family or close friends
here. Denies tobacco, alcohol, illicit drug use.
Family History:
Father - DM
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 115/61, 55, 12, 100%RA
General: pale, fatigued, AAOx3, conversive, pleasant
HEENT: PERRLA, EOMI, MMM, oropharynx clear, no JVD, no LAD, neck
supple
CV: S1S2, RRR, no m/r/g
Chest: CTA b/l, no w/r/r
Abd: soft, ND, NT, +BS, RLQ and LLQ feels 'bloated' to patient,
no HSM
Ext: 2+ pitting edema to knees bilaterally, 2+ peripheral pulses
Neuro: CN II-XII grossly normal, 5/5 strength throughout.
DISCHARGE PHYSICAL EXAM
VS: Afebrile, BP 80s-130/50s-70s, P50s-80, 18, 98/RA
Gen: NAD. Alert and oriented x3. Mood and affect appropriate.
Pleasant and cooperative. Resting in bed.
CV: RRR. Normal S1, S2. No murmur, rubs, or gallops.
Chest: Respiration unlabored, no accessory muscle use. CTAB. No
wheezes or rhonchi.
Abd: Soft, NT, ND, +BS, no organomegaly noted
Ext: 2+ distal pulses, no c/c/e
Neuro: Strength and sensation intact.
Pertinent Results:
ADMISSION LABS
[**2151-1-7**] 04:27PM BLOOD WBC-3.7* RBC-2.01* Hgb-5.4* Hct-18.1*
MCV-90 MCH-26.8* MCHC-29.8* RDW-24.6* Plt Ct-253
[**2151-1-7**] 04:27PM BLOOD Neuts-77* Bands-0 Lymphs-14* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2151-1-7**] 04:27PM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-2+ Pencil-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**] [**Name (STitle) 24904**]
[**2151-1-7**] 04:27PM BLOOD Glucose-106* UreaN-9 Creat-0.8 Na-137
K-3.5 Cl-106 HCO3-22 AnGap-13
[**2151-1-7**] 04:27PM BLOOD LD(LDH)-154
[**2151-1-8**] 04:56AM BLOOD ALT-12 AST-14 LD(LDH)-121 AlkPhos-25*
TotBili-1.7*
[**2151-1-7**] 04:27PM BLOOD Albumin-4.4 Iron-15*
[**2151-1-8**] 04:56AM BLOOD Albumin-3.6 Calcium-8.0* Phos-3.7 Mg-2.3
Iron-109
[**2151-1-8**] 04:56AM BLOOD calTIBC-359 VitB12-600 Folate-GREATER TH
Hapto-50 Ferritn-40 TRF-276
[**2151-1-8**] 04:56AM BLOOD TSH-12*
[**2151-1-8**] 04:56AM BLOOD Free T4-0.96
DISCHARGE LABS
[**2151-1-13**] 07:30AM BLOOD WBC-5.0# RBC-3.42* Hgb-10.3* Hct-30.0*
MCV-88 MCH-30.2 MCHC-34.5 RDW-20.2* Plt Ct-174
[**2151-1-13**] 07:30AM BLOOD Glucose-90 UreaN-5* Creat-0.8 Na-141
K-3.7 Cl-105 HCO3-26 AnGap-14
ECHOCARDIOGRAM
The left atrium is mildly dilated. 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) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
EGD:
EKG [**1-7**]: NSR at 70, NA, NI, no ST changes
PERTINENT LABS
[**2151-1-8**] 04:56AM BLOOD Ret Man-6.2*
[**2151-1-10**] 05:21AM BLOOD ALT-12 AST-12 AlkPhos-27* TotBili-1.1
DirBili-0.3 IndBili-0.8
[**2151-1-7**] 04:27PM BLOOD proBNP-280*
[**2151-1-8**] 04:56AM BLOOD calTIBC-359 VitB12-600 Folate-GREATER TH
Hapto-50 Ferritn-40 TRF-276
[**2151-1-8**] 04:56AM BLOOD TSH-12*
[**2151-1-8**] 04:56AM BLOOD Free T4-0.96
[**2151-1-12**] 08:10AM BLOOD tTG-IgA-4
EGD [**2151-1-9**]
Findings: Esophagus: Normal esophagus.
Stomach: Mucosa: Mild patchy erythema and congestion of the
mucosa without bleeding were noted throughout the stomach. These
findings are compatible with gastritis.
Other On retroflexion, a pool of bilious fluid was suctioned
from the cardia to reveal small blood clots and some fresh
blood. Despite flushing and further suctioning, no source of
bleeding could be indentified.
Duodenum: Normal duodenum.
Impression: Mild gastritis
Evidence of recent bleeding in the cardia of unclear source -
consider scope trauma since this was not seen on entering the
stomach and no source was identified.
Otherwise normal EGD to third part of the duodenum
Recommendations: Test and treat for H. pylori
Repeat EGD to assess for bleeding source in the stomach - can be
delayed until pt is out of the unit or performed sooner if she
shows signs of active bleeding and no source is identified on
the upcoming colonoscopy
[**Last Name (un) **] [**2151-1-9**]
Findings:
Protruding Lesions Large non-bleeding internal hemorrhoids were
noted.
Other Tiny flecks of blood were noted throughout the colon.
There was also a significant amount of residual stool. No
mucosal lesions were identified on this exam to the terminal
ileum to explain the presence of blood.
Impression: Large internal hemorrhoids - unlikely to explain
such a profound anemia
Tiny flecks of blood without obvious source as well as
significant residual stool throughout the colon
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: Suggest repeat exam after additional bowel
preparation and at the time of her follow-up EGD. If the patient
remains stable, this could be done in our endoscopy unit after
she is out of the ICU. If no source identified on repeat exams,
then she should have a capsule endoscopy.
EGD: [**2151-1-12**]
Findings: Esophagus: Normal esophagus.
Stomach:
Other Cold forceps biopsies were performed for histology at
the stomach antrum.
Duodenum:
Other There was mild diffuse atrophy in the duodenum with a
very small (2mm) area of white mucosa ?aphthus ulcer. Cold
forceps biopsies were performed for histology at the second part
of the duodenum and third part of the duodenum.
Impression: There was mild diffuse atrophy in the duodenum with
a very small (2mm) area of white mucosa ?aphthus ulcer. (biopsy)
(biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow-up biopsy results
Nothing seen to accound for degree of anemia. Would suggest
capsule endoscopy either here or as an out-patient (TBD with
primary team).
[**Last Name (un) **] [**2151-1-12**]
Findings:
Protruding Lesions Large Grade 3 internal hemorrhoids with
stigmata of recent bleeding were noted.
Impression: Grade 3 internal hemorrhoids
Otherwise normal colonoscopy to terminal ileum
Recommendations: Suggest capsule endoscopy (see EGD report).
Brief Hospital Course:
45 F with h/o hemorrhoids and rectal prolapse presents with a
hematocrit of 18 in setting of BRBPR and bilateral LE swelling.
#. ANEMIA/[**Name (NI) 11092**] pt has a history of hemorrhoids and rectal
prolapse, both of which can explain her GI bleed. Based on her
description of the blood as red and liquid, coating her stools,
it is most likely lower GI in etiology. Patient has never had a
colonoscopy. Differential also includes bleeding
diverticulosis, AVM, peptic ulcer disease. Does not sound like
it is from upper GI as stools are not described to be melanotic,
but shouldn't discount a bleeding ulcer. She was started on IV
PPI [**Hospital1 **]. Pt was transfused 4 units, goal hct>25. Initial EGD and
colonoscopy showed flecks of blood throughout but too much stool
to visualize. Patient stop bleeding and hct stabilized. Was
converted to PO PPI [**Hospital1 **].
Given the poor prep/endo/[**Last Name (un) **], pt was again prepped for a repeat
endo/[**Last Name (un) **]. The repeat found gastritis in the antrum of the
stomach (see report in prior section, bxs taken), and also found
grade 3 hemorrhoids with stigmata of recent bleeding. A capsule
endoscopy was attempted in house, however due to technical
issues, the study was not able to be interpreted. Given that
her severe anemia is thought likely [**1-27**] the hemorrhoidal
bleeding, we felt that it would be important for her to seek
care by a colorectal surgeon. An appointment was set up with
Dr. [**Last Name (STitle) 1120**] and her NP (see below for further details). A capsule
endoscopy is of course a possibility, however we will leave that
to the discretion of her new PCP at [**Hospital3 14092**]. That can be done through [**Hospital1 18**] (see below for details).
In the interim, the pt was counseled on eating a diet that is
high in fiber and water, and we started the pt on hydrocortisone
suppositories. In terms of why the pt has such severe
hemorrhoids, concern for portal HTN led us to check LFTs, INR,
and albumin, which were all wnl.
#. SWELLING - unclear what is causing her facial, arm and leg
swelling. Patient does not appear to be volume overloaded. No
history of heart failure, although patient has had very limited
medical care in the past. BNP of 280 on admission to the ED.
TTE showed LVEF 70%. Of note patient takes herbal medications of
unknown ingredients. Thought is that swelling (which resolved
on its own after HD2) could be a side effect of chinese herbs
that she was taking, or from high outpt CHF [**1-27**] severe anemia.
Albumin was checked which was normal. LFTs were also checked
which were wnl.
# SICK EUTHYROID/SUBCLINICAL HYPOTHYROIDISM: Pt's TSH noted to
be 12 in house with normal free T4. In setting of severe
illness, did not start pt on outpt regimen of synthroid. Will
likely need repeat testing in the outpatient arena.
# LEUKOPENIA: In the setting of severe anemia, leukopenia was
concerning for a pancytopenic process. We trended her WBC which
recovered to 5.0 on the date of d/c. Of note, possibility of
chinese herbs causing leukopenia and anemia (on top of GI Bleed)
was considered, unfortunately, Ms. [**Known lastname 1256**] was unable to inform us
of which herbs she used. She will likely need further lab work
in the outpt arena to test for persistent cell line depression,
and we will defer possible referral to hematology based on those
results. We are discharging her with a nl WBC count today.
# SOCIAL ISSUES AND FOLLOW UP: Patient is from [**Country 651**] who
emigrated 6y ago. She was previously working as a nanny but was
fired because of persistent illness. She has been intermittently
homeless and is without family or close friends, and without
insurance. As per the pt, she was taken in by a Chinese family
and has a place to stay for now.
In terms of her follow up, we were able to set up the patient
with a f/u appt with Dr. [**First Name (STitle) **] at [**Hospital3 14092**]. We have impressed upon her the importance of keeping
that appointment and to pursue help for applying for "Health
Safety Net." (Her appointment at [**Hospital3 **] is on Wed, [**2151-1-20**] a 1 pm).
After her insurance has been set up, she will be able to go to
[**Hospital1 18**] for some of her referral care. A follow up appointment
has been set for her in the colorectal surgery department on
[**2151-3-18**], and prior to her appointment, her insurance
information must be relayed to the colorectal surgery department
([**Telephone/Fax (1) 17489**]). Also, once her insurance information is set up,
she can also request for an earlier appointment. As far as the
possibility of a capsule endoscopy, she can be referred to [**Hospital1 18**]
for that study once her insurance has been set up, however that
will also be deferred to the judgement of her new PCP at [**Hospital 26626**].
Medications on Admission:
unknown chinese herbal medication
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. hydrocortisone acetate 25 mg Suppository Sig: One (1)
suppository Rectal twice a day for 2 weeks.
Disp:*28 suppositories* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
GI Bleed, likely secondary to hemorrhoids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of your during your
hospitalization. You were admitted to [**Hospital1 18**] with a GI Bleed
that required an endoscopy and colonoscopy. You received blood
transfusions and once you were stable, you were able to be
discharged.
PLEASE MAKE THE FOLLOWING MEDICATIONS CHANGES
1) START taking OMEPRAZOLE 40 MG by mouth twice daily
2) START using HYDROCORTISONE SUPPOSITORIES 25 MG by rectum
twice daily for 2 weeks
If you do not see the capsule pass and you develop abdominal
pain, please contact your doctor immediately to have an
abdominal x-ray taken.
Please be sure to keep your appointments with your physicians as
indicated below.
Followup Instructions:
An appointment has been made for you at [**Hospital3 89729**] in [**Location 16080**].
DOCTOR: [**Name6 (MD) 1730**] [**Name8 (MD) **], MD
DATE: WEDNESDAY, [**2151-1-20**] AT 1 PM
PHONE: [**Telephone/Fax (1) 8236**]
The most important thing will be to set up your 'Health Safety
Net' at [**Hospital3 **].
You have also been scheduled for an appointment with Dr. [**Last Name (STitle) 1120**]
and Ms. [**Name13 (STitle) 1124**] at [**Hospital1 18**] for surgical evaluation of your
hemorrhoids.
LOCATION: [**Location (un) **], [**Hospital Ward Name **] FLOOR 3
DR/NP: [**Doctor Last Name **]/[**Doctor Last Name **]
DATE/TIME OF APPT: [**2151-3-18**]; 1 pm
PHONE: [**Telephone/Fax (1) 17489**]
You must also have the staff at [**Hospital3 **] call with your
insurance information when that is set up. They can also call
once your insurance is set up to move your appointment earlier.
If after meeting with the surgeons, you and your PCP feel that
there is a need for a capsule endoscopy, you will need to call
[**Hospital1 18**] with your insurance information to set up the study. If
you DO NOT see the capsule pass, you will need an abdominal
X-RAY (KUB) prior to the repeat capsule study to ensure it is
not retained in your bowels. To schedule this test after you
have your insurance set up, please call [**Telephone/Fax (1) 13545**] and speak
with [**First Name8 (NamePattern2) 13544**] [**Last Name (NamePattern1) 39685**] (please have staff at [**Hospital3 **] help you set
this up).
Completed by:[**2151-1-13**]
|
[
"535.11",
"782.3",
"569.1",
"280.0",
"244.9",
"427.89",
"455.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
14511, 14517
|
9245, 12725
|
371, 399
|
14603, 14603
|
4147, 9222
|
15446, 16972
|
3239, 3252
|
14182, 14488
|
14538, 14582
|
14124, 14159
|
14754, 15423
|
3267, 4128
|
12736, 14098
|
2696, 3035
|
264, 333
|
427, 2677
|
14618, 14730
|
3057, 3094
|
3110, 3223
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,856
| 105,385
|
24803
|
Discharge summary
|
report
|
Admission Date: [**2118-9-28**] Discharge Date: [**2118-10-6**]
Date of Birth: [**2053-5-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea on exertion and palpitations
Major Surgical or Invasive Procedure:
[**9-28**] CABG x 2(LIMA, SVG->PDA), Mechanical AVR, RF Maze, LAA
oversew
History of Present Illness:
65 year old female with coronary artery disease as well as
aortic and mitral valve disease. She has experienced
palpitations (paroxysmal atrial fibrillation) over the past 5
years. Positive exercise tolerance test in [**2116**] and underwent
stenting to her LAD. She has been followed by serial
echocardiograms for her valvular disease. A recent cardiac
catheterization was significant for three vessel disease. She
admits to dyspnea with moderate ecertion. She presents for
surgical revascularization.
Past Medical History:
CAD s/p LAD stenting in [**2116**]
Diabetes
Hypercholesterolemia
Hypothyroid
Arthritis
PAF
Hysterectomy
Social History:
Lives with daughter. Active [**Name2 (NI) 1818**]. 1 ppd for 50 years. No
alcohol use.
Family History:
Maternal uncles with premature CAD
Physical Exam:
GEN: WDWN in NAD
BP:112/59 SR 73 Afebrile
HEENT: Poor dentition, OP benign
NECK: Supple, No JVD
LUNGS: Clear
HEART: RRR, + holosystolic murmur
ABD: Benign
EXT: No edema, no varicosities
NEURO: Nonfocal
Pertinent Results:
[**2118-10-3**] 12:58PM BLOOD WBC-10.0 RBC-3.66* Hgb-11.4* Hct-33.3*
MCV-91 MCH-31.1 MCHC-34.1 RDW-14.0 Plt Ct-138*
[**2118-10-6**] 07:15AM BLOOD PT-19.5* INR(PT)-2.7
[**2118-10-6**] 07:15AM BLOOD UreaN-21* Creat-0.8 K-4.7
[**2118-10-6**] CXR
PA and lateral chest compared to earlier postop film since
[**9-29**], most recently [**10-4**]. The large
postoperative cardiomediastinal silhouette, large left pleural
effusion and left lower lobe collapse are unchanged since
[**10-3**]. Small right pleural effusion has decreased. Right
lung is grossly clear. There is no pneumothorax. The patient has
had median sternotomy and AVR.
[**2118-9-28**] EKG
Normal sinus rhythm with occasional atrial pacing and diffuse T
wave flattening which is non-specific. Compared to the previous
tracing of [**2118-9-19**] the downsloping ST segment depressions in the
anterior leads are no longer present and the occasional atrial
pacing is new.
Brief Hospital Course:
Ms. [**Known lastname 13662**] was admitted to the [**Hospital1 18**] on [**2118-9-28**] for elective
surgical management of her aortic valve and coronary artery
disease. She was taken to the operating room where she underwent
coronary artery bypass grafting to two [**Last Name (LF) 56207**], [**First Name3 (LF) **] aortic valve
replacement with 1 19mm ST. [**Male First Name (un) 923**] regent valve, a radiofrequency
MAZE procedure and a left atrial appendage over sew.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Ms. [**Known lastname 13662**] [**Last Name (Titles) **]e neurologically intact and was extubated. Amiodarone and
coumadin were started. Her drains were removed. She was then
transferred to the cardiac surgical step down unit for further
recovery. Ms. [**Known lastname 13662**] was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility. She
developed some brief episodes of self limited rate controlled
atrial fibrillation. Beta blockade was started in addition to
her amiodarone and titrated for optimal heart rate and blood
pressure control. As her INR was slow to increase, heparin was
started as a bridge to coumadin. He Lasix was increased for mild
pleural effusions. Ms. [**Known lastname 13662**] continued to make steady progress
and was discharged home on postoperative day eight. She will
follow-up with Dr. [**Last Name (STitle) **], her cardiologist and her primary care
physician as an outpatient. Dr. [**Last Name (STitle) **] will monitor her INR for
coumadin dosing as an outpatient with a goal INR of 2.0-3.0. She
will also have a repeat chest x-ray with her primary care
physician [**Last Name (NamePattern4) **] 1 week for follow-up of her pleural effusions.
Medications on Admission:
Metformin 850mg twice daily
Asppirin 81mg once daily
Plavix 75mg once daily
Coumadin 7.5mg daily
Lopressor 25mg twice daily
Digoxin 0.25mg once daily
Lisinopril 10mg once daily
Synthroid 50mcg once daily.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
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:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 10
days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO ONCE (once) for 1
doses: 7.5 mg today, INR to be drawn [**10-7**] with results to Dr.
[**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 5 days: 400mg QD x 5 days, then 200 QD.
Disp:*45 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA CARE [**Location (un) **]
Discharge Diagnosis:
CAD s/p LAD stent [**2116**]
NIDDM
Hyperlipidemia
Hypothyroid
arthritis
PAF
s/p hystectomy
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision, or weight
gain more than 2 pounds in one day or five in one week, or
shortness of breath or chest pain.
Shower, wash incision with soap and water and pat dry.
No driving or lifting more than 10 pounds until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 3-4 weeks
Dr. [**Last Name (STitle) 62479**] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks, Dr. [**Last Name (STitle) **] also to follow INR and dose coumadin
Please get chest x ray in next 1-2 weeks and discuss results
with Dr. [**Last Name (STitle) **] at [**Hospital1 **].
Completed by:[**2118-11-21**]
|
[
"398.91",
"V45.81",
"250.00",
"244.9",
"272.4",
"414.01",
"716.98",
"427.31",
"401.9",
"396.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.04",
"35.22",
"36.11",
"36.15",
"37.33",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
6227, 6287
|
2441, 4309
|
358, 434
|
6422, 6430
|
1486, 2418
|
6761, 7099
|
1213, 1249
|
4564, 6204
|
6308, 6401
|
4335, 4541
|
6454, 6738
|
1264, 1467
|
282, 320
|
462, 966
|
988, 1093
|
1109, 1197
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,703
| 109,449
|
32164+57789
|
Discharge summary
|
report+addendum
|
Admission Date: [**2168-10-14**] Discharge Date: [**2168-11-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
ORIF of left hip
History of Present Illness:
86 [**Hospital **] [**Hospital 45534**] transferred from [**Hospital3 **] after
unwitnessed fall/L hip fracture & ? C-spine injury (? fracture
of C1 and C2), initially scheduled for [**Hospital3 **]-trauma hip surgery.
In ED, [**Hospital3 **]/trauma surgery plan for L femoral neck fracture
and ? cervical vertebrae injury, admitted to medicine for
syncopal episode and pre-op assessment.
On [**10-15**] AM, medicine administered beta blockade in
preparation for OR, SBPs/HR and hemodynamics stable overnight,
with admission hct 38. In PACU, noted to have SBP in 70s,
required peripheral dobutamine and neosynephrine to maintain
MAPs >60, hct drop to 26.4 --> transfused 1 unit, given 1L [**Hospital **]
transferred to MICU.
Upon transfer to MICU at 1130am, left subclavian/axillary
line placed with stabilization of systolic pressures >100,
transitioned to levophed. At 12:31, pt had bradycardia -->
asystolic arrest, had immediate CPR with intubation, 2 epi, 1
atropine, with resumption of pulse and pressure at 12:39pm. EKG
showed st-depressions v3-v5, transfused 1 unit PRBCs with hct
rise to 26.7, given 1L NS, repleted calcium/magnesium, levophed
administered to maintain MAPs>60, lactate 4.0 - 5.0, R-A line
placed. CXR showed no pulmonary edema, ?globular heart, bedside
echo initial read showed no tamponade with EF~30%.
Past Medical History:
1. Alzheimer's with significant brain atrophy
2. Afib for 8 yrs on coumadin
3. Cirrhosis
4. urinary and fecal incontinence
5. depression
6. Asthma
7. Chronic CHF - alcoholic cardiomyopathy
8. chronic constipation
9. previous fracture of the cervical bends - stabilized by
neurosurgery. Healed.
10. hx of falls
11. GERD
12. osteoarthritis
Social History:
Lives in [**Location (un) 5503**]. He is demented at baseline and wheelchair
bound. Granddaughter [**Name (NI) **] #[**Telephone/Fax (1) 75243**].
Family History:
Non-contributory
Physical Exam:
VS:BP 95/57 HR95 RR13-17, sats 100% on RA AC TV 500 RR 14 Fio2
40%. CVP 22-26.
GEN: WDWN elderly male in NAD.
HEENT: NCAT, pupils 2mm, nonreactive, no scleral icterus. OP
clear, MM dry.
NECK: No LAD, no carotid bruits.
CV: Irreg irreg, tachy. Cannot appreciate any murmurs.
PULM: CTA anteriorly, at bases. No crackles/wheezes.
ABD: Soft, NTND, + BS, no HSM.
EXT: Cool upper/lower extremities. 2+ DP pulses bilaterally.
Has warmth and some tightness but no visible ecchymosis over L
thigh. ?livedo reticularis anterior right thigh.
Pertinent Results:
STUDIES:
[**2168-10-12**]: report from [**Hospital3 15402**] head CT [**10-12**]
[**2168-10-13**]: CT head scan w/o contrast at [**Hospital3 15402**] : No hemorrhage
or mass effect. See report in chart.
.
[**2168-10-13**]: CT of cervical spine at [**Hospital3 15402**]: Good healing of the
fracture at the base of the odontoid process. There is evidence
of a fracture on the right side of the body of C2 posteriorly
and superiorly wher there was a fracture previously so I do not
know if this is due to poor healing or a new fracture. There
appears to be an undisplaced fracture involving the right side
of the posterior arach of C2 which I cannot identify on the last
exam. Otherwise, there is a cervical spondylosis.
.
[**2168-10-14**] CXR: No evidence of acute cardiopulmonary process.
.
[**2168-10-14**] L HIP/FEMUR XR:
1. Left intertrochanteric fracture with a medially displaced
lesser
trochanter fracture fragment.
2. Severe left knee osteoarthritis
[**2168-11-2**] 07:00AM BLOOD WBC-6.7 RBC-2.97* Hgb-9.3* Hct-29.3*
MCV-99* MCH-31.2 MCHC-31.6 RDW-19.1* Plt Ct-473*
[**2168-10-25**] 06:50AM BLOOD Neuts-62 Bands-1 Lymphs-25 Monos-10 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2168-11-2**] 07:00AM BLOOD PT-14.6* INR(PT)-1.3*
[**2168-11-2**] 07:00AM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
[**2168-11-1**] 06:40AM BLOOD ALT-30 AST-31 LD(LDH)-353* AlkPhos-221*
TotBili-1.7*
[**2168-11-2**] 07:00AM BLOOD TotBili-1.4
[**2168-10-16**] 12:57PM BLOOD CK-MB-6 cTropnT-<0.01
[**2168-10-29**] 10:10AM BLOOD Lipase-44
[**2168-11-2**] 07:00AM BLOOD Mg-1.9
[**2168-10-29**] 10:10AM BLOOD calTIBC-238* Ferritn-397 TRF-183*
.
Microbiology:
AEROBIC BOTTLE (Final [**2168-10-24**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] CC6D AT 21:45 ON
[**2168-10-22**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
ANAEROBIC BOTTLE (Final [**2168-10-24**]):
CITROBACTER FREUNDII COMPLEX. FINAL SENSITIVITIES.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 R
TOBRAMYCIN------------ <=1 S
.
GRAM STAIN (Final [**2168-10-21**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2168-10-23**]):
OROPHARYNGEAL FLORA ABSENT.
ESCHERICHIA COLI. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
Overall course: patient was brought to hospital with hip
fracture, admitted to medicine. Due to hemodynamic instability
was transferred to MICU where found to have HCT drop of 10pts.
Subsequently had bradycardic arrest, successful resuscitation.
Went to the OR and had ORIF of left hip. Subsequently became
septic with E coli in sputum, Citrobacter in blood, started on
ABX. Also started on metronidazole for Cdiff but d/c'd when
toxins came back negative. Electrophysiology evaluated the
patient and determined that while no intervention is required
now outpatient followup in [**12-29**] months is indicated.
1). Hip Fracture: According to the family, the patient fell out
of his bed while trying to get up; he is non-ambulatory at
baseline. The patient was taken to the emergency room on [**10-18**]
for an ORIF of his left hip. He tolerated the procedure well
and was placed on Lovenox prophylaxis afterwards. He continued
to work with occupation and physical therapy during his stay.
He will continue Lovenox until his INR is therapeutic (between
2.0 and 3.0).
2). Sepsis/Hypotension: The patient was hypotensive requiring a
MICU transfer for pressors in the setting of a 10 point
hematocrit drop over an 18 hour period shortly after admission.
The HCT drop was thought to be secondary to bleeding into his
left thigh after his fracture. He has a CTA which was negative
for pulmonary embolus and bilateral lower extremity ultrasounds
that did not show clot. A cortisol stim test was negative for
adrenal insufficiency. His blood cultures grew Citrobacter
freundii x 2 and coag negative staph x 1; a sputum culture grew
out E Coli. The cultures were resistant to piperacillin and
ciprofloxacin; the patient was started on cefepime for coverage.
3). Atrial fibrillation with Rapid Ventricular
Response/Bradycardia/Asystolic Arrest: The patient had a
witnessed bradycardic episode in the MICU with asystole. Chest
compressions were performed and the patient was resuscitated.
An electrophysiology consult was obtained and the etiology of
his bradycardia was thought to be secondary to excessive beta
blockade and possible sick sinus. He was stabilized and slowly
restarted on beta blocker therapy and digoxin therapy. After
transfer from the ICU the patient began to have RVR to the
150's; the digoxin was stopped and he was transitioned to
longer-acting beta blockade with atenolol. The patient began to
have occasional pauses between 1.5 and 2.8 seconds on telemetry
which were entire asymptomatic. Electrophysiology was
re-consulted and the patient's beta blockade was titrated
downwards. He will be discharged on beta blocker therapy with
electrophysiology follow up in [**1-30**] months. Per the PCP request
the patient the patient was restarted on Coumadin for long-term
anticoagulation.
4). Anemia: The patient's HCT was low in the context of sepsis,
bleeding and his hip surgery. It remained stable between 25 and
30 for the last week of his stay. His iron studies reflect a
mixed picture, but he has a strong reticulocytosis. He should
follow up with his primary care physician once this acute
episode has resolved.
5). Acute renal failure: The patient had acute renal failure
upon presentation with a creatinine of 1.4 and a rise to 2.0
post-code. This was most likely due to poor perfusion and a
hypodynamic state in the context of his bleed. Once he was
resuscitated his acute renal failure resolved.
6). Alzheimer's Dementia: The patient has dementia at baseline.
He had occasional episodes of delirium in the context of his
sepsis but he improved with antibiotic therapy.
7). Cardiomyopathy/Chronic Systolic Congestive Heart Failure:
The patient had his medications held but had his beta blocker
and captopril reinitiated when he was on the floor.
8). Elevated liver function tests: The patient had elevated
liver function tests upon transfer to the floor; a RUQ
ultrasound and CT abdomen were negative. A liver consult was
obtained and his hepatitis panel was negative. His Tbili slowly
resolved, but he should have his liver function tested a week
after discharge.
Medications on Admission:
Warfarin 3 mg DAILY
Coreg 6.35 mg [**Hospital1 **]
Capoten 25 mg [**Hospital1 **]
Lasix 20 mg DAILY
Potassium Cholride 20 mEq DAILY
Duragesic Patch 50 mcg Q3days
Oxycodone/Acetominophen 10/325 mg [**Hospital1 **]
Omperazole 20 mg DAILY
Fluoxetine 20 mg DAILY
Mag Citrate qwednesday
Nortryptyline 25 mg QHS
Aricept 10 mg QHS
Duo Neb
Lactulose 60 ml DAILY
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours): may discontinue once INR is
between 2 and 3.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10ml PO BID (2
times a day) as needed.
3. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 4 days.
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
the highlander
Discharge Diagnosis:
Sepsis
Hip Fracture s/p ORIF
Musculoskeletal Chest Pain
Anemia
Atrial fibrillation with rapid ventricular response
chronic systolic congestive heart failure
Alzheimer's Dementia
Discharge Condition:
stable
Discharge Instructions:
Please continue to take your medications as prescribed. You
were started on coumadin. Please have your INR checked every
2-3 days and titrate with a goal INR between 2 and 3. Once your
INR has reached therapeutic levels you may discontinue the
lovenox therapy.
You should have your liver function tests evaluated in a week.
You will continue to have occasional fast heart beats and
occasional slow beats. If these are not asymptomatic you should
contact a physician. [**Name10 (NameIs) **] addition, if you develop fevers,
chills, or any other concerning symptoms please contact a
physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 7568**] [**Telephone/Fax (1) 75244**] in two weeks.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] [**Telephone/Fax (1) 902**]
(electrophysiology) in [**1-30**] months.
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2168-11-10**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2168-11-10**] 11:30
Completed by:[**2168-11-3**] Name: [**Known lastname 12369**],[**Known firstname 3834**] Unit No: [**Numeric Identifier 12370**]
Admission Date: [**2168-10-14**] Discharge Date: [**2168-11-3**]
Date of Birth: [**2082-7-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 653**]
Addendum:
Medication List updated
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours): may discontinue once INR is
between 2 and 3.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10ml PO BID (2
times a day) as needed.
3. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 4 days.
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
titrate to INR of [**1-30**]. Check level every day for 4 days until
stable, then check every 2-3 days. Tablet(s)
Discharge Medications:
Medication List updated
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours): may discontinue once INR is
between 2 and 3.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10ml PO BID (2
times a day) as needed.
3. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 4 days.
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
titrate to INR of [**1-30**]. Check level every day for 4 days until
stable, then check every 2-3 days. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
the highlander
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 655**] MD [**MD Number(2) 656**]
Completed by:[**2168-11-3**]
|
[
"787.91",
"428.0",
"331.0",
"820.21",
"038.40",
"401.9",
"599.0",
"294.10",
"V11.3",
"E888.9",
"584.9",
"427.5",
"482.82",
"427.89",
"428.23",
"995.92",
"518.81",
"999.9",
"790.4",
"427.31",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.72",
"99.04",
"99.07",
"79.35",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16935, 17131
|
6380, 10504
|
272, 290
|
12379, 12388
|
2801, 6357
|
13065, 15505
|
2214, 2232
|
15528, 16912
|
12178, 12358
|
10530, 10886
|
12412, 13042
|
2247, 2782
|
224, 234
|
318, 1663
|
1685, 2033
|
2049, 2198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,478
| 112,995
|
47131
|
Discharge summary
|
report
|
Admission Date: [**2130-2-8**] Discharge Date: [**2130-2-11**]
Service: MEDICINE
Allergies:
Vioxx / Bactrim / Codeine / Aspirin / Gabapentin / Ranitidine
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
mesenteric angiography via femoral catheter
History of Present Illness:
Pt is a 88 year old with history of diverticular bleed, who
presents after two episodes of bright red blood per rectum last
evening. She became concerned after she felt lightheaded, dizzy
and weak and used her life line to call EMS. She denies any abd
pain, nausea or vomiting, and has chronic diarrhea. No fever, or
chills.
Patient had diverticulitis, complicated by abscess in the past,
has a history of 8 units of red blood cells transfusion in [**2127**]
for lower gaterointestinal bleed, with negative angiogram.
In the ED, initial vitals were: temp 98 pulse 82 blood pressur
160/70 respirations 16 Oxygen sat 100%. Patient was given 3L
noramal saline and 2 IVs were place, GI consulted.
In the MICU, GI was consulted. She received 2 units of PRBCs on
night of admission and hematocrits stabilized without further
transfusion. Her EKG was unchanged from baseline. She went to
angiogram suite on day of transfer without evidence of active
bleed. Surgery was consulted. Vitals on transfer were temp 98.1
pulse 66 blood pressure 156/54 satuation of 97% on roonm air.
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,
constipation or abdominal pain. No recent change in bladder
habits, has chronic [**Last Name (un) 940**] stools. No dysuria. Denied arthralgias
or myalgias.
Past Medical History:
- diverticulosis [**2127**] requiring 8 units transfusion with
negative angiogram.
- grade 1 internal hemorrhoids
- sigmoid diverticulitis with an adjacent abscess [**9-/2129**]
- Afib: not on coumadin
- Chronic diarrhea
- Insulin Dependent Diabtes Mellitus
- Hypertension
- Asthma
- Gout
- Recurrent urinary tract infections
- gastroesphogeal reflux
- Tremor: essential tremor, followed previously by Dr. [**Last Name (STitle) 17281**]
- Chronic Renal Failure
- Choledocholithiases/cholangitis ([**2126-4-20**]): found to have
pseudomonas bacteremia, treated with ceftazidime and flagyl, and
referred for cholecystectomy but patient refused
- Neuropathic pain
- Right hip fracture
- bilateral knee replacements
- right leg pins
- cataract repair
Social History:
No alcohol, tobacco, or other drugs. Currently living with her
daughter in [**Location (un) 686**]. From [**State 2690**] originally. Three children,
six grandkids, 7 greatgrandkids
Family History:
Father died of MI at 43 yo. Maternal history of breast cancer.
Uncle with stomach cancer, uncle with liver cancer, brother with
prostate cancer. Brother and 2 daughters with diabetes.
Physical Exam:
ICU Admission Exam:
Vitals: Temp: 98.1 blood pressure: 130/40 Pulse: 94 Resp: 14 O2:
98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry muccous membranes, oropharynx clear
Neck: supple, neck veins not elevated, no masses
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
Pertinent Results:
labs-
[**2130-2-8**] 12:40AM BLOOD WBC-5.7 RBC-3.59* Hgb-10.4* Hct-31.2*
MCV-87 MCH-28.9 MCHC-33.3 RDW-16.8* Plt Ct-240
[**2130-2-8**] 06:00AM BLOOD WBC-8.2 RBC-2.66*# Hgb-8.0* Hct-23.7*
MCV-89 MCH-30.1 MCHC-33.8 RDW-17.2* Plt Ct-219
[**2130-2-11**] 01:17AM BLOOD Hct-31.2*
[**2130-2-11**] 07:05AM BLOOD WBC-9.1 RBC-3.78* Hgb-11.5* Hct-32.1*
MCV-85 MCH-30.5 MCHC-36.0* RDW-16.4* Plt Ct-113*
[**2130-2-8**] 12:40AM BLOOD Neuts-51.2 Lymphs-41.3 Monos-4.0 Eos-3.3
Baso-0.3
[**2130-2-8**] 12:40AM BLOOD PT-14.0* PTT-24.9 INR(PT)-1.2*
[**2130-2-10**] 02:55AM BLOOD PT-14.5* PTT-26.9 INR(PT)-1.3*
[**2130-2-8**] 08:16PM BLOOD Fibrino-312
[**2130-2-8**] 12:40AM BLOOD Glucose-127* UreaN-33* Creat-1.3* Na-139
K-5.1 Cl-106 HCO3-28 AnGap-10
[**2130-2-11**] 07:05AM BLOOD Glucose-160* UreaN-12 Creat-0.9 Na-140
K-4.2 Cl-107 HCO3-28 AnGap-9
[**2130-2-8**] 06:00AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8
[**2130-2-10**] 02:55AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.0
[**2130-2-8**] 01:02PM BLOOD pH-7.26*
[**2130-2-8**] 04:05PM BLOOD Type-ART pH-7.37
[**2130-2-8**] 01:02PM BLOOD freeCa-1.08*
[**2130-2-8**] 04:05PM BLOOD freeCa-1.22
[**2130-2-8**] 6:00 am MRSA SCREEN NASAL SWAB.
**FINAL REPORT [**2130-2-9**]**
MRSA SCREEN (Final [**2130-2-9**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
Reports-
EKG [**2130-2-8**]
Atrial fibrillation. There is a late transition with tiny R
waves in the
anterior leads consistent with possible prior anterior
infarction.
Non-specific ST-T wave changes. Compared to the previous tracing
atrial
fibrillation is new.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 0 84 346/393 0 -10 79
-------------------
EKG [**2130-2-8**]
Sinus rhythm. Compared to the previous tracing of [**2129-9-12**] ectopy
has
resolved.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 172 78 358/393 23 -12 70
[**2130-2-8**] cxr
HISTORY: New central line, check position or complications.
IMPRESSION: AP chest compared to [**2129-9-11**]. Tip of the new
right
internal jugular line projects low over the SVC. No
pneumothorax, mediastinal widening or pleural effusion. Heart
size is top normal. Lungs are clear.
Angiogram- mesenteric
-no active source of bleeding visible
--------------------
Doppler LE
INDICATIONS: 88-year-old female with GI bleed status post
angiographic
procedure and right-sided groin bruits. Please rule out hematoma
or fistula.
FINDINGS: Limited arterial and venous duplex was performed in
the right
femoral location. The common femoral artery is patent with
biphasic waveforms and uniform color saturation. The profunda
and proximal superficial femoral artery also patent with
biphasic waveforms.
The common femoral and proximal saphenous are patent without any
evidence of fistula. There is no evidence of pseudoaneurysm and
no significant hematoma.
IMPRESSION: Essentially normal Duplex of the right femoral
vessels. No
source of the bruits identified.
Brief Hospital Course:
ICU Course:
The patient was admitted with hypotension and ongoing bright red
blood per rectum. Hematocrit on admission was 23.7. She was
bolused with IV fluids and transfused 2 units of packed red
blood cells, and her blood pressure stabilized. Her
post-transfusion hematocrit was 37.2. GI and surgery were
consulted upon admission. On hospital day one, per
GI/interventional radiologist, she was taken directly to
angiography, but no bleeding source was found. Upon removal of
her femoral sheath, she developed groin pain and a bruit.
Ultrasound was obtained, which showed no atriovenous fistula or
pseudoaneurysm, with patent vessels. She was prepped for
colonoscopy, but as she had no more bleeding over 36 hours.
Therefore, GI decided not to pursue a scope during this
admission. Given her prior history of diverticular bleed, it is
likely that this episode was also from diverticula. Her
hematocrit at the time of floor transfer was 31.0, stable over
36 hours. Her blood pressure had also stabilized and was
increasing to SBPs 150s, with a plan to restart home BP
medications on the floor.
Medicine floor course:
After transfer to the floor, the patients blood pressure
increased overnight to the 170s. She was given captopril and
metoprolol short acting. Her hematocrit remained stable
overnight at 32.2 and then she was restarted on her home blood
pressure medications of lisinopril and verapamil ER. She had no
abdominal pain and her vitals remained stable, but with an
improved blood pressure to the 130s. She was seen by PT and was
able to ambulate and climb stairs independently. She had
complaint of gas and was started on simethicone PRN. She also
had complaint of skin irritation under her left breast and was
instructed to use a zinc oxide containing powder twice a day.
She was discharged home and will have follow up with her PCP and
the [**Hospital **] clinic.
Medications on Admission:
Insulin NPH SS
Albuterol 2puffs prn
Allopurinol 100mg PO
Atorvastatin 1mg
Duloxetine 20mg
Fluticasone 110 mcg 2puffs
Lisinopril 10mg
Pantoprazole 40mg
Verapamil 120mg
Montelukast 10mg
ASA mg
Discharge Medications:
1. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*2*
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) units
Injection ASDIR (AS DIRECTED): use as before admission.
3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO TID (3 times a day) as needed for gas: for gas.
Disp:*45 Tablet, Chewable(s)* Refills:*3*
6. over the counter
powder with zinc oxide, apply under the breasts twice a day,
avoid inhalation
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation three times a day.
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Tablet(s)
10. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation once a day: use as before.
11. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day as needed for shortness of breath or
wheezing.
12. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for pain.
14. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO three times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
primary:
acute blood loss anemia
lower gastrointestinal bleed
secondary:
type 2 diabetes
gout
hypertension
chronic diarrhea
Discharge Condition:
stable, afebrile
Discharge Instructions:
You were admitted for blood in your stool complicated by anemia.
You received 2 units of blood while you were here. You were
initially monitored in the ICU. There, your blood pressure and
blood counts were stable. You had a scan to detect bleeding in
your colon. The results of that were negative.
Please see your gasteroenterologist to schedule a colonoscopy.
Please follow up with all of your appointments and take all of
your medications as directed.
If you should have further bleeding, lightheadedness/dizzyness,
weakness, chest pain, or shortness of breath, please call your
primary care physician or present to the emergency department.
Followup Instructions:
You have the following appointments.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2130-3-22**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2130-3-1**] 10:10- Please recheck HCT as pt had recent
admission for lower GI bleeding.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1941**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 1942**]
Date/Time:[**2130-2-20**] 12:45
Call Dr. [**Last Name (STitle) 174**], your gasterenterologist, for an appointment,
([**Telephone/Fax (1) 22346**]. You will need to discuss your need for a
colonscopy.
Completed by:[**2130-2-12**]
|
[
"585.9",
"530.81",
"V43.65",
"274.9",
"250.00",
"285.1",
"427.31",
"562.12",
"493.90",
"403.90",
"333.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
10340, 10397
|
6719, 8600
|
296, 341
|
10566, 10585
|
3644, 6696
|
11280, 12169
|
2851, 3036
|
8842, 10317
|
10418, 10545
|
8626, 8819
|
10609, 11257
|
3051, 3625
|
229, 258
|
1460, 1865
|
369, 1442
|
1887, 2636
|
2652, 2835
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,811
| 155,856
|
44086
|
Discharge summary
|
report
|
Admission Date: [**2188-9-12**] Discharge Date: [**2188-9-17**]
Date of Birth: [**2111-6-6**] Sex: M
Service: CICU
CHIEF COMPLAINT: Chest pain, hypertension on nitroglycerin
drip.
HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old
gentleman with a history of atrial fibrillation, coronary
artery disease, status post coronary artery bypass graft in
[**2181**], history of congestive heart failure with ejection
fraction of 40% who was admitted for chest pain and rule out
myocardial infarction to Acove Service. On the night of
admission the patient developed 9 out of 10 chest pain that
lasted more then thirty minutes. It was not relieved with
sublingual nitroglycerin. Required 9 mg of morphine and
nitroglycerin drip to improve the pain. While on
nitroglycerin drip the patient developed mild hypertension
with systolic blood pressure in the low 90s for which he was
transferred to the Intensive Care Unit. The patient was
recently discharged from [**Hospital1 69**]
after admission for a urinary tract infection/pneumonia
treated with Levofloxacin. At that time urine culture was
not available and at the present time is growing MRSA. On
the day prior to admission the patient reported chest pain
associated with shortness of breath, diaphoresis and some
nausea. The chest tightness was not relieved with the
nitroglycerin, but resolved with Darvocet. At the time of
his transfer to the Intensive Care Unit the patient's enzymes
times three were negative. The chest pain that led to an
initiation of a heparin drip was slightly different from the
admission chest pain. It was persistent and associated with
shortness of breath, diaphoresis and it radiated to the
shoulder. It did improve with the nitroglycerin drip and
morphine. There were no electrocardiogram changes noted,
however, the patient is AV paced with wide left bundle branch
block appearing QRS.
PAST MEDICAL HISTORY: 1. Atrial fibrillation on Amiodarone.
2. History of gastrointestinal bleed secondary to peptic
ulcer disease in [**2187-12-1**]. 3. Coronary artery
disease with his last coronary artery bypass graft in [**2181**]
with two saphenous vein grafts and left internal mammary
coronary artery to left anterior descending coronary artery.
The echocardiogram showed severe MR, tricuspid regurgitation,
ejection fraction of 36%, severe pulmonary hypertension and
1+ aortic regurgitation. His last cardiac catheterization
was in [**2188-2-29**], which showed apical akinesis
anterolateral and anterior apical hypokinesis, totally
occluded saphenous vein graft and totally occluded native
vessels. 4. Status post DDI pacemaker in [**2179**], which was
changed in [**2188-7-31**] for atrial fibrillation and sick
sinus syndrome. 5. Hypercholesterolemia. 6. Chronic renal
insufficiency with creatinine between 2.2 and 2.4. 7.
Diabetes insulin dependent. 8. Gastroesophageal reflux
disease. 9. Hyperthyroidism.
MEDICATIONS ON ADMISSION: Humalog insulin 24 q.a.m., NPH 26
and 60 in the morning and in the afternoon respectively.
Levofloxacin 250 q.d., Spironolactone 25 mg po q.d., Protonix
40 mg po q day, Toprol 25 mg po b.i.d., Lipitor 10 mg po
b.i.d., Lasix 80 mg b.i.d., aspirin 81 mg po q.d., Colace 100
mg po b.i.d., Levothyroxine 25 mcq po q.d., Amiodarone 200 mg
po q.d., Digoxin 0.125 mg po q.d., Lisinopril 20 mg po q.d.,
Vancomycin 1 gram received.
PHYSICAL EXAMINATION: Temperature 96.9. Pulse 70 AV paced.
Blood pressure 104/50. Respiratory rate 18. O2 sat 97% on
room air. In general, the patient was an elderly man in no
acute distress. HEENT extraocular movements intact. Pupils
are equal, round and reactive to light. No lymphadenopathy.
No JVD. Oropharynx dry. Lungs clear to auscultation
bilaterally. Heart regular rate and rhythm, 3 out of 6
systolic ejection murmur at sternal border. Abdomen soft,
nontender, nondistended with good bowel sounds. Extremities
show no clubbing, cyanosis or edema. There was 2+ pulses on
the left and 1+ pulses on the right.
LABORATORY FINDINGS ON ADMISSION: White blood cell count
10.5, hematocrit 33.7, platelet count 384. Differential on
the white blood cell was 77 neutrophils, 16 lymphocytes, 6
monocytes, 1 eosinophils. Chem 7 sodium 138, potassium 4.1,
chloride 103, bicarb 24, BUN 50, creatinine 2.0, glucose 107.
His creatinine clearance was estimated at 43. His calcium
was 9.0, phosphate 5.3, magnesium 2.2, albumin 3.0, TSH 2.5,
sed rate 89, PT and INR of 12.7 and 1.1. PTT 24. His CK was
48, 43 and 39. Troponin was less then 0.3 times three.
Digoxin was 0.7. Vancomycin level was 12. Blood cultures
from [**9-12**] were pending. Urine cultures from [**9-6**] grew 10 to
100,000 MRSA. Chest x-ray showed no congestive heart
failure. There was persistent opacification in the right
middle lobe and the left base with atelectasis.
HOSPITAL COURSE: In summary the patient is a 77 year-old
gentleman with significant coronary artery disease, history
of congestive heart failure who presents with chest pain
requiring morphine and nitroglycerin drip. The patient's
issues during the hospitalization included:
1. Cardiac: The constellation of the patient's symptoms
could represent acute coronary syndrome for which he was
started on a heparin drip and nitroglycerin drip. His
Lipitor, aspirin, Lasix and oxygen supplementation were
continued. He was evaluated by his primary cardiologist Dr.
[**First Name (STitle) **] and underwent Persantine stress test during which he
did not develop any arm, neck, back or chest discomfort. His
electrocardiogram was not interpretable for ischemia and
images revealed severe partially reversible perfusion defect
of the lateral wall as well as severe predominantly fixed
perfusion defect of the inferior wall in addition to moderate
global hyperkinesis with ejection fraction of 33%. Based on
these findings and prior cardiac catheterization showing
severe native three vessel disease and totally occluded to
saphenous vein graft and graft with patent left internal
mammary coronary artery, the patient was judged not to have a
disease that could be intervened on by cardiac
catheterization. The decision was made to manage him
medically. His heparin as well as nitroglycerin drips were
discontinued and he remained chest pain free with the
exception of a single episode during which he had 2 out of 10
chest pain relieved by nitroglycerin. The patient's beta
blocker was changed to Toprol and titrated up to 37.5 mg q.d.
Throughout this hospitalization the patient's congestive
heart failure remained compensated. He was continued on his
outpatient regimen of congestive heart failure medications.
2. Infectious disease: During this hospitalization the
patient received a course of Vancomycin for his MRSA urinary
tract infection. In addition, he continued on his
Levofloxacin for the right middle lobe infiltrate. He
remained afebrile with normal white count and without left
shift.
3. Diabetes: During this hospitalization the patient's
diabetes was controlled with outpatient insulin regimen with
good blood sugars.
4. Prophylaxis: He was continued on his Protonix and
heparin subQ.
5. He is being discharged home to follow up with his
cardiologist Dr. [**First Name (STitle) **] as well as his primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 94642**] within the next two weeks.
MEDICATIONS ON DISCHARGE: Humalog insulin 24 units q
breakfast, NPH insulin 26 units q breakfast, 6 units q
bedtime, Humalog sliding scale, Amiodarone 200 mg po q day,
Digoxin 0.125 mg po q day, Lisinopril 20 mg po q day, Lipitor
10 mg po q day, Lasix 80 mg po b.i.d., Colace 100 mg po q.d.,
Levothyroxine 25 mcq po q.d., Levofloxacin 250 mg po q.d.
until [**9-23**]. Spironolactone 25 mg po q.d., Protonix 40 mg po
q.d., Toprol XL 37.5 mg po q.d., Ambien 5 mg po q.h.s. prn,
aspirin 81 mg po q.d., nitroglycerin 0.3 mg sublingual prn
chest pain.
DISCHARGE DIAGNOSES:
1. Coronary artery disease to be managed medically, patent
left internal mammary coronary artery, partially reversible
severe perfusion defect of the lateral wall.
2. Congestive heart failure with an ejection fraction of 33.
3. Hypertension.
4. Atrial fibrillation.
5. Status post DDD.
6. Hypercholesterolemia.
7. History of gastrointestinal bleed.
8. Chronic renal insufficiency with a creatinine of 2.2.
9. Hypothyroidism.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2188-9-17**] 10:38
T: [**2188-9-23**] 10:33
JOB#: [**Job Number **]
|
[
"397.0",
"428.0",
"427.31",
"414.01",
"593.9",
"599.0",
"486",
"413.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7970, 8691
|
7426, 7949
|
2968, 3392
|
4872, 7399
|
3415, 4044
|
150, 199
|
228, 1905
|
4059, 4854
|
1928, 2941
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,149
| 127,920
|
4151
|
Discharge summary
|
report
|
Admission Date: [**2158-9-13**] Discharge Date: [**2158-9-24**]
Date of Birth: [**2097-9-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Simvastatin / Tape [**12-18**]"X10YD / Hydrochlorothiazide /
Eptifibatide / CellCept
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2158-9-21**] 1. Left mini thoracotomy and placement of epicardial
left
ventricular pacing lead x2. The lead leads are the
following: Number 1 is [**Hospital 18121**] Medical reference
number [**Serial Number 18122**], serial number [**Serial Number 18123**]. This was the one
that was hooked up to the device. The capped second
lead in an [**Hospital 18124**] Medical lead, reference number [**Serial Number 18122**],
serial number [**Serial Number 18125**].
2. Removal of old single chamber pacemaker.
3. Placement of new biventricular dual chamber pacing
system. It is a St. [**Hospital 923**] Medical model number PM3210,
serial number [**Serial Number 18126**], item number [**Serial Number 18127**].
History of Present Illness:
Mr. [**Known lastname 5850**] is a 61 year old gentleman with a history of
systolic congestive heart failure, moderate to severe mitral
regurgitation, coronary artery disease s/p multiple
angioplasties with recurrent in-stent restenoses, s/p coronary
artery bypass grafting and patent foramen ovale closure in
[**2154-12-23**], recurrent atrial fibrillation s/p atrioventricular
nodal ablation and permanent pacemaker, hypertension, Wegener's
granulomatosis, chronic kidney disea s/p renal transplant and
prior stroke, who presented with shortness of breath. For the
past two days, the patient has been experiencing progressively
worsening shortness of breath, paroxysmal nocturnal dyspnea and
orthopnea, along with increasing abdominal girth and weight gain
of four pounds. Of note, he ran out of his daily Lasix 100 mg
prescription, which he receives by mail order, so he was only
able to take 50mg on [**9-11**] and nothing on [**9-12**]. He believes that
his difficulty breathing began at the time of taking the
decreaed dose of Lasix. He saw his cardiologist, Dr.[**Doctor Last Name 3733**]
in clinic on Friday [**9-8**], at which time his weight was 181.5
pounds and he noted dyspnea on exertion of one flight of stairs.
Friday [**9-8**] was also his birthday, and the patient thinks that
he may have taken in a bit more fluid that day than usual. He
was formerly evaluated by Dr.[**Doctor Last Name 3733**] on [**2158-7-13**] for
biventricularpacemaker placement, but the left ventricular lead
was unable to be placed; the patient subsequently underwent
atrioventicular nodal ablation with a ventricular lead placed on
the right ventricular apex. Afterwards, from [**Date range (1) 18128**], he was
readmitted with congestive heart failure exacerbation but
improved with adjustment of his diuretics.
Past Medical History:
Chronic systolic heart failure, mitral regurgitation, s/p
multiple angioplasties with recurrent in-stent re-stenosis,
recurrent atrial fibrillation, s/p atrioventricular node
ablation/permanent pacemaker, hypertension, hyperlipidemia,
chronic renal failure, Wegener's granulomatosis (remission for
15 years), cerebral [**Date range (1) 1106**] accident, gastric reflux,
Anxiety/Depression, obstructive sleep apnea, coronary artery
bypass grafting/closure of patent foramen ovale 1/7/[**2154**]/, left
renal transplant in [**2153**] secondary to Wegener's granulomatosis,
umbilical hernia repair in '[**37**] and '[**53**], s/p St. [**Hospital 923**] Medical
Accent RF PM1210 S/N [**Numeric Identifier 18129**] implanted [**2158-7-18**]
Social History:
Mr. [**Known lastname 5850**] is divorced and is a retired teacher. He has a
remote smoking history. He drinks socially and denies illicit
drug use.
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
VS: T 98.5 BP 130/84 HR 75 RR 16 O2 sat 100% CPAP
GENERAL: Very pleasant, comfrotable. 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: Unable to appreciate JVP.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: Breathing comfortably. Minimal end-inspiratory crackles
at left lung base. Otherwise CTAB.
ABDOMEN: Soft, NTND. No HSM or tenderness. Normoactive bowel
sounds.
EXTREMITIES: Trace pedal edema bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 1+
Left: Carotid 2+ DP 2+ PT 1+
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 1575**] [**Hospital1 18**] [**Numeric Identifier 18130**] (Complete)
Done [**2158-9-21**] at 10:05:54 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2097-9-7**]
Age (years): 61 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Cerebrovascular event/TIA. Chest pain.
Congestive heart failure. Coronary artery disease. Dilated
cardiomyopathy. H/O cardiac surgery. Hypertension. Left
ventricular function. Mitral valve disease. Pericarditis.
Pulmonary hypertension. Shortness of breath.
ICD-9 Codes: 428.0, 402.90, 786.05, 786.51, 423.9, 424.0
Test Information
Date/Time: [**2158-9-21**] at 10:05 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 25% to 35% >= 55%
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
is seen in the LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Moderate (2+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Thoracotomy for mLV Lead Placement.
1. The left atrium is mildly dilated. No spontaneous echo
contrast is seen in the left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated.
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion. There
was no significant pericardial effusion after lead placement.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2158-9-23**] 5:04 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 18131**]
Reason: interval change
Wet Read: SHSf SAT [**2158-9-23**] 8:05 PM
Unchanged right base atelectasis or scarring. Left base is
better aerated.
Cardiomegaly as before.
Final Report
PA AND LATERAL CHEST
HISTORY: Post-thoracotomy.
COMPARISON: [**2158-9-22**].
FINDINGS: Right IJ line has been removed. Heart remains mildly
enlarged.
There is no pulmonary [**Month/Day/Year 1106**] congestion or pneumothorax.
Minimal bibasilar
atelectasis, not significantly changed.
[**2158-9-12**] 08:10PM BLOOD WBC-12.0*# RBC-3.89* Hgb-11.7* Hct-33.1*
MCV-85 MCH-30.1 MCHC-35.3* RDW-15.3 Plt Ct-217
[**2158-9-14**] 06:30AM BLOOD WBC-7.2 RBC-3.76* Hgb-10.9* Hct-33.0*
MCV-88 MCH-29.1 MCHC-33.2 RDW-15.5 Plt Ct-157
[**2158-9-15**] 05:56AM BLOOD WBC-8.0 RBC-3.83* Hgb-11.1* Hct-33.8*
MCV-88 MCH-29.1 MCHC-32.9 RDW-15.2 Plt Ct-169
[**2158-9-16**] 08:06AM BLOOD WBC-6.6 RBC-3.67* Hgb-10.8* Hct-32.2*
MCV-88 MCH-29.5 MCHC-33.6 RDW-15.1 Plt Ct-172
[**2158-9-17**] 07:30AM BLOOD WBC-6.2 RBC-3.90* Hgb-11.1* Hct-33.4*
MCV-86 MCH-28.5 MCHC-33.2 RDW-14.8 Plt Ct-201
[**2158-9-20**] 05:50AM BLOOD WBC-6.6 RBC-3.67* Hgb-10.4* Hct-33.2*
MCV-91 MCH-28.4 MCHC-31.4 RDW-14.0 Plt Ct-192
[**2158-9-21**] 06:00AM BLOOD WBC-8.4 RBC-3.98* Hgb-11.7* Hct-34.9*
MCV-88 MCH-29.4 MCHC-33.5 RDW-14.0 Plt Ct-228
[**2158-9-22**] 02:04AM BLOOD WBC-12.1* RBC-3.47* Hgb-10.0* Hct-30.3*
MCV-87 MCH-28.7 MCHC-32.9 RDW-14.2 Plt Ct-177
[**2158-9-23**] 06:30AM BLOOD WBC-9.2 RBC-3.33* Hgb-9.6* Hct-29.3*
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.7 Plt Ct-172
[**2158-9-24**] 06:45AM BLOOD WBC-9.4 RBC-3.46* Hgb-9.9* Hct-30.4*
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.6 Plt Ct-183
[**2158-9-21**] 11:59AM BLOOD PT-14.7* PTT-26.2 INR(PT)-1.3*
[**2158-9-22**] 02:04AM BLOOD Plt Ct-177
[**2158-9-23**] 06:30AM BLOOD PT-14.4* INR(PT)-1.2*
[**2158-9-23**] 06:30AM BLOOD Plt Ct-172
[**2158-9-24**] 06:45AM BLOOD PT-16.7* INR(PT)-1.5*
[**2158-9-24**] 06:45AM BLOOD Plt Ct-183
[**2158-9-12**] 08:10PM BLOOD Glucose-112* UreaN-44* Creat-2.8* Na-138
K-3.9 Cl-102 HCO3-20* AnGap-20
[**2158-9-13**] 06:24AM BLOOD Glucose-152* UreaN-42* Creat-2.6* Na-141
K-3.7 Cl-103 HCO3-23 AnGap-19
[**2158-9-14**] 06:30AM BLOOD Glucose-123* UreaN-46* Creat-2.8* Na-139
K-3.2* Cl-101 HCO3-22 AnGap-19
[**2158-9-14**] 03:00PM BLOOD UreaN-47* Creat-2.9* Na-140 K-4.3 Cl-101
[**2158-9-15**] 05:56AM BLOOD Glucose-124* UreaN-59* Creat-3.0* Na-143
K-3.9 Cl-102 HCO3-28 AnGap-17
[**2158-9-16**] 08:06AM BLOOD Glucose-118* UreaN-59* Creat-3.0* Na-140
K-3.8 Cl-102 HCO3-25 AnGap-17
[**2158-9-17**] 07:30AM BLOOD Glucose-107* UreaN-59* Creat-2.9* Na-141
K-4.0 Cl-106 HCO3-21* AnGap-18
[**2158-9-18**] 06:10AM BLOOD Glucose-116* UreaN-60* Creat-3.0* Na-140
K-4.2 Cl-105 HCO3-24 AnGap-15
[**2158-9-19**] 05:50AM BLOOD Glucose-109* UreaN-61* Creat-2.9* Na-141
K-4.0 Cl-104 HCO3-24 AnGap-17
[**2158-9-20**] 05:50AM BLOOD Glucose-128* UreaN-54* Creat-2.8* Na-143
K-5.2* Cl-107 HCO3-19* AnGap-22*
[**2158-9-20**] 01:15PM BLOOD Glucose-221* UreaN-53* Creat-2.6* Na-139
K-3.6 Cl-106 HCO3-21* AnGap-16
[**2158-9-21**] 06:00AM BLOOD Glucose-140* UreaN-53* Creat-2.6* Na-139
K-4.2 Cl-106 HCO3-23 AnGap-14
[**2158-9-21**] 11:59AM BLOOD Glucose-153* UreaN-45* Creat-2.5* Na-141
K-4.9 Cl-110* HCO3-17* AnGap-19
[**2158-9-21**] 06:36PM BLOOD Na-141 K-4.2 Cl-110*
[**2158-9-22**] 02:04AM BLOOD Glucose-130* UreaN-45* Creat-2.7* Na-138
K-4.6 Cl-105 HCO3-17* AnGap-21*
[**2158-9-23**] 06:30AM BLOOD Glucose-141* UreaN-31* Creat-2.2* Na-136
K-3.6 Cl-103 HCO3-19* AnGap-18
[**2158-9-24**] 06:45AM BLOOD Glucose-132* UreaN-34* Creat-2.2* Na-137
K-3.4 Cl-101 HCO3-21* AnGap-18
[**2158-9-12**] 08:10PM BLOOD proBNP-[**Numeric Identifier 18132**]*
[**2158-9-12**] 08:10PM BLOOD cTropnT-<0.01
[**2158-9-13**] 06:24AM BLOOD CK-MB-2 cTropnT-<0.01
[**2158-9-19**] 05:50AM BLOOD %HbA1c-5.8 eAG-120
[**2158-9-18**] 06:10AM BLOOD Triglyc-135 HDL-25 CHOL/HD-4.5 LDLcalc-60
[**2158-9-24**] 06:45AM BLOOD tacroFK-5.3
Brief Hospital Course:
Mr. [**Known lastname 5850**] is a 61 year old gentleman who presented with
dyspnea, weight gain, elevated ProBNP and pulmonary congestion,
consistent with exacerbation of his congestive heart failure.
He diuresed well after receiving lasix. He underwent an attempt
to place a biventricular pacemaker, but it was unsuccessful due
to an inability to place the left ventricular lead. Cardiac
surgery was consulted. Transplant Nephrology were also consulted
to follow him given his history of left renal transplant. On
[**2158-9-21**] he underwent a left thoracotomy, left ventricular lead
placement, pacemaker replacement performed by Dr. [**Last Name (STitle) 914**].
Please see operative report for details. He tolerated the
procedure well and was transferred in critical but stable
condition to the surgical intensive care unit. He soon
extubated. Left paravertebral blocks were administered, as were
intravenous opioids. POD1 he was transferred to the floor.
Physical therapy was consulted for strength and mobility and
cleared him for home when medically ready. Warfarin for atrial
fibrillation and lasix were restarted on POD2. POD3 found him
afebrile, voiding adequate amounts, tolerating a regular diet
with pain well controlled. He was discharged on POD3 in stable
condition to home with VNA. All follow up appointments were
advised.
Medications on Admission:
- [**Last Name (STitle) **] 325 mg PO daily
- atorvastatin 10 mg PO daily
- azelastine 137 mcg aerosol spray, 2 puffs in nostrol [**Hospital1 **]
- calcium acetate 667 mg, 1 capsulte PO TID
- clopidogrel 75 mg PO daily
- eplerenone 25 mg PO daily
- fluticasone 50 mcg spray suspension, [**12-18**] sprays each nostril
[**Hospital1 **]
- furosemide 100 mg PO daily
- lisinopril 10 mg PO daily
- metoprolol succinate 100 mg PO daily
- metronidazole 0.75% lotion, apply to face [**Hospital1 **]
- mycophenolate sodium (delayed release) 360mg 2 tablets [**Hospital1 **]
- nifedipine ER 30 mg PO daily
- oxycodone-acetaminophen 5 mg-325 mg 1-2 tablets PO q6 PRN pain
- sertraline 150 mg PO daily
- tacrolimus 1 mg PO q12
- trazodone 50 mg PO qHS PRN insomnia
- warfarin 2.5 mg tablet 1-3 tablets PO daily, adjust per
[**Hospital **] clinic
- cholecalciferol 1000 units PO daily
- famotidine 10 mg PO daily
- sennosides 8.6 mg PO PRN constipation
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**12-18**]
Sprays Nasal [**Hospital1 **] (2 times a day).
6. lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. metronidazole 1 % Gel Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for rosacea.
9. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
10. sertraline 100 mg Tablet Sig: 1.5 Tablets PO once a day.
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Check PT/INR on Tues [**9-26**].
Disp:*30 Tablet(s)* Refills:*2*
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
15. mycophenolate sodium 360 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day.
16. azelastine 137 mcg Aerosol, Spray Sig: Two (2) puffs Nasal
[**Hospital1 **] ().
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Hold for loose stools.
Disp:*60 Capsule(s)* Refills:*2*
18. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
19. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 10 days: No driving,
drinking alcohol, or operating machinery while taking this
medication.
Disp:*50 Tablet(s)* Refills:*0*
20. famotidine 10 mg Tablet Sig: One (1) Tablet PO once a day.
21. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
22. furosemide 40 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
vna and hospice of greater [**Location (un) **]
Discharge Diagnosis:
acute on chronic systolic heart failure
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by [**Location (un) 5059**]. 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
[**Location (un) 5059**] 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
[**Telephone/Fax (1) **]: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 198**] W. [**Telephone/Fax (1) 250**] in [**3-21**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication
Goal INR
First draw
Results to phone fax
Department: [**Hospital3 249**]
When: TUESDAY [**2158-9-19**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2158-11-10**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2158-12-27**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2158-9-24**]
|
[
"425.4",
"427.31",
"V42.0",
"428.23",
"403.90",
"V45.82",
"V45.81",
"V15.81",
"428.0",
"584.9",
"585.3",
"446.4",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.50"
] |
icd9pcs
|
[
[
[]
]
] |
17187, 17265
|
12641, 13987
|
369, 1116
|
17349, 17560
|
4660, 7420
|
18517, 20186
|
3904, 3922
|
14979, 17164
|
17286, 17328
|
14013, 14956
|
17584, 18494
|
7459, 12618
|
3962, 4641
|
310, 331
|
1144, 2960
|
2982, 3719
|
3735, 3888
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,167
| 155,314
|
53179
|
Discharge summary
|
report
|
Admission Date: [**2155-8-15**] Discharge Date: [**2155-8-22**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
woman from the [**Hospital **] Rehabilitation facility, who
presented with a proximal femoral shaft fracture. The
patient fell while walking to the bathroom on the evening
prior to admission. X-rays on admission revealed a fracture,
as noted below. The patient was found to be in minimal pain
unless her leg was moved. The admitting team reported that
the patient denied any headache, neck pain, chest pain or
shortness of breath.
PAST MEDICAL HISTORY:
1. C3-C4 facet pain.
2. History of breast cancer, status post bilateral
lumpectomy in [**2139**].
3. Gastroesophageal reflux disease.
4. Gait unsteadiness.
5. Depression.
6. Urinary incontinence.
7. Status post L3 compression fracture secondary to fall.
8. Hypertension.
9. Degenerative joint disease.
ALLERGIES: There were no known drug allergies
MEDICATIONS ON ADMISSION:
Aspirin 81 mg p.o. q.d.
Lidoderm patch.
Gabapentin 300 mg p.o. t.i.d.
Trandolapril 2 mg p.o. q.d.
Doxepin 10 mg p.o. q.d.
Murine eye drops, two drops o.u. q.d.
Colace 100 mg p.o. t.i.d.
Fentanyl patch 25 mcg every three days.
Multivitamin one tablet p.o. q.d.
Tylenol p.o. p.r.n.
Caltrate 600 mg p.o. b.i.d.
Lansoprazole 15 mg p.o. q.d.
Calcitonin nasal spray q.d., alternating nostrils.
SOCIAL HISTORY: The patient is married. Her husband also
[**Name2 (NI) 546**] at the [**Name (NI) **] Rehabilitation facility. The patient
normally ambulates with a walker at her baseline. However, a
recent L3 compression fracture has limited this to some
extent. The patient's primary care physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 34013**]. Her son is [**Name (NI) **] Trust; his cell phone number is
[**Telephone/Fax (1) 109480**] and his home phone number is [**Telephone/Fax (1) 109481**]. The
patient's son has been very involved in the patient's care.
PHYSICAL EXAMINATION ON ADMISSION (as obtained by the
orthopedics team): Vital signs revealed a temperature of
98.2??????F, a heart rate of 84, a blood pressure of 146/72,
respirations of 18 and an oxygen saturation of 94% on room
air. In general, the patient was an 85-year-old woman in no
acute distress. The head was normocephalic and atraumatic.
The pupils were equal and reactive to light. The neck was
supple with no cervical spine tenderness.
The chest was clear to auscultation bilaterally. The
cardiovascular examination revealed an S1 and S2 without
murmurs, rubs or gallops. The abdomen was soft, nontender
and nondistended. The left leg was tender to palpation and
movement; there was a 2+ dorsalis pedis pulse with positive
capillary refill. Sensation was intact. No bruising was
visible.
LABORATORY DATA ON ADMISSION: The CBC revealed a white blood
cell count of 11,100 with a hematocrit of 32.3 and platelet
count of 399,000. Chem 7 revealed a sodium of 131, potassium
of 5.7 (which was hemolyzed), chloride of 95, bicarbonate of
21, BUN of 19, creatinine of 1.1 and glucose of 142.
Coagulation studies revealed a prothrombin time of 12.8,
partial thromboplastin time of 31.3 and INR of 1.1.
RADIOLOGY DATA ON ADMISSION: A left hip film revealed a
proximal femur fracture that was medially displaced and
shortened. A left knee film revealed degenerative joint
disease without any visible fracture. A chest x-ray revealed
retrocardiac atelectasis. A lumbar spine film revealed no
acute fractures.
HOSPITAL COURSE: The patient was initially admitted to the
orthopedics team, where she was put in Buck traction at five
pounds. She was prepared for the operating room. On the
following day, [**2155-8-16**], the patient underwent an
intermedullary rod placement for her left subtrochanteric
fracture (Gamma nail). This was performed by Dr. [**Last Name (STitle) **].
The patient's postoperative course was complicated by what
was initially felt to be atrial fibrillation although, on
further review, only the fact that the patient had an
occasional irregular heart rhythm could be determined. It
was felt that the patient had a rapid ventricular response
and that she had experienced some hemodynamic instability.
The patient responded to Lopressor and converted back to a
normal sinus rhythm.
On the next morning, [**2155-8-17**], the patient became
hypotensive with systolic blood pressures ranging in the 60s
to 70s. Her hypotension responded to two 250 cc boluses of
normal saline. The patient at this time had an oxygen
saturation of 97% on three liters by nasal cannula.
The medicine team was consulted and found abdominal
tenderness. A subsequent KUB was reportedly negative. An
electrocardiogram was performed and revealed nonischemic
sinus rhythm. A chest x-ray at that time revealed
cardiomegaly and revascularization as well as left lower lobe
infiltrate and a possible right lower lobe infiltrate.
Furthermore, the patient was found to have a urinary tract
infection, which grew out enterococcus. Later on the evening
of [**2155-8-17**], the patient was noted to be somnolent.
The neurology team was consulted and felt that the patient's
somnolence was secondary to her urinary tract infection
and/or her medications. The patient was placed on Levaquin
to address her pneumonia and vancomycin to address her
enterococcal urinary tract infection.
Also, over the course of [**2155-8-17**], the patient was
noted to have her hematocrit drop from 32 to 21 with her
stools being guaiac negative. Thus, the patient underwent an
abdominal, pelvic and thigh CT scan. The CT scan was
negative for significant bleeding anywhere in the abdomen and
pelvic, including the retroperitoneum. There was no hematoma
evident at the left thigh on CT scan, although probable
bleeding was noted. (However, this was felt by the
radiologist not to be sufficient enough to justify the drop
in hematocrit.) The patient was subsequently transfused two
units of packed red blood cells and her hematocrit rose to 28
for the next two hematocrit checks. On the afternoon of
[**2155-8-18**], the patient was transferred to the
medicine service and the medicine floor.
HOSPITAL COURSE SPECIFIC TO MEDICINE SERVICE: Following is a
summary of the patient's course while on the medicine
service, reviewed by problem list:
1. CARDIOVASCULAR:
a) Pump and blood pressure issues: The patient, as
noted above, was somewhat hypotensive over the day and
evening of [**2155-8-17**]. Her hypotension responded to
fluid boluses. Over the remaining days of the patient's
hospitalization, her blood pressure was stable for the most
part, although she did experience one or two limited episodes
of hypotension which were responsive to further fluid
loading.
b) Rate and rhythm issues: The patient had an
undocumented history of possible atrial fibrillation
postoperatively. Upon transfer to the medicine floor, the
patient was monitored on telemetry and the cardiology service
was consultation. Telemetry did reveal that the patient had
an occasional irregular rhythm with premature ventricular
contractions; however, the cardiology consultant felt that,
for the most part, the patient's rhythm was normal and that
there was no indication for current anticoagulation.
(Nonetheless, it should be noted that the patient was on
Lovenox anyway, since she was status post hip surgery.) If
the patient's heart rate and rhythm again become irregular,
the patient may need to be followed in the atrial
fibrillation clinic. Her heart rate was well controlled, for
the most part, with occasional runs of tachycardia to
110-120. These tachycardic runs were brief.
2. INFECTIOUS DISEASE: The patient exhibited occasional low
grade temperatures. She received five days of vancomycin for
her enterococcal urinary tract infection. A subsequent urine
culture was negative for any bacterial growth. The patient
had been started on Levaquin for her apparent pneumonia on
chest x-ray. A follow up chest x-ray on [**2155-8-20**]
revealed no evidence of pneumonia. The patient should finish
a ten day course of Levaquin.
3. HEMATOLOGY: The patient's hematocrit dropped from 32 to
21, as noted above, on [**2155-8-17**]. A CT scan of the
abdomen, pelvis and thigh was negative for significant
bleeding. The patient was subsequently transfused two units
of packed red blood cells with a subsequent rise in
hematocrit. The patient did not have any melena, nor did she
have any guaiac positive stools during her hospitalization.
on [**2155-8-21**], the patient again exhibited a
hematocrit drop from 29.6 to 26. Although not overwhelming,
this hematocrit drop was addressed with subsequent
transfusion of two more units of packed red blood cells with
a rise in the hematocrit of 34.5.
4. ORTHOPEDIC:
a) Left femur fracture, status post intramedullary rod
placement: The patient was followed by the orthopedics team,
who recommended that the patient be out of bed to the chair
b.i.d. They also recommended that the physical therapy
service work with the patient and that the patient remain on
Lovenox. As noted below, the patient is to follow up with
Dr. [**Last Name (STitle) **] on [**2155-9-1**] to have her staples removed
and to have postoperative evaluation.
5. PROPHYLAXIS: The patient was maintained on Lovenox,
pneumoboots and Protonix.
CONDITION ON DISCHARGE: The patient remained afebrile over
the last several days of her hospitalization. Her blood
pressure, although earlier labile, improved following the
discontinuation of Lopressor. Similarly, the patient's urine
output increased. The patient's vital signs were stable and
she had an oxygen saturation of 94% on room air at the time
of discharge.
DISCHARGE DIAGNOSES:
1. Status post left femur fracture with intramedullary rod
placement on [**2155-8-16**].
2. Hypertension.
3. C3 and C4 facet pain.
4. Gastroesophageal reflux disease.
5. Depression.
6. Status post L3 compression fracture.
7. Dyspnea.
DISCHARGE MEDICATIONS:
Gabapentin 300 mg p.o. t.i.d.
Lovenox 30 mg subcutaneous every 12 hours.
Murine eye drops, two drops o.u. q.d.
Protonix 40 mg p.o. q.d.
Calcitonin nasal spray, one spray q.d., alternating nostrils.
Ferrous sulfate (FESO4) 325 mg p.o. t.i.d.
Multivitamin one p.o. q.d.
Thiamine 100 mg p.o. q.d.
Folate 1 mg p.o. q.d.
Colace 100 mg p.o. b.i.d.
Levofloxacin 500 mg p.o. q.d. times five more days.
Lidoderm patches: 2 x 2 cm patch to head from 7 AM to 7 PM
and 10 x 7 cm patch to back from 7 AM to 7 PM.
Caltrate (chewable) one tablet p.o. b.i.d.
Tylenol 325 to 650 mg p.o. every four hours p.r.n. for pain.
FOLLOW UP: The patient should follow up with her primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34013**], with the next week. She also
has an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of the
orthopedics practice on [**2155-9-1**] at 12:40 PM. (Dr.[**Name (NI) 109482**] office has been made aware of the patient and
they are to call the patient at [**Hospital **] Rehabilitation if
any earlier appointment is necessary. Dr.[**Name (NI) 109483**]
office number is [**Telephone/Fax (1) 1228**]. Furthermore, because of the
patient's periodic anemia, her hematocrit should be checked
every day for five days while at [**Hospital1 **] in order to ensure
that it remains stable. Also, the patient should work with
physical therapy regarding her postoperative course and
subsequent improvement in her lower extremity functioning.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
[**MD Number(1) 34018**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2155-8-22**] 16:32
T: [**2155-8-22**] 19:15
JOB#: [**Job Number **]
|
[
"401.9",
"E888",
"997.1",
"820.22",
"285.9",
"486",
"458.2",
"599.0",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
9801, 10043
|
10066, 10672
|
997, 1386
|
3567, 6357
|
10684, 11881
|
123, 589
|
6372, 9407
|
3270, 3549
|
611, 971
|
1403, 2848
|
9432, 9780
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,824
| 128,983
|
19251+57035
|
Discharge summary
|
report+addendum
|
Admission Date: [**2114-10-6**] Discharge Date: [**2114-10-19**]
Date of Birth: [**2054-7-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
60 y/o male w/end stage liver disease
Major Surgical or Invasive Procedure:
- liver transplant
- T-tube cholangiogram
- placement of central line
History of Present Illness:
60 y/o Male with end stage liver disease with a history of heavy
EtOH use until [**2103**] and HCV infection. Pt. has had multiple
recent admissions for encephalopathy but no recent infectious
episodes. Pt. also with known grade 2 varices without history
of upper GI bleeds. Pt. s/p TIPS in [**Month (only) 216**] of this year. Pt.
now presenting for liver transplant.
Past Medical History:
PMH:
1. Cirrhosis
2. Hep c, [**2107**]
3. Ascites - no SBP, no paracentesis
4. Varices, grade 2 - no UGIB
5. CRI (Cr 1.8 -> 2.1)
6. Cholelithiasis
7. s/p TIPS [**7-20**]
PSH:
1. s/p appy 30 yrs ago
2. Inguinal hernia repair, [**2112**]
3. Adenoids
4. L ankle fracture, [**2095**]
Social History:
Per OMR records, patient currently lives with his wife at home.
He has 2 healthy sons. History of heavy alcohol use, quit in
[**2103**]. Ex-smoker, quit in [**2088**]. History of IVDU in past.
Family History:
Cirrhosis in father, mother, and brother [**1-17**] EtOH; no cancer
Physical Exam:
Vitals:
Pertinent Results:
DUPLEX DOPP ABD/PEL [**2114-10-12**] 10:55 AM
CONCLUSION:
1. Patent portal and hepatic veins and hepatic arteries. No
peritransplant collection.
2. Moderate sized effusion at the right lung base.
UNILAT LOWER EXT VEINS [**2114-10-18**] 3:17 PM
FINDINGS: Grayscale and color Doppler examination of the deep
veins of the right thigh and posterior knee demonstrate normal
compressibility, color flow, respiratory variation, and
augmentation. There is no sign of intraluminal thrombus. There
is a small amount of fluid behind the right knee, which may
represent edema or a small [**Hospital Ward Name **] cyst.
IMPRESSION: No DVT.
[**2114-10-18**] 05:00AM BLOOD WBC-5.0# RBC-4.22* Hgb-12.9* Hct-38.0*
MCV-90 MCH-30.7 MCHC-34.1 RDW-17.9* Plt Ct-78*
[**2114-10-6**] 11:15PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**]
[**2114-10-18**] 05:00AM BLOOD Plt Ct-78*
[**2114-10-8**] 01:57AM BLOOD Fibrino-302
[**2114-10-17**] 12:25PM BLOOD K-4.9
[**2114-10-18**] 05:00AM BLOOD ALT-293* AST-130* AlkPhos-448*
TotBili-3.0*
[**2114-10-17**] 04:55AM BLOOD ALT-258* AST-136* AlkPhos-402*
TotBili-3.6*
[**2114-10-16**] 03:15PM BLOOD ALT-239* AST-119* AlkPhos-387*
TotBili-4.7*
[**2114-10-16**] 05:00AM BLOOD ALT-224* AST-103* LD(LDH)-186
AlkPhos-376* TotBili-4.5*
[**2114-10-15**] 04:57AM BLOOD ALT-232* AST-95* AlkPhos-363*
TotBili-5.8*
[**2114-10-14**] 06:15AM BLOOD ALT-211* AST-78* LD(LDH)-168 AlkPhos-277*
Amylase-32 TotBili-7.0*
[**2114-10-13**] 05:55AM BLOOD ALT-217* AST-91* AlkPhos-220*
TotBili-6.6*
[**2114-10-12**] 06:19AM BLOOD ALT-253* AST-109* AlkPhos-237*
TotBili-9.4*
[**2114-10-11**] 06:15AM BLOOD ALT-240* AST-115* AlkPhos-160*
TotBili-9.5*
[**2114-10-10**] 06:00AM BLOOD ALT-268* AST-168* AlkPhos-104
TotBili-12.4* DirBili-8.5* IndBili-3.9
[**2114-10-8**] 02:38PM BLOOD ALT-330* AST-297* AlkPhos-78
TotBili-11.9*
[**2114-10-8**] 01:57AM BLOOD ALT-358* AST-372* AlkPhos-85
TotBili-13.6* DirBili-3.1* IndBili-10.5
[**2114-10-6**] 11:15PM BLOOD ALT-53* AST-80* AlkPhos-187* TotBili-3.1*
[**2114-10-18**] 05:00AM BLOOD Albumin-2.5* Calcium-8.3* Phos-4.9*
Mg-2.0
[**2114-10-6**] 10:22PM BLOOD HBsAb-POSITIVE
[**2114-10-18**] 05:00AM BLOOD FK506-12.4
[**2114-10-16**] 05:00AM BLOOD FK506-15.6
[**2114-10-15**] 04:57AM BLOOD FK506-17.2
[**2114-10-14**] 06:15AM BLOOD FK506-10.3
[**2114-10-12**] 04:07PM BLOOD HEPARIN DEPENDENT ANTIBODIES-
Brief Hospital Course:
Pt. was admitted to the transplant service after undergoing
a liver transplant. The pt. tolerated the procedure well -
please see the op note for further details on the procedure.
After the procedure the patient was transferred, intubated, to
the SICU for recovery. Overnight the patient was given
additional blood products and continued on antibiotics that were
started during the operation. The patient did well - remained
afebrile with a stable blood pressure in the 150s/60s but
required the support of the ventilator until pod #2. Pt. was
also on an insulin drip to control blood sugars while in the
unit. On the evening of POD 2 the patient was doing well
extubated, had remained afebrile, and was stable for transfer to
the floor.
The patient was transferred to the floor and did well
overnight. The pt. remained afebrile, vitals were stable, pt.
pain was well controlled, and he was tolerating his tube feeds
without complaint. The JP drains continued to have significant
output and the pt. was scheduled for a t-tube cholangiogram for
later in the week. Moreover, nutrition, [**Last Name (un) **], OT, and PT
evaluated the pt. while he was on the floor. The patient
continued to thrive while on the floor, increasing his PO intake
and activity and improving on a daily basis. Nutrition
recommended that we continue the tube feeds - which we did.
[**Last Name (un) **] help initially manage blood sugars while the patient was
on high dose steroids and started the pt. on some antigylcemic
medications when his sugars remained elevated after the steriods
finished. The patient was also given lasix to aid his diuresis
as his lower extremities and genital region had become quite
edematous. The patient tolerated the t-tube cholangiogram
without incident. On post op day 7 one of the JP drain was
taken out nad the pt. had remained afebrile throughout his
hospitalization. The patient was continued on tube feeds and
tolerating a liquid/supplemented diet, vitals were stable, and
pain was well controlled. On post-op day 8 there was a slight
rise in the pt.s alk phos level and the pt. continued to loose
between 1-2 liters of fluid through the remaining JP drain.
Albumin replacement was started and the pt. remained in house to
further monitor liver function tests. Post-op day 10 LFTs
continued to be slightly elevated with a decrease in total
bilirubin to 3.6. The dobhoff tube had been replaced secondary
to it getting clogged and the pt.s BUN/Cr had risen slightly
most likely due to prograf levels. Post-op day 11 the alk phos
remained elevated and a repeat cholangiogram showed less
narrowing in the area of the t-tube/anastamosis compared with
previous studies, no dilitation of the bile ducts and no
evidence of a leak. Post-op day 12 overall the pt. was vastly
improved. He continued on the tube feeds to supplement PO
intake that was between [**Telephone/Fax (1) 34966**] cal a day, edema of lower
extremities was much improved though RLE still slightly swollen
- negative for DVT by ultrasound [**2114-10-18**], he was afebrile with
stable vitals, tolerating POs, pain well controlled and deemed
ready for discharge. He was discharged the following day to a
rehabilitation center.
Medications on Admission:
Ca Carbonate 600 [**Hospital1 **]
Protonix 40 qday
mycelex 2 qid
lactulose 10 tid
spironolactone 150 qday
lasix 40 qday
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day:
decrease to 17.5mg qd on [**2114-11-1**].
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale units Injection four times a day: Fingerstick
QACHSInsulin SC Fixed Dose Orders
Bedtime
Glargine 14 Units
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**12-17**] amp D50
61-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 4 Units
201-240 mg/dL 6 Units
241-280 mg/dL 8 Units
281-320 mg/dL 10 Units
> 320 mg/dL Notify M.D.
Ordered by [**Last Name (LF) **],[**Name8 (MD) **], MD Beeper#: [**Numeric Identifier 40158**] on [**10-14**] @ .
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
12. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p liver transplant
cholelithiasis
HCV
EtOH cirrhosis - prior to tx
Discharge Condition:
good
Discharge Instructions:
- You may shower
- You should continue your tube feedings
- You should continue a regular soft diet w/goal of 60gm of
protein a day and low sodium - may be advanced to a full diet as
tolerated when pt. has dentures and ability to chew regular
food.
- You should continue the medication regimen that you started in
the hospital as many of your pre-transplant medications have
been changed
- You should call the clinic or return to ER if T>101.5, chills,
nausea, vomitting, chest pain, shortness of breath, erythema or
drainage from wound site, or any other concern.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2114-10-24**] 2:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2114-10-31**] 2:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2114-11-7**] 9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2114-10-19**] Name: [**Known lastname 1511**],[**Known firstname **] Unit No: [**Numeric Identifier 9768**]
Admission Date: [**2114-10-6**] Discharge Date: [**2114-10-19**]
Date of Birth: [**2054-7-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 48**]
Addendum:
The patient had recieved Prograf at 0.5 on [**10-18**] pm and 0.5 on
[**10-19**] am for a level of 12.4 on [**10-18**]. On [**10-19**], his Prograf level
was 7.5, sp we switched him to 1.0 and 1.0. He should continue
on Prograf [**12-16**] at rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2114-10-19**]
|
[
"593.9",
"070.54",
"571.2",
"303.93",
"456.21",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"99.07",
"96.6",
"87.54",
"50.59",
"99.04",
"38.93",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
11152, 11388
|
3932, 7160
|
352, 424
|
9195, 9202
|
1470, 3904
|
9815, 11129
|
1357, 1426
|
7330, 8980
|
9103, 9174
|
7186, 7307
|
9226, 9792
|
1441, 1451
|
275, 314
|
452, 826
|
848, 1130
|
1146, 1341
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,358
| 107,725
|
27676
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 67586**]
Admission Date: [**2110-7-22**]
Discharge Date: [**2110-7-30**]
Date of Birth: [**2038-10-14**]
Sex: M
Service: CSU
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is a 71-year-old man who
over the past several months has had several episodes of
exercise angina. He had a positive stress test and then
underwent cardiac catheterization which revealed 60% left
main, 60% LAD, 50% OM2 and occluded RCA and mild left
ventricular dysfunction.
PAST MEDICAL HISTORY: Diabetes mellitus, bilateral
mastoidectomies.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Glipizide 5 mg daily, aspirin 81
mg daily, Lorazepam 15 mg daily, multivitamin.
FAMILY HISTORY: No CAD.
SOCIAL HISTORY: Married with 3 children.
REVIEW OF SYMPTOMS: No TIAs or CVAs. No melena. No GI bleed.
PHYSICAL EXAMINATION: Vital signs: Height 6 foot, 2 inches,
weight 208 pounds. Vital signs: Heart rate 56, blood pressure
109/53, respiratory rate 18, temperature 96.8. general: No
acute distress. HEENT: Extraocular movements intact. Pupils
equal, round and reactive to light, noninjected, anicteric.
Chest: Clear to auscultation bilaterally. Regular rate and
rhythm. Murmurs, rubs, or gallops. Abdomen: Soft, nontender,
nondistended with normoactive bowel sounds. Extremities: Warm
and well perfused with no edema.
LABORATORY DATA: EKG sinus rhythm with a rate of 62, old
inferior wall MI.
Chest x-ray showed no evidence of acute cardiopulmonary
process.
White count 6.8, hematocrit 42.6, platelets 206; INR 1.1;
urinalysis negative; sodium 136, potassium 3.6, chloride 104,
CO2 24, BUN 11, creatinine 0.8, glucose 105; LFTs
unremarkable, albumin 3.5; hemoglobin A1C 7.4.
HOSPITAL COURSE: On the 13th, the patient was a direct
admission to the operating room where he underwent coronary
artery bypass grafting. Please see the OR report for full
details. In summary, the patient had a CABG x 3 with a LIMA
to the LAD, saphenous vein graft to the PDA and saphenous
vein graft to the OM. The patient tolerated the operation
well. His bypass time was 66 minutes with a cross-clamp time
of 53 minutes. Following the surgery, the patient was
transferred from the operating room to the cardiothoracic
intensive care unit.
At that time, he was in sinus rhythm at 80 beats per minute
with a mean arterial pressure of 77 and a CVP of 13. He had
propofol at 20 mcg/kg/min and Neo-Synephrine at 0.5
mcg/kg/min.
The patient did well in the immediate postoperative period.
Anesthesia was reversed. He was weaned from the ventilator
and successfully extubated. On postoperative day 1, he was
hemodynamically stable; however, he did require low-dose Neo-
Synephrine for adequate blood pressure. Additionally, the
patient was noted to be increasingly confused following
administration of narcotics.
During the course of postoperative day 1, Neo-Synephrine
infusion was weaned to off; however, the patient remained in
the cardiothoracic intensive care unit to monitor his
confusion. Additionally, the patient was noted to have short
bursts of atrial fibrillation and was started on amiodarone
and beta-blockade at that time.
On postoperative day 3, the patient remained confused. It was
felt that some of the confusion may be due to benzodiazepine
withdrawal, and he was restarted on low-dose benzodiazepine,
as well as multivitamin, thiamin and folate.
Following this regime, the patient did seem to intermittent
improve, and on postoperative day 5, he was transferred to
the floor for continuing postoperative care and
rehabilitation.
Over the next several days, the patient's mental status waxed
and waned. On postoperative day 6, it was noted that he was
increasingly confused. His medications were once again
reviewed. His standing Ativan was decreased. He was begun on
low-dose Haldol following which his mental status did show a
marked improvement.
His activity level was increased with the assistance of the
nursing staff. He had by this point converted to normal sinus
rhythm on amiodarone and beta-blockade. He continued to be
diuresed.
On postoperative day 7, he was mentally cleared and nonfocal,
and it was decided at that point that if he had 24 hours of
mental acuity, he would be discharged to home.
On postoperative day 8, the patient remained mentally sharp,
and he was discharged to home with visiting nurses.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature
97.9, heart rate 60 in sinus rhythm, blood pressure 143/70,
respiratory rate 18, O2 saturation 94% on room air, weight at
discharge 92.6 kg, preadmission he was 96 kg. General: Alert
and oriented, moves all extremities. Follows commands.
Nonfocal exam. Pulmonary: Clear to auscultation bilaterally.
Cardiac: Regular rate and rhythm. S1 and S2 with no murmurs.
Sternum: Stable. Incision with staples, no erythema or
drainage. Abdomen: Soft, nontender, nondistended with
normoactive bowel sounds. Extremities: Warm and well perfused
with no edema. The __________ site is clean and dry with
Steri-Strips.
DISCHARGE STATUS: The patient is to be discharged to home.
FOLLOW UP: In the wound clinic in 2 weeks, followup with Dr.
[**Last Name (STitle) **] in 4 weeks. Additionally, he is to have followup with
Dr. [**Last Name (STitle) 44432**] in the [**Hospital **] Clinic in [**4-12**] weeks and Dr. [**Last Name (STitle) 6073**]
and/or Dr. [**Last Name (STitle) **] in [**4-12**] weeks.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting with a left internal mammary artery to
the left anterior descending artery, saphenous vein graft
to posterior descending artery and saphenous vein graft
to obtuse marginal.
2. Postoperative confusion.
3. Diabetes mellitus.
4. Bilateral mastoid surgery.
DISCHARGE MEDICATIONS: Multivitamin 1 daily, aspirin 81
daily, Colace 100 b.i.d., Motrin 1 q.8 hours p.r.n.,
atorvastatin 10 daily, folate 1 daily x 1 month, glipizide 5
mg daily, thiamin 100 mg daily x 1 month, Lopressor 25 mg
b.i.d., Haldol 2 mg b.i.d. x 2 days, then 1 mg b.i.d. x 4
days, then 1 mg q.h.s. x 4 days, then discontinue, Ativan 1
mg b.i.d. x 2 days, then 1 mg q.h.s. x 4 days, then
discontinue, amiodarone 400 mg daily x 7 days, then 200 mg
daily x 1 month, tramadol 50 mg 1 tablet q.6-8 hours p.r.n.
as needed for pain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2110-7-30**] 17:57:59
T: [**2110-7-30**] 19:19:05
Job#: [**Job Number 67587**]
|
[
"427.31",
"250.00",
"794.39",
"414.01",
"293.9",
"427.89",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"88.72",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
736, 745
|
5816, 6602
|
5447, 5792
|
638, 719
|
1748, 4390
|
5114, 5426
|
4413, 5102
|
180, 193
|
222, 503
|
526, 611
|
762, 851
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
188
| 132,401
|
20305
|
Discharge summary
|
report
|
Admission Date: [**2161-11-1**] Discharge Date: [**2162-1-17**]
Date of Birth: [**2105-5-18**] Sex: M
Service: SURGERY
Allergies:
Codeine / Ambien / Shellfish Derived / Hydromorphone
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
Dobhoff Tube placement ([**2161-11-30**], [**2161-12-7**], [**2161-12-10**], [**2161-12-11**],
[**2161-12-30**], [**2162-1-5**])
Tunneled Hemodialysis Catheter Removal ([**2161-11-5**])
Temporary Hemodialysis Catheter Placement ([**2161-11-11**], [**2161-11-17**],
[**2161-12-7**])
Tunneled Hemodialysis Catheter Placement ([**2161-11-20**])
PICC Line Placement ([**2161-11-23**])
Diagnostic and Therapeutic Paracentesis ([**2161-11-2**], [**2161-11-5**],
[**2161-12-2**], [**2161-12-21**])
History of Present Illness:
56 year-old male with hepatitis C cirrhosis and HCC s/p liver
transplant ([**2156**]) with recurrent decompensated hepatitis C
cirrhosis, ESRD, diabetes mellitus type II, and hypertension
admitted [**2161-11-1**] with acute worsening of chronic low back pain.
Patient has had chronic LBP attributed to scoliosis of
lumbosacral spine. He reports prior flares lasting 2-3 days.
The current flare began approximately 3 days ago, following a
scheduled weekly paracentesis (6L removed). The pain is
localized to the lower back and does not radiate. He denies
bowel or bladder retention or incontinence or difficulty with
ambulation. He believes this may be related to increased
physical activity over the past 1 week. In the past, he has
received epidural steroid injections. Narcotic use has been
limited by encephalopathy.
Past Medical History:
PMH:
-Hepatitis C cirrhosis and HCC s/p RFA x3, liver
transplantation ([**1-10**])
-Recurrent hepatitis C cirrhosis, decompensated. Ascites
requiring weekly paracentesis, encephalopathy, grade I varices
-ESRD on HD (MWF)
-Hypertension
-Diabetes mellitus, type II
-Levoscoliosis
-Adrenal insufficiency (diagnosed [**11-12**])
-Urolithiasis, s/p stent placement and removal [**3-18**] by Urology
-Enterococcal bacteremia ([**7-16**])
-VRE ([**3-/2161**] rectal swab)
-b/l hearing loss due to noise during work as fireman
PSH: appendectomy, tonsillectomy, cervical laminectomy, R
forearm ORIF, bone graft from hip to elbow, knee surgery, stent
placement/removal [**3-18**] for urolithiasis, liver transplant
Social History:
Former fireman and bar owner; positive tobacco history; 2 packs
per day x 30 years, quit prior to liver transplant. He is not
using IV drugs. Lives with his wife. Very involved family.
Family History:
His father has renal failure.
His mother has hypothyroidism.
Physical Exam:
Physical Exam On Transfer:
VS: T 99.2, BP 128/58, HR 93, RR 22, SpO2 95% on RA
General: Sedated but awakens to calling his name. Answers
questions with 1-2 word answers. Oriented to person, place, and
year.
HEENT: NCAT. PERRL, EOMI, mild scleral icterus. MMM, OP benign.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
CV: RRR. Normal S1, S2. Blowing holosystolic murmur [**3-14**] heard
best at LLSB with radiation to apex.
Chest: Respiration unlabored. Slightly decreased breath sounds
at right base. Few scattered crackles.
Abd: BS present. Significant tense ascites.
Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap
refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+.
Neuro: Moving all four limbs. Unable to assess fully due to
mental status.
Pertinent Results:
Labs On Admission:
[**2161-11-1**] 08:50AM BLOOD WBC-8.3 RBC-3.32* Hgb-9.8* Hct-30.5*
MCV-92 MCH-29.6 MCHC-32.3 RDW-21.4* Plt Ct-81*
[**2161-11-1**] 08:50AM BLOOD Neuts-82.9* Lymphs-9.3* Monos-6.0 Eos-1.5
Baso-0.3
[**2161-11-1**] 08:50AM BLOOD PT-18.9* PTT-42.0* INR(PT)-1.7*
[**2161-11-1**] 08:50AM BLOOD Glucose-310* UreaN-25* Creat-5.3* Na-125*
K-4.6 Cl-89* HCO3-22 AnGap-19
[**2161-11-2**] 06:05AM BLOOD ALT-15 AST-27 LD(LDH)-185 AlkPhos-210*
TotBili-3.9*
[**2161-11-2**] 06:05AM BLOOD Albumin-3.3* Calcium-8.8 Phos-4.5 Mg-1.7
[**2161-11-2**] 06:05AM BLOOD tacroFK-7.5
LUMBO-SACRAL SPINE (AP & LAT) [**2161-11-1**]
Essentially unchanged levoscoliosis of the lumbosacral spine
with no evidence of new compression fracture.
CT PELVIS W/CONTRAST Study Date of [**2161-11-4**] 6:00 PM
IMPRESSION:
1. Stable appearance of the transplanted liver with markedly
dilated portal veins. No thrombus is present.
2. Stable splenomegaly, collaterals, and worsening
intra-abdominal ascites.
3. Mild-to-moderate layering right pleural effusion with
compressive atelectasis. Development of plate-like atelectasis
left lower lobe.
4. Kidneys without hydronephrosis and nonspecific stranding. At
the lower pole of the left kidney, a single non-obstructive
calculus is remaining measuring 5-6 mm.
5. Segmental wall thickening and mural edema of the sigmoid
colon, nonspecific in the setting of ascites. Mild uncomplicated
colitis cannot be excluded. No rim-enhancing lesions,
pneumatosis or extraluminal air. No evidence of bowel
obstruction.
.
MR L SPINE W/O CONTRAST [**2161-11-6**]
1. Increased intrinsic signal abnormality within the L2-3 disc
with surrounding endplate signal changes since the previous MRI
of [**2161-9-19**]. Subtle soft tissue prominence is also identified,
but no definite fluid collection is seen. No evident paraspinal
soft tissue prominence seen. These findings could be due to
advancing degenerative change or due to low-grade infection.
Given the clinical suspicion of infection, further evaluation
with repeat lumbar spine study with gadolinium is recommended.
Given patient's low EGFR, a consent could be obtained and,
clinically, it should be determined whether the study is
important for any decision making.
2. Multilevel degenerative changes are identified as above with
spinal stenosis at L3-4 and L4-5 levels as well as at L2-3
level.
.
[**2162-1-10**] CT abdomen/pelvis IMPRESSION: 1. Right-sided pleural
effusion, unchanged compared with the previous study. 2.
Moderate-to-large ascites, unchanged compared with previous
study. 3. No reaccumulation of the retroperitoneal fluid
collection which was previously drained.
Brief Hospital Course:
The patient is an 56 year old male with hepatitis C
cirrhosis/HCC s/p liver transplant ([**2156**]) with recurrent
decompensated hepatitis C cirrhosis, ESRD on HD, diabetes
mellitus type II, who was admitted for acute on chronic low back
pain and was found to have coag-negative staph bacteremia and
L2-3 discitis / osteomyelitis.
.
Initial [**Doctor Last Name 3271**]-[**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) **]:
.
# GPC Bactermia: He has had several prior episodes of bacteremia
requiring removal of his HD catheter. Blood culture from his HD
line on [**2161-12-2**] grew coag negative staph. Spinal plain films
from his admission on [**2161-12-1**] were unrevealing. CT abdomen
pelvis on [**2161-11-4**] showed no acute findings concerning for
infection. His HD catheter was removed on [**2161-11-5**] after an
early HD session. Noncontrast MRI on [**2161-11-6**] showed possible
low grade discitis at L2-3. Multiple consecutive blood cultures
from [**11-2**] to [**11-12**] grew coagulase negative staph. His continued
bacteremia was concerning for a persistent source of infection.
TTE and TEE showed no evidence of endocarditis or paravalvular
abscess. ID was consulted and recommended an 8 week antibiotic
course. He was treated with Vancomycin following HD protocol
from [**2161-11-4**] through [**2161-11-11**] without clearing the bacteremia, at
which point he was switched to Daptomycin. Gallium and bone
scans showed no evidence of infection except for the region of
discitis at L2-3. His Daptomycin dose was increased from 500 mg
Q48H to 650 mg Q48H on [**2161-11-19**] per ID recs for 8 week course to
be completed with last dose on [**2162-1-7**] per ID. A new tunneled
HD catheter was placed on [**2161-11-20**]. He has subsequent clinical
deterioration with new low grade fevers to 100.0 on [**2161-11-23**] and
100.1 on [**2161-11-26**], blood culture positive for GPCs on [**2161-11-24**],
and worsening back pain with new radiation to the buttocks.
Lumbar spine plain film on [**2161-11-26**] showed progressive
destructive changes. Lumbar spine MRI with contrast on [**2161-11-27**]
showed increased collapse of the superior endplate of L3 and an
epidural soft tissue mass spanning L2 and L3, which most likely
reflects a phlegmon and causes moderate to severe canal
encroachment. He received dialysis immediately after the MRI
study and again the next day. His PICC line was pulled and the
tip sent for culture. His HD line was pulled on [**2161-11-28**] after
dialysis. Ortho Spine was consulted regarding the possible need
for surgical debridement of the phlegmon. Patient chose to
pursue surgery.
.
# Left Flank Erythema: He had significant leakage from a prior
paracentesis site noted on [**2161-11-17**] with some flank swelling
from subcutaneous fluid. It was sutured on [**2161-11-18**] and stopped
leaking. A few days later on [**2161-11-21**], his left flank was noted
to have increased swelling, erythema, pruritis, and tenderness.
He has continued to have symptoms in this area. The itching is
fairly well controlled with Sarna lotion. Abdominal wall US on
[**2161-11-28**] did not identify any drainable fluid collections.
.
# Back pain: He has acute on chronic back pain, which was his
initial reason for presenting to the ED. Prior MRI on [**2161-9-20**]
showed lower lumbar levoscoliosis with severe spinal canal
stenosis and severe degenerative disc, endplate, and facet joint
disease. Spine Xray on admission did not show any acute
fracture. CT abdomen and pelvis did not show any acute changes.
A Pain Service consult was called and did not believe that a
procedural intervention would be helpful, though TENS may be
useful as an outpatient. Noncontrast MRI on [**2161-11-6**] showed
possible low grade discitis at L2-3. Later gallium and bone
scans were consistent with an infection at this location. His
back pain on [**2161-11-21**] was significantly worse after walking to
the bathroom and he required additional pain meds for the first
time in many days. His Oxycontin dose was increased to 20 mg PO
BID on [**2161-11-24**]. His back pain has worsened since then with new
radiation to the buttocks.
.
# Altered mental status: He was in grade III encephalopathy on
transfer to the liver service, stuporous and unable to give more
than single word answers to questions. He has cleared
significantly since admission, and was fairly clear even during
his active bacteremia. His initial MS changes were most likely
due to medication effects (received Dilaudid 1 mg IV and
Lorazepam 3 mg IV total over 24 hours for back pain). Infection
was likely contributing, particularly given his associated
leukocytosis with left shift and persistent GPC bacteremia.
Baseline hepatic encephalopathy from from decompensated liver
disease was also a likely contributor. Diagnostic paracentesis
on admission showed no evidence of SBP, and subsequent
therapeutic paracentesis has also showed no evidence of SBP. He
has remained quite clear since his initial presentation. He was
continued on his home regimen of Lactulose and Rifaximin for
most of his stay.
.
# Hyponatremia: He was hyponatremic on admission with Na 125,
which largely resolved after HD. It is likely due to his
underlying cirrhosis, but SIADH from severe pain may also have
played a role. He has been mildly hyponatremic at various times
during his admission.
.
# ESLD: He was transplanted in [**2156**] for HCV cirrhosis, with
subsequent HCV recurrence and cirrhosis of the transplanted
liver. His course has been complicated by esophageal varices,
coagulopathy, encephalopathy, and refractory ascites. His MELD
was 33 on admission. It has improved to the high 20s during the
course of his stay. He was continued on Pantoprazole and
Propranolol per his home regimen.
.
# Liver Transplant History: He was previously on Tacrolimus 0.5
mg PO BID. This was decreased to 0.5 mg daily on [**2161-11-3**], and
further decreased to 0.5 mg every other day on [**2161-11-6**]. His
goal level was set at <5 and his Tactolimus doses were held
briefly. His Tacro level was 3.9 on [**2161-11-15**] and Tacrolimus was
restarted at 0.5 mg every other day. His levels have since
dropped below 2.
.
# Adrenal Insufficiency: He has a history of adrenal
insufficiency and is on chronic Hydrocortisone 10 mg PO QAM and
5 mg PO QHS. He did not require stress dose steroids during
this admission, though it was considered initially.
.
# Diabetes mellitus, type II: He was previously well controlled
on his home regimen of NPH 55 units [**Hospital1 **] and Humalog sliding
scale. His glucose levels have been labile recently, likely due
to the changes in his dialysis schedule, dietary changes, and
the stress of infection. No changes were made to his Insulin
regimen.
.
# ESRD: He is usually on a MWF hemodialysis schedule. He had an
early session on [**2161-11-5**] prior to HD catheter removal and an HD
holiday. His electrolytes were closely monitored and he had
back to back sessions on [**2161-11-10**] and [**2161-11-11**]. He was started on
Calcitriol on [**2161-11-5**] based on his elevated PTH level of 135
from [**2161-11-4**]. His phosphate levels have been mildly elevated,
and he was started on Sevelamer 800 mg PO TID. He was also
started on Nephrocaps. A new tunneled HD catheter was placed on
[**2161-11-20**]. He had dialysis three days in a row from [**2161-11-18**]
through [**2161-11-20**]. He then returned to a MWF schedule. With his
recurrent bacteremia on [**2161-11-24**], his new tunneled catheter was
pulled on [**2161-11-28**]. He has tolerated the disruptions in his
dialysis schedule well, without any significant problems. [**Name (NI) 3003**]
to spine surgery, patient had temporary line placed on [**2161-12-7**]
and received dialysis on [**2161-12-7**] and [**2161-12-8**].
.
# Depression: Paroxetine was continued per his home regimen.
.
# Nutrition: He was kept on a low sodium, diabetic diet. After
his HD catheter was pulled, he was temporarily placed on a more
restrictive diet. These restrictions were later lifted after it
was clear he could tolerate a more regular diet despite his
disrupted HD schedule. PO intake was encouraged and he was
provided Ensure supplements and Beneprotein with meals. He was
seen by Nutrition who recommended Dobbhoff placement and
initiation of tube feeds which he tolerated well.
.
SICU course:
Patient underwent spine surgery for debridement of L2-L3
osteomyelitis on [**2161-12-9**]. Admitted to surgical ICU afterwards,
intubated. Difficulty weaning off ventilator for one week due to
fluid overload. Received CVVH but eveually transitioned to HD.
Required pressors from [**2161-12-9**] - [**2161-12-15**]. Post-pyloric Dubhoff
tube placed. Treated empirically with Zosyn for VAP.
Post-pyloric Dubhoff placed and tubefeeds initiated. Wound
culture from spine grew Coagulase negative Staphylococcus
resistent to daptomycin, switched to linezolid at ID
recommendation. Placed on hydrocortisone given known adrenal
insufficiency. Transferred to the floor on [**2161-12-17**].
.
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] course # 2:
On the floor, patient was initially afebrile with no
leukocytosis. He was continued on linezolid and ciprofloxacin
was started empirically for SBP prophylaxis. Therapeutic and
diagnostic paracentesis were performed. Negative for SBP. CT
abdomen/pelvis with contrast was obtained to look for
retroperitoneal bleed, which was negative. There was a pararenal
collection of fluid which was drained and culture negative.
Multiple paracentesis were negative for infection, but given
continual leukocytosis, fever, and mental status changes,
patient was kept on linezolid, ceftriaxone, and po vancomycin
for broad spectrum coverage. His continued to develop
encephalopathy and lactulose doses had to be closely titrated.
Patient was continued on dialysis. He worked with physical
therapy to regain strength and made minimal progress.
.
Transplant Surgery/SICU course
Patient was transferred again to the ICU on [**1-10**] under the
transplant team for worsening lactic acidosis up to 12.6. He had
a CT scan demonstrating no evidence of bowel ischemia and stable
ascites. Linezolid was d/c'd for possible association with
lactic acidosis and was changed to tigecycline for SBP coverage.
He was started on CVVH on [**1-10**] after transfer and the lactate
improved to 5.6. Upon transfer to the ICU pt had mild bloody
emesis, so an NGT lavage was performed and was positive. An EGD
on [**1-11**] demonstrated hypertensive gastropathy with friable
mucosa, but no local site to intervene. His Hct was stable after
transfusing 3U pRBC before the EGD. He needed to be intubated
for the EGD and was kept intubated for aspiration risks given
the amounts of blood in the stomach. On [**1-12**] a postpyloric
dobhoff feeding tube was placed. The CVVH filter was clogged and
lactate went up to 11.2, but then decreased after resuming CVVH.
On [**1-13**] Vancomycin/Cefepime was started as WBC increased from
6.1 to 13.9. A decision was made to take him off the liver and
the kidney transplantion lists, as patient seemed too ill to be
a candidate. After long discussions with the family about his
poor prognosis, patient was made DNR/DNI on [**1-15**]. CVVH
continued. On [**1-16**] patient was made [**Name (NI) 3225**], pt was extubated and
died on [**1-17**] at 5:49 am. Autopsy was denied by the family.
Medications on Admission:
B COMPLEX-VITAMIN C-FOLIC ACID
CIPROFLOXACIN 750mg QSunday
HYDROCORTISONE 10mg in AM, 5mg in PM
HUMALOG sliding scale insulin
LACTULOSE 60cc by mouth three times daily
NPH INSULIN 55 units SQ in the am; 55 SQ units in the pm
PANTOPRAZOLE 40mg PO BID
PAROXETINE 40mg PO daily
PROPRANOLOL 10mg PO daily
RIFAXIMIN 600mg PO BID
BACTRIM 400 mg-80 mg Tablet MWF
TACROLIMUS 0.5mg PO BID
MAGNESIUM OXIDE 400mg PO daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary Arrest
Decompensated Liver Failure
Spontaneous Bacteral Peritonitis
Osteomyelitis/Discitis at L2-3
Status post partial vertebrectomy L2-3/debridement/Fusion L2-3
Coagulase Negative Staphylococcus Bacteremia
Hepatic Encephalopathy
Status post Liver Transplant
Hepatitis C Cirrhosis
End Stage Renal Disease
Diabetes Mellitus Type 2
Adrenal Insufficiency
Levoscoliosis
Discharge Condition:
Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
Completed by:[**2162-2-18**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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18137, 18146
|
6171, 10383
|
323, 816
|
18571, 18580
|
3501, 3506
|
18644, 18690
|
2621, 2684
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18108, 18114
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18167, 18550
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17672, 18085
|
18604, 18621
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2699, 3482
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273, 285
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844, 1670
|
3520, 6148
|
10399, 17646
|
1692, 2399
|
2415, 2605
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,190
| 129,608
|
8884
|
Discharge summary
|
report
|
Admission Date: [**2156-4-28**] Discharge Date: [**2156-5-4**]
Date of Birth: [**2101-7-13**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / [**Last Name (un) **]-Angiotensin Receptor Antagonist / Precedex
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Stridor
Major Surgical or Invasive Procedure:
Fiberoptic bronchoscope at bedside
History of Present Illness:
54 yo male with a h/o Hep C, previously on pegasys, telaprevir
and ribavirin (started on [**2156-2-3**], stopped during prior
admission), HTN on lisinopril (stopped on last admission) and
CKD who was recently admitted to the MICU for angiodemema
believed to be from lisinopril who is now being readmitted for
stridor.
He was admitted from [**Date range (1) 30914**] for angioedema. At that time he
woke up with tongue swelling. He came to the ED where he was
intubated via fiber optic nasal scope and admitted to the MICU.
He was treated with solumedrol, vbenadryl and famotidine. He was
transitioned to po prednisone, benadryl and famotidine on the
day of transfer to the medical floor. On the floor he remained
stable, so was discharged with a prednisone taper and continued
on fexofenadine while on the taper. Benadryl was stopped due to
complaints of somnolence.
After discharge he went to see his PCP with complaints of
difficulty swallowing saying solids and liquids were irritating
and causing him to regurgitate. His PCP noted stridor and
referred him back to the ED. He denies any dyspnea, nor any of
the tongue swelling symptoms he had with prior presentation.
Initial vitals in the ED were: 100 140/82 16 100%. He was given
decadron, famotidine and benadryl. ENT was consulted who
performed a laryngoscopy which showed narrow airway, poor cord
movements, swelling diffusely around cords posterior > anterior.
They recommnded MICU for airway monitoring, plan re-scope at
11:00 AM. [**Month (only) 116**] have continued sequela of angioedema versus trauma
from intubation. also rec Protonix 40 IV. Admission Vitals: 85
159/90 18 98%
Upon arrival to the MICU initial vitals were 91 154/89 18 98%.
He was breathing comfortable and speaking in full sentences.
Past Medical History:
Hep C- currently being treated with telaprevir, peggylated
interferon and ribavirin ([**2156-2-3**])
Hypertension
CKD Stage III
Social History:
He lives in JP and is married. He worked as a personal care
attendant but is currenlty unemployed. No ETOH, alcohol or
illicit drug use. Pt. has 1 child with this partner, 2 others
with other partners.
Family History:
No h/o liver dz or CA. [**Name (NI) 1094**] Fatherr had an MI at age 62. Mother
and 8 sibs in good health. No history of significant allergic
reactions.
Physical Exam:
Admission Physical Exam:
General: Well appearing, breathing comfortably on RA, voice
mildly raspy, speaking mostly in full sentences but occasionally
stopping mid sentence to breath
HEENT: No swelling of the lips or tongue.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Mild stridourous breath sounds bilaterally, otherwise
CTAB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE EXAM
VS - Temp 98.8 F, BP 147/77(147/77- 160/97), HR 69 , R 20 ,
O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear, tongue of normal
size
NECK - no stridor
LUNGS - CTA bilat, no r/rh/wh, good air movement
HEART - RRR, no MRG, nl S1-S2
ABDOMEN- no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact.
LABS: See below.
Pertinent Results:
ADMISSION LABS
[**2156-4-28**] 08:00PM PT-12.1 PTT-24.8* INR(PT)-1.1
[**2156-4-28**] 08:00PM PLT COUNT-245
[**2156-4-28**] 08:00PM PLT COUNT-245
[**2156-4-28**] 08:00PM WBC-7.0# RBC-2.78* HGB-9.1* HCT-28.1*
MCV-101* MCH-32.8* MCHC-32.4 RDW-15.2
[**2156-4-28**] 08:00PM WBC-7.0# RBC-2.78* HGB-9.1* HCT-28.1*
MCV-101* MCH-32.8* MCHC-32.4 RDW-15.2
[**2156-4-28**] 08:00PM GLUCOSE-143* UREA N-27* CREAT-1.8*
SODIUM-131* POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-25 ANION GAP-19
[**2156-4-28**] 08:20PM LACTATE-1.6
[**2156-4-28**] 08:20PM TYPE-[**Last Name (un) **]
.
DISCHARGE LABS
[**2156-5-4**] 06:10AM BLOOD WBC-4.7 RBC-2.79* Hgb-9.3* Hct-29.0*
MCV-104* MCH-33.4* MCHC-32.1 RDW-14.8 Plt Ct-246
[**2156-5-4**] 06:10AM BLOOD Glucose-216* UreaN-24* Creat-1.1 Na-134
K-4.6 Cl-95* HCO3-28 AnGap-16
[**2156-5-4**] 06:10AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9
.
CHEST (PORTABLE AP) Study Date of [**2156-4-28**] 7:45 PM
IMPRESSION: Suboptimal evaluation of the lower lungs which in
this patient
with recent right lower lobe pneumonia renders this exam
incomplete.
Recommend dedicated PA and lateral views to more clearly the
lung bases.
CHEST (PA & LAT) Study Date of [**2156-4-29**] 12:17 AM
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Normal lung volumes, no evidence of pleural effusions or
pneumothorax. Tortuosity of the thoracic aorta. Normal
appearance of the
lung parenchyma, no pulmonary edema. No focal parenchymal
opacities.
CT CHEST W/O CONTRAST Study Date of [**2156-4-29**] 3:42 PM
IMPRESSION:
1. Normal caliber intrathoracic trachea without evidence for
wall thickening
or stenosis.
2. Multiple small foci of ground-glass opacity in the right
lower lobe, most
likely reflecting subclinical aspiration. Early or resolving
infection are
also possible in the appropriate clinical setting.
3. Please see separately dictated CT neck for evaluation of the
vocal
cords/larynx.
CT NECK W/O CONTRAST (EG: PAROTIDS) Study Date of [**2156-4-29**] 3:42
PM
IMPRESSION: Study limited due to non-contrast technique.
Symmetric
thickening of the vocal cords with marked narrowing of the
larynx. Soft
tissue along the posterior commissure is likely related to
post-intubation
scarring. Please correlate with direct laryngoscopy.
Fullness in the piriform sinuses- correlate with direct ENT
examination.
Consider MRI for better assessment if not CI, if clinically
necessary.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
Pt is a 54 yo male with a h/o Hep C, previously on pegasys,
telaprevir and ribavirin (started on [**2156-2-3**], stopped during
prior admission), HTN on lisinopril (stopped on last admission)
and CKD who was recently admitted to the MICU for angiodemema
believed to be from lisinopril who is now being readmitted for
stridor and concern for airway edema.
#Laryngeal/airway edema:
His current edema may be from continued/recurrent angioedema
versus trauma from intubation. Reflux may also be playing some
component. He is no longer having his previous swelling of his
tongue or lips. His angioedema was initially believed to be from
lisinopril. He has not taken lisinopril since prior to his last
admission. If his angioedema has recurred this could be from the
natural course of edema or tapering steroids and stopping
Benadryl. Alternately there may be another inciting factor
separate from the lisinopril. Other potential causes of
angioedema include Hepatitis C treatment though he has also not
been taking these medications since his prior admission, food
ingestion, C1-inhibitor deficiency. Patient was given Decadron
10 mg q8h, famotidine 20 mg IV bid, Protonix 40mg IV BID and
benadryl 50 mg q8h. A repeat laryngoscopy showed improved edema,
however patient did have inability to relax vocal cords leading
to a suboptimal exam. Allergy was consulted and gave medication
recommendations. Initially a suture lateralization was
recommended by ENT, but he was serially reexamined by ENT and
his vocal cord immobility improved throughout his MICU stay and
he was transferred to the floor after his airway improved. He
was transitioned to oral decadron 6 mg PO TID, and PO benadryl.
He will continue on this dose for 7 more days and then be slowly
tapered over 2 weeks. This dose was to be continued for 7 days
and then tapered slowly. The patient will follow-up with ENT. He
will also have allergy testing as an outpatient.
STABLE ISSUES
# Benign Hypertension:
Patient was initially managed with IV labetalol but was
transitioned back to PO hypertension medications after taking
POs. His home HCTZ was held given concern that this medication
was contributing to the edema. He was discharged on a regimen of
amlodipine and labetalol.
#Hepatitis C:
Previously treated with triple therapy but stopped on previous
admission. We held triple therapy per liver recommendations
#Anemia:
Above his recent baseline. Seems to have been caused by HCV
therapy and is now improving.
#CKD:
At baseline. Medications were renally dosed and electrolytes
were trended.
.
TRANSITIONAL ISSUES
- Full code
- Patient with follow-up with ENT, allergy, and his PCP
Medications on Admission:
1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day
for 8 days: TAPER instructions: 4 tabs on [**4-27**]; 3 tabs on [**4-28**];
2 tabs on [**5-7**]; 1 tab on [**4-14**]; then stop.
3. fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day
for 8 days: take while on steroids; can stop after steroid taper
is complete.
4. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID
.
Medications prior to last admission:
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day - No Substitution
LISINOPRIL - 30 mg Tablet - 1 Tablet(s) by mouth once a day
Ribavirin 600 mg [**Hospital1 **]
Telaprevir 750 mg tid
Pegasys 180 mcg weekly injections
.
Discharge Medications:
1. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
every eight (8) hours: do not drive while taking this medication
as it can make you tired .
Disp:*63 Capsule(s)* Refills:*0*
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 21 days: take
while on steroids .
Disp:*21 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. dexamethasone 2 mg Tablet Sig: see below Tablet PO three
times a day: 3 tabs three times a day x 7 days then 2 tabs
three times a day x 3 days then two tabs twice a day x 3 days
then two tabs once daily x 3 days then one tab daily x 3 days .
Disp:*102 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Laryngeal edema (swelling of the airway)
Secondary Diagnosis
Hypertension (High blood pressure)
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 634**],
You were admitted to [**Hospital1 69**] for
concerns of stridor (difficulty breathing). We gave you
anti-inflammatory medications. Our ENT doctors saw [**Name5 (PTitle) **]. They
looked at you airway with a scope which showed swelling of your
airway. You were given IV steroids with improvement in the
swelling. You were transitioned to oral steroids which you need
to continue for 3 more weeks. Swelling was likely caused by both
inflammation related to the lisinopril you were previously
taking in addition to trauma from your recent intubation. It
will be important that you follow-up with allergy to see if the
swelling was caused by a medication allergy.
We made the following changes to your medications
1. START
-Decadron 6 mg (3 tabs) three times a day for 7 days until
[**2156-5-11**]
-then 4 mg (2 tabs) three times a day for 3 days until [**2156-5-14**]
-then 4 mg (two tabs) twice a day for 3 days until [**2156-5-17**]
-then 4 mg (two tabs) once daily for 3 days until [**2156-5-20**]
-then 2 mg daily for 3 days until [**2156-5-23**]
2. STOP HCTZ as this medication might be causing the swelling
3. START benadryl 25 mg three times a day while on steroids
4. START omeprazole 40 mg daily while on steroids
Please continue to take all other medications as instructed.
Please feel free to call with any questions or concerns.
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: THURSDAY [**2156-5-6**] at 9:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: LIVER CENTER
When: MONDAY [**2156-5-10**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 30913**], PA [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV OF ALLERGY AND INFLAM
When: TUESDAY [**2156-5-11**] at 11:00 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: OTOLARYNGOLOGY-AUDIOLOGY
When: THURSDAY [**2156-5-13**] at 10:00 AM
With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"31.42",
"33.23"
] |
icd9pcs
|
[
[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,577
| 165,419
|
52796
|
Discharge summary
|
report
|
Admission Date: [**2129-4-3**] Discharge Date: [**2129-4-12**]
Date of Birth: [**2052-12-16**] Sex: F
Service: NEUROLOGY
Allergies:
Diflucan
Attending:[**First Name3 (LF) 57490**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Lumbar Puncture x2
History of Present Illness:
76 year old AA woman who was transferred from [**Hospital3 417**]
hospital for management of seizures and possible intracranial
mass vs. bleed. She has a remote hx of colon CA ([**2111**]),
thalassemia, was recenlty admitted to OMED (d/c'd [**3-30**]) for
hypercalcemia, acute renal failure in context of new diagnosis
of multiple myeloma.
Her history actually begins approximately six weeks ago. At that
time, she began having pain in her chest and her back which
became worse over time. She became immobilized by pain. Her
abdominal area and torso seems to have swelled and she has had
weight loss of about ten pounds over the last six to seven weeks
with poor appetite. O/P workup revealed multiple lytic bone
lesions and an abnormal monoclonal spike that was c/w IgD
lambda. She was refered to OMED for o/p bone marrow bx. During
this visit she was found to have acute renal failure (Cre 6.8)
and hypercalcemia (12.5) and was directly admitted to the OMED
service. During her admission, she was found to have a
monoclonal gammopathy (IgD). Her ARF was thought to be secondary
to light chain nephropathy and hypercalcemia. She was treated
with decadron and alkaline fluids. She rece'd total of 5
plasmaphareses and continued on steriods. Skeletal survey
revealed multiple destructive lesions in calvarium and spine
with several vertebral body fractures. She was discharged [**3-30**] on
decadron with bactrim for PCP and [**Name9 (PRE) 38229**] prophylaxis.
According to her husband, she has been sleepy, but otherwise OK
since her discharge on Wednesday. She remains in a significant
amount of pain and has therefore been taking narcotics on a
regular basis for relief thus contributing to her fatigue. He
cannot recall her complaining of anything in particular today.
When he went to give her medications at 6:00 last night, he
found her sitting on the floor next to the bed (as if she had
fallen out of bed). She was not responsive to voice or touch. He
called EMS who apon arriving found her to be responsive to
painful stimuli. They transported her to [**Hospital3 **] hospital
where she was noted to be "confused". As per her husband, she
became
more awake while in the ER there. She was given Narcan. Later
witnessed to have a GTC seizure x 1 min. She was given dilaudid,
ativan (1mg) and dilantin (1g).
She had a CT scan which showed right para falcine,
parieto-occipital hyperdensity c/w acute blood with surrounding
edema as well as a left parasagital meningioma.
On arrival to the [**Hospital1 18**] ED, vital signs temp 99.1, HR 63, BP
150/71, RR 18, 97% on room air. Rpt head CT showed stable right
parietal bleed. Patient was LP'd, given Ceftriaxone 2gram IV,
dilantin 1gram IV, Decadron 4mg IV, and FFP for mild
coagulopathy (INR 1.4). She had an MRI and abdominal/pelvis CT
for abdominal distension.
Patient denies headache, photophobia, nausea, chest pain,
shortness of breath or abdominal pain. She said that she had
some difficulty with her medications. No BM recently, but can't
remember when.
Past Medical History:
-recently diagnosed IgD myeloma and hypercalcemia
-colon CA Duke's C2 s/p resection in [**2111**]; normal C-scope in
[**2125**] except for diverticulosis
-thalassemia trait, microcytic anemia
-HTN
-gout
Social History:
She is married for the last 14 years. She has two living
daughters, though she had one daughter who died because of a CNS
aneurysm. Her daughter had polycystic kidney disease. Mrs.
[**Known lastname 9480**] does not smoke tobacco or alcohol and has never done so
significantly in her life. She is a retired [**Location (un) 86**] public school
administrator. She retired in [**2122**]
Family History:
Daughter had CNS aneurysm
Diabetes
Lung CA
Physical Exam:
T 98.8 BP 80's-130's/40's-60's HR60's RR18 O2 Sat 94% (on
3L NC)
Gen: On ED stretcher, minimally responsive
Neck: +nuchal rigidity, no thyromegaly
CV: RRR, Nl S1 and S2, 2/6 SEM
Lung: Clear to auscultation bilaterally
aBd: +BS soft, distended, no fluid wave appreciated,
+hepatomegaly
ext: bilateral pedal edema
Neurologic examination:
Mental status: Minimally responsive, opens eyes to verbal or
tactile stimulation, but immediately closes them. Doesn't
follow
commands.
Cranial Nerves:
Pupils 2mm bilaterally, sluggish. No blink to threat. Fundi
could not be visualized secondary to miosis. +corneal
bilaterally. +dolls eyes. Cannot test gag or pallate elevation
as
patient will not allow her mouth to be opened
Motor:
Normal bulk bilaterally. Tone Increased bilaterally UE and LE.
No
observed myoclonus or tremor. Withdraws to pain in all 4
extremities, slightly more briskly on the right.
Sensation: Withdraws and localizes pain in UE
Reflexes:
B T Br Pa Ach
Right 2 2 2 3 2
Left 2 2 2 3 2
brisk throughout
Toes were upgoing on left, mute on right
Coordination: unable to assess
PHYSICAL EXAM TODAY
Pertinent Results:
[**2129-4-3**] 08:25AM CK(CPK)-250*
[**2129-4-3**] 08:25AM cTropnT-0.13*
[**2129-4-3**] 08:25AM CK-MB-6
[**2129-4-3**] 08:25AM PHENYTOIN-13.9
[**2129-4-3**] 08:25AM PT-14.9* PTT-28.0 INR(PT)-1.4
[**2129-4-3**] 06:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-82*
GLUCOSE-60
[**2129-4-3**] 06:30AM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-[**2114**]*
POLYS-94 BANDS-1 LYMPHS-4 MONOS-1
[**2129-4-3**] 06:30AM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-2370*
POLYS-93 LYMPHS-5 MONOS-2
[**2129-4-3**] 04:00AM PT-15.0* PTT-28.6 INR(PT)-1.4
[**2129-4-3**] 12:35AM GLUCOSE-103 UREA N-56* CREAT-5.0* SODIUM-137
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
[**2129-4-3**] 12:35AM ALT(SGPT)-7 AST(SGOT)-30 CK(CPK)-245* ALK
PHOS-82 AMYLASE-122* TOT BILI-1.0
[**2129-4-3**] 12:35AM LIPASE-90*
[**2129-4-3**] 12:35AM cTropnT-0.23*
[**2129-4-3**] 12:35AM CK-MB-8
[**2129-4-3**] 12:35AM TOT PROT-5.4* ALBUMIN-3.9 GLOBULIN-1.5*
CALCIUM-8.2* MAGNESIUM-2.1
[**2129-4-3**] 12:35AM ACETONE-POSITIVE
[**2129-4-3**] 12:35AM WBC-12.7* RBC-3.19* HGB-8.7* HCT-26.9* MCV-85
MCH-27.4 MCHC-32.5 RDW-15.7*
[**2129-4-3**] 12:35AM NEUTS-95.1* BANDS-0 LYMPHS-2.6* MONOS-1.9*
EOS-0.4 BASOS-0
[**2129-4-3**] 12:35AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2129-4-3**] 12:35AM PLT SMR-NORMAL PLT COUNT-184
[**2129-4-3**] 12:35AM PT-15.1* PTT-28.6 INR(PT)-1.4
[**2129-4-3**] 12:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2129-4-3**] 12:30AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2129-4-3**] 12:30AM URINE RBC-[**7-8**]* WBC-[**4-2**] BACTERIA-FEW
YEAST-NONE EPI-1
Head CT showed:
1) Right parafalcine parietal hyperdense areas representing
hemorrhage,
perhaps into a mass, or related to a vascular process. Recommend
MRI with
gadolinium for further evaluation.
2) Calcified meningioma in the left parafalcine region.
3) Lytic lesions in the skull are consistent with multiple
myeloma or
metastases.
MRI w/ gad:
Extensive areas of T2 signal hyperintensity are evident in the
cortex and subcortical white matter. There is no diffusion
signal abnormality associated with this finding to suggest
infarction. The most likely explanation would be edema related
to hypertension, seizure activity, or perhaps drug therapy, the
so-called reversible posterior leukoencephalopathy syndrome.
Abd/pelvis CT without contrast:
1. Stable appearance of the abdomen.
2. No evidence of acute intra-abdominal pathology.
3. Very limited study due to lack of oral and IV contrast.
4. Bone findings consistent with multiple myeloma.
5. Stable appearance of liver and renal cysts.
6. Large cyst in the upper pole of the left kidney has a more
solid
appearance, however, ultrasound from [**2129-3-24**] demonstrated
this lesion to be cystic.
EKG: NSR @65bpm, normal axis, Qs in V4-V6, I and aVL
Thyroid Scan
Findings consistent with multinodular goiter.
Renal US
1) Complex cyst in the upper pole of the left kidney
demonstrating a thickened wall with a 10mm mural nodule. MRI is
recommended for more definititive characterization.
2) Stable appearance of multiple other simple renal and hepatic
cysts demonstrating no complex features.
3) Increased echogenicity of the renal cortices, consistent with
renal parenchymal disease.
CSF:
Cytology: Negative for Malignant cells
Oligo bands: none present, band present in serum is NOT present
in CSF
Brief Hospital Course:
76 yo with recent dx of myeloma and ARF s/p plasmapheresis who
presents with new onset seizures and was found to have a right
parietal hemorrhage of unclear etiology.
NEURO:
The patient was admitted to the neuro ICU for evaluation of ICH
and seizure management. Her initial CT scan was stable and
showed no increase in the size of the hemorrhage. The etiology
of the hemorrhage was unclear. (underlying mass (plasmacytoma?)
vs infection vs venous infarct vs hypertensive hemorrhage). MRI
with gado not helpful in further narrowing differential, but did
show evidence of posterior leukoencephalopathy which was thought
to be due renal failure or hypertension (though she was not
hypertensive on admission). MRV was negative for sinus
thrombosis. She had an LP which showed 2000RBCs, 5WBCs. She
received empiric antibiotic coverage with
vanco/ceftriaxone/acyclovir until CSF culture negatives. The
Acyclovir was d/c'd sec to low suspicion for herpes
encephalitis. Decadron was initially started at 4mg q6 for
cerebral edema, but was later increased to 10mg q6 hours for
myeloma treatment. For seizure control, she was initially
treated with dilantin, but was later transitioned to Keppra.
She was evaluated by neurosurgery who recommended repeating the
MRI in [**5-4**] weeks.
Her mental status dramatically improved over first 24 hours of
admission and she has had no further seizures. She was
transferred to the neurology floor on [**4-5**] for further w/u of
intracranial bleed. Given her history and the location of the
bleed, it was felt that her bleed was most likely due to an
underlying mass. She had a repeat LP on [**4-6**] for cytology and
oligoclonal bands. Tap again showed 2000RBCs (not traumatic).
CSF cytology was negative for malignant cells nor was there
evidence of paraprotein. There was a question of dural
enhancement on the first MRI (though this was difficult to
determine do to motion artifact). She had a repeat MRI with
contrast which showed "surrounding edema which is slightly
increased since the previous study. However, previously seen
diffuse increased signal in the occipital lobes bilaterally and
in the posterior temporal lobes have resolved confirming the
findings to be secondary to posterior reversible encephalopathy.
In the area of
hemorrhage in the right occipital region, subtle enhancement is
identified
following the administration of gadolinium. Subtle
leptomeningeal enhancement
is also seen in this region. "
She will be discharged on a Decadron taper. She will follow up
in Brain [**Hospital 341**] clinic where decision will be made whether to
pursue biopsy. A repeat MRI will be done in [**5-4**] weeks to assess
for underlying mass. She will continue Keppra for seizure
prevention.
ONC:
Oncology (Dr. [**First Name (STitle) **] followed her throughout her admission.
She started her 2nd steroid pulse for multiple myeloma and
completed 4 days of high dose Decadron (10mg q 6h). Because it
is not common for myeloma to cause parenchymal CNS disease,
there was concern that her hemorrhage could be due to a second
primary tumor with metastasis. Her last CT scans showed small
thyroid nodules and lung nodules as well as multiple renal
cysts. She had a thyroid and renal US to further evaluate.
Thyroid US showed evidence of multinodular goiter and renal US
showed multiple simple cysts and one complex cyst. A renal MRI
was done to further characterize the complex cyst and showed:
"cyst within the upper pole of the left kidney demonstrates a 5
mm enhancing nodule in its anteromedial aspect, which is
concerning for an intracystic neoplasm".
A mammogram was also ordered and the patient will be getting it
as an outpatient. CA 27.29 level was sent and is pending.
Urine cytology was sent and is pending at the time of discharge.
CSF cytology was negative.
RENAL:
ARF secondary to cast nephropathy due to light chain production.
Creatinine is slowly trending down. At this time is 4.0 BUN is
in the lower 60's. Renal recommended starting Bicitra for
metabolic acidosis. Continue low K diet, renal dose
medications.
CV:
Troponin leak present on admission was felt to be due to renal
failure. Repeated troponin trended down. There were no acute
ischemic EKG changes. Her hypertension was initially well
controlled on metoprolol, but her BPs slowly began to increase.
Metoprolol increased to 100mg po BID and Amlodipine 10mg po QD
added to control hypertension. Will continue to monitor BP with
goal SBP<140 and increase meds as needed to maintain this
pressure.
HEME:
-She received 2 Units of PRBCs on [**4-8**] for Hct 25. Also rec'd
Procrit 40 on [**4-9**].
-mild coagulopathy: likely poor PO and early vitamin K
deficiency. Repleated with subcutaneous vitamin K. INR now 1,2.
Dispo:
Patient is going to be discharged to [**Hospital **] [**Hospital **] rehab.
Medications on Admission:
1. Triamcinolone 0.025 % Cream [**Hospital1 **] (2 times a day) PRN for
breast rash.
2. Oxycodone HCl 5-10 mg PO Q4-6H PRN
3. Pantoprazole 40 mg PO Q24H
4. Metoprolol Tartrate 25 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Bisacodyl 10 mg PO DAILY as needed.
7. Allopurinol 100 mg PO EVERY OTHER DAY
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet PO QMOWEFR
9. Isoniazid 300 mg PO DAILY
10. Pyridoxine HCl 50 mg PO DAILY
11. Decadron 4 mg PO once a day for 10 doses.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
Disp:*24 Tablet(s)* Refills:*0*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*1*
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*1*
5. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
6. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Ten
(10) ML PO twice a day.
Disp:*900 ML(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
10. Decadron 0.5 mg Tablet Sig: Eight (8) Tablet PO every eight
(8) hours: Taper dose as follows:
8 tablets q8h for 2 days, then re-start decadron pulse (see Rx).
Restart 4mg q 8hours on [**4-18**] (after decadron pulse).
Disp:*200 Tablet(s)* Refills:*2*
11. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
12. Decadron 4 mg Tablet Sig: 2.5 Tablets PO every six (6) hours
for 16 doses: Please begin on Thursday, [**4-14**].
Disp:*40 Tablet(s)* Refills:*0*
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Intracranial Hemorraghe.
2. Seizures.
3. Multiple Myeloma IgD
4. Acute Renal Failure
Discharge Condition:
Stable.
Discharge Instructions:
Please continue to take your medications as directed. Your dose
of decadron will slowly be tapered. You should continue to take
Keppra to prevent seizures. If you feel more lethargic, have
new weakness, numbness, change in vision, chest pain, shortness
of breath, or fever please call Dr. [**Last Name (STitle) 3029**] or return to the
Emergency Room.
Followup Instructions:
1. Oncology
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Where: [**Hospital Ward Name 23**] Bldg. Floor #9, [**2129-4-13**] at
noon.
2. Brain [**Hospital 341**] Clinic
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2129-4-18**] 11:30
3. Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**]
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2129-4-15**] 11:50
Completed by:[**0-0-0**]
|
[
"285.9",
"780.39",
"274.9",
"241.1",
"401.9",
"282.49",
"V10.05",
"203.00",
"584.9",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
15783, 15855
|
8700, 13539
|
279, 300
|
15988, 15997
|
5199, 8677
|
16399, 17115
|
3999, 4044
|
14063, 15760
|
15876, 15967
|
13565, 14040
|
16021, 16376
|
4059, 4371
|
232, 241
|
328, 3355
|
4548, 5180
|
4410, 4532
|
4395, 4395
|
3377, 3581
|
3597, 3983
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,028
| 186,775
|
39037
|
Discharge summary
|
report
|
Admission Date: [**2119-3-15**] Discharge Date: [**2119-3-23**]
Date of Birth: [**2041-1-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
reflux, increasing abdominal pain
Major Surgical or Invasive Procedure:
1. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy
2. Buttressing of esophagogastric anastomosis with intercostal
muscle
3. Laparoscopic jejunostomy
4. Esophagoscopy
5. Therapeutic bronchoscopy
History of Present Illness:
78yo male with long standing history of intermittent reflux
treated with over the counter antacids, was seen [**11/2118**] by his
PCP for increasing abdominal pain. An upper endoscopy which
revealed a mass 20 cm from the incisors in the mid-esophagus and
iopsy revealed poorly differentiated adenocarcinoma. Since
[**Month (only) 1096**], he has lost [**9-22**] pounds, has dysphagia for solids
more than liquids and feels food getting stuck mid sternum at
times. He has not had any recent chest infections, no change in
voice, no fever/chills.
Past Medical History:
COPD, HTN, diverticulosis, hiatal hernia (untreated), asthma
HLD, glaucoma, kidney stones
Past Surgical History
s/p CABG [**2103**]
s/p Left inguinal hernia
s/p phlebectomy for varicose veins
Social History:
- married, lives with family
- former tobacco user
- EtOH: 1-2 drinks/day
- denies exposure risk
Family History:
father - MI
Physical Exam:
VS: 98.8 HR: 72 AFib BP: 124/72 Sats: 95% RA WT
General 78 year-old male who appears well
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: irregular, normal S1,S2. no murmur/gallop or rub
Resp: decreased breath sounds R>L otherwise clear
GI: benign. J-tube site clean no erythema or discharge
Extr:warm no edema
Incision: Right thoracotomy site clean, intact, margins well
approxmicated no erythema
Neuro: awake, alert, oriented. moves all extremities
Pertinent Results:
[**2119-3-21**] WBC-9.7 RBC-3.39* Hgb-11.3* Hct-32.8 Plt Ct-254
[**2119-3-20**] WBC-10.3 RBC-3.48* Hgb-12.2* Hct-35.1 Plt Ct-252
[**2119-3-14**] WBC-5.7 RBC-4.37* Hgb-14.4 Hct-43.3 Plt Ct-191
[**2119-3-23**] PT-15.0* PTT-37.2* INR(PT)-1.3*
[**2119-3-22**] PT-13.4 INR(PT)-1.1
[**2119-3-22**] Glucose-111* UreaN-19 Creat-0.7 Na-139 K-4.2 Cl-102
HCO3-29
[**2119-3-21**] Glucose-111* UreaN-19 Creat-0.6 Na-138 K-4.1 Cl-104
HCO3-26
[**2119-3-14**] UreaN-15 Creat-0.9 Na-140 K-4.0 Cl-102 HCO3-31 AnGap-11
[**2119-3-22**] Calcium-7.9* Phos-3.5 Mg-2.1
CXR:
[**2119-3-22**] Small bilateral pleural effusions are unchanged
following removal of the right pleural tube. Tiny right apical
pleural air collection is stable. Small left pleural effusion
unchanged. The postoperative cardiomediastinal silhouette,
including the distended neoesophagus and preexisting large
hernia, is stable.
Esophagus
[**2119-3-21**]: FINDINGS: Barium flowed freely throughout the
esophagus without evidence of stricture, lesion or leak,
especially around the anastomotic site. Barium was able to pass
freely from the esophagus into the stomach, from the stomach
into the small intestine, the path of the barium was noted to be
narrowed consistent with postoperative inflammation/edema.
IMPRESSION: No evidence of leak; narrowed channel from stomach
into small
bowel consistent with postoperative inflammation/edema.
Brief Hospital Course:
Mr [**Known firstname 7208**] [**Last Name (Titles) 1834**] an [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy, buttressing of
esophagogastric anastomosis with intercostal muscle,
laparoscopic jejunostomy, esophagoscopy, and therapeutic
bronchoscopy on [**2119-3-15**] for esophageal adenocarcinoma. He was
extubated in the operating room, transferred to the PACU for
monitoring and subsequently transferred to the surgical ICU for
the immediate post-operative period then to the inpatient floor
on POD2.
Respiratory: aggressive incentive spirometry was encouraged and
during his admission post-operatively, he was weaned off the
oxygen to room air with saturations of xx
Drains: The [**Doctor Last Name 406**] drain was placed to water-seal in the SICU.
It was removed on POD6. Chest X-ray showed (see report) A JP
drain was removed on POD6 following esophagus study which was
negative for leak
Cardiac: POD2 he has rate control atrial fibrillation HR 60-80's
He was continued on his home dose of beta-blocker. He remained
hemodynamically stable.
GI: Patient remained NPO post-operatively and started on J-tube
feeds on POD1 that were well tolerated. Replete full strength
Goal 80 mL/hr x 18 hrs. On [**2119-3-21**] he was started on clear
liquid diet advanced to soft solid which he tolerated.
Incision: Right thoracotomy site clean, no erythema
Pain: Epidural was placed for analgesia and discontinued on POD6
with transition to PO pain medication with good analgesic
effect.
Heme: After speaking with his cardiologist Dr. [**First Name (STitle) **] he was
started on Lovenox-Warfarin bridge for atrial fibrillation. INR
Goal 2.0-2.5. He will follow-up with him for further Warfarin
dosing. Given 5 mg coumadin [**2119-3-21**], [**2119-3-22**], [**2119-3-23**]. INR
on discharge 1.3.
Disposition: Patient progressively increased his activity level
during this admission and ambulated in the halls on the
inpatient floor while continued to make steady progress and was
discharged to Holiday Inn with his family. He will follow-up
with Dr. [**First Name (STitle) **] in 1 week then return home.
Medications on Admission:
Lipitor 20', Symbicort 80-4.5', Kapidex 60', Persantine 75',
Lopressor 50', Carafate 1g/10ml, Vit B12, Ascorbic Acid
Discharge Medications:
1. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve [**First Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*6 Tablet, Rapid Dissolve(s)* Refills:*0*
2. Travoprost 0.004 % Drops [**First Name (STitle) **]: One (1) Ophthalmic qdaily ().
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**First Name (STitle) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*450 ML(s)* Refills:*0*
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
5. Atorvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
6. Replete
Goal 80 mL/hr x 18 hrs. Cycle 1500-0900
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Enoxaparin 100 mg/mL Syringe [**Last Name (STitle) **]: Ninety (90) mg Subcutaneous
[**Hospital1 **] (2 times a day): stop when INR 2.0.
Disp:*7 mg* Refills:*2*
9. Warfarin 1 mg Tablet [**Hospital1 **]: as directed Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Miralax 17 gram Powder in Packet [**Hospital1 **]: One (1) packet PO once
a day.
Disp:*30 packets* Refills:*2*
11. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day:
while taking narcotics.
12. Warfarin 2.5 mg Tablet [**Hospital1 **]: as directed Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
esophageal adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 3020**] or [**Telephone/Fax (1) 2348**] if you
experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops drainage
-Chest tube site cover with a bandaid until healed or clean dry
dressing if site oozing. Change as needed
-You may shower. No tub bathing or swimming for 4 weeks
-No driving while taking narcotics.
-Take stool softners with narcotics
-Walk 4-5 times a day for 10-15 minutes to a goal of 30 minutes
daily
-Lovenox take twice daily until INR 2.0 then stop
-Warfarin take as directed. INR Goal 2.0-2.5 for atrial
fibrillation
Warfarin take 5mg (2 tablets) tonight.
INR Friday and call for further dosing.
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**2118-3-30**]:00 [**0-0-**] on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Chest X-Ray 30 minutes before your appointment on the [**Location (un) 861**]
Radiology Deparatment
Follow-up with your cardiologist Dr. [**First Name (STitle) **] for further Warfarin
dosing once you are home
Completed by:[**2119-3-28**]
|
[
"V13.01",
"997.1",
"530.81",
"365.9",
"272.4",
"553.3",
"V45.81",
"562.10",
"530.85",
"493.90",
"787.29",
"401.9",
"E878.8",
"427.31",
"150.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.41",
"03.90",
"33.23",
"42.58",
"53.83",
"46.39",
"42.23",
"54.21",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7273, 7331
|
3421, 5565
|
320, 544
|
7401, 7401
|
2006, 3398
|
8320, 8749
|
1466, 1479
|
5733, 7250
|
7352, 7380
|
5591, 5710
|
7552, 8297
|
1494, 1987
|
247, 282
|
572, 1120
|
7416, 7528
|
1142, 1336
|
1352, 1450
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,564
| 129,742
|
6866
|
Discharge summary
|
report
|
Admission Date: [**2130-6-13**] Discharge Date: [**2130-6-15**]
Date of Birth: [**2074-6-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 25936**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
s/p [**Company 1543**] Revo RVDR01 dual chamber pacer placement
History of Present Illness:
56F with history of Hodgkins lymphoma s/p XRT in [**2096**], BrCA s/p
masectomy and Chemo in [**4-/2140**], and AVR with BP valve in [**2123-8-3**]
and ongoing work up for DOE of unclear etiology presenting to
the [**Name (NI) **] with cc of syncopal event last night. She was sitting on
the couch when she developed tunnel vision, became lightheaded
and lost consciousness for about 10 seconds the son describes
contraction of her right and right leg. She awoke immediately
after and was herself without a postictal period. No fall or
trauma. Denies fever headache nausea vomiting chest pain
shortness of breath or pain in her neck arm back or jaw.
In the ED she had a 36 second episode of complete heart block
with no escape beats that was symptomatic. She convierted
spontaneously and a temp wire was placed in the ED. She is
admitted to the CCU for monitoring and will need pacer placement
tomorrow AM. Threshold was sset at 0.8 and the length of the
catheter is 37 cm.
Of note she was recently admitted for elective diagnostic cath
for worsenign DOE of unclear etiology. The cath showed mild
mitral stenosis and LV RV equalization of pressures that was not
felt to be indicative of a restrictive process
ROS per HPI
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: no prior
3. OTHER PAST MEDICAL HISTORY:
Hodgkin's Lymphoma s/p XRT [**5-/2097**]
Aortic valve stenosis s/p minimally invasive AVR [**7-30**] # 23
carp-[**Doctor First Name **] at [**Hospital1 112**]
Breast CA s/p right mastectomy/reconstruction [**1-26**] and
chemotherapy.
Osteoarthritis s/p right knee replacement [**2127**]
Rectal Adenoma CA s/p resection [**2115**]
Morbid Obesity
COPD with severe obstruction and mild restrictive disease (?
Related to XRT therapy)
Mediastinal fibrosis
Pancreatic cyst neoplasm (negative biopsy)
Hypothyroidism
GERD
Type 2 diabetes
Social History:
Nurse, lives with family. Nonsmoker, no EtOH or illicits
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
VA 97.8, 130s/60s, RR 12, Sat > 94% RA
Gen: A/O, NAD
HEENT: bruising right next [**1-26**] RIJ line, unable to assess JVD
CV: RRR, no M/R/G
Chest: CTAB.
ABD: obese, soft, NT
Extr: no edema, feet warm
On Discharge:
VS 97.7, HR 80-94 SR/ST, RR 18, BP 91-104/45-64 O2 sat 96% RA
exam unchanged except:
Right pacer site with mild swelling, no redness or ecchymosis
Pertinent Results:
On admission:
[**2130-6-13**] 12:45PM BLOOD WBC-6.9 RBC-4.50 Hgb-13.0 Hct-43.4 MCV-96
MCH-29.0 MCHC-30.1* RDW-14.6 Plt Ct-307
[**2130-6-13**] 12:45PM BLOOD Neuts-66.9 Lymphs-22.0 Monos-8.1 Eos-1.7
Baso-1.3
[**2130-6-13**] 12:45PM BLOOD Plt Ct-307
[**2130-6-13**] 12:45PM BLOOD Glucose-166* UreaN-26* Creat-1.4* Na-134
K-4.9 Cl-101 HCO3-21* AnGap-17
[**2130-6-13**] 12:45PM BLOOD Calcium-9.6 Phos-3.2 Mg-1.5*
.
On discharge:
[**2130-6-15**] 07:03AM BLOOD WBC-7.7 RBC-4.33 Hgb-13.0 Hct-41.7 MCV-96
MCH-29.9 MCHC-31.1 RDW-14.7 Plt Ct-243
[**2130-6-15**] 07:03AM BLOOD Glucose-131* UreaN-28* Creat-1.5* Na-134
K-4.7 Cl-100 HCO3-21* AnGap-18
[**2130-6-15**] 07:03AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.6
IMAGING:
CXR [**2130-6-15**] post-PPM placement:
Right transvenous pacemaker leads terminate in standard position
in the right atrium and right ventricle. Cardiac size is top
normal. The lungs are clear. There is no pneumothorax or
pleural effusion. There is kyphosis and decrease in height of a
mid thoracic vertebral body. Sternal wires are aligned. The
patient is status post valve replacement.
Brief Hospital Course:
Ms. [**Known lastname **] is a 56 year old female with history of aortic valve
repair (AVR), Chest radition and Chemo who presented for
syncopal work up and was found to have 36 second asystole pause
with complete heart block. She underwent placement of permanent
pacemaker.
.
# Complete heart block: Patient with confirmed heart block on
telemetry. Appeared from the tele strip that there was a PVC
infranodally which triggered the episode. Likely etiology was
felt to be scaring from chemotherapy or XRT. Her beta blockers
were held while awaiting pacemaker placement. Had successful
placement of pacer on [**2130-6-14**] and post-op course was
uncomplicated. Should follow up in device clinic and with
cardiology. After pacer placed, did not have further
arrhythmias and heart rate remained controlled in the 70s-90s so
her metoprolol was not restarted.
.
# Acute kidney injury: Baseline Cr 1.1 and was 1.4-1.5 on
admission. Likely secondary to poor forward flow in setting of
pulselessness. Will have repeat labs on follow-up and expect
resolution. Held her lisinopril until follow-up creatinine is
checked (was not hypertensive during admission).
.
# Hypertension (HTN): Was not hypertensive during admission even
when metoprolol and lisinopril were held for reasons above.
Thus, discontinued both metoprolol and lisinopril.
.
CHRONIC ISSUES BY PROBLEM:
# Hyperlipidemia (HLD)- Continued simvastatin
# Hypothyroidism: Continued synthroid
# Chronic obstructive pulmonary disease (COPD): continued
inhalers
# Diabetes mellitus (DM): Sliding scale insulin in house,
restarted metformin at discharge.
TRANSITIONAL ISSUES:
- Follow up device clinic
- Please trend creatinine on follow-up and consider further work
up for kdney injry if not returned to baseline (Cr 1.1 at
baseline)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation daily
4. Tiotropium Bromide 1 CAP IH DAILY
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
6. Levothyroxine Sodium 250 mcg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 10 mg PO DAILY
10. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Outpatient Lab Work
Please check Chem-7 on Tuesday [**6-20**] with results to Dr [**Last Name (STitle) 23239**] at
Phone: [**Telephone/Fax (1) 24047**]
Fax: [**Telephone/Fax (1) 6808**]
ICD-9 584.9
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
3. Aspirin 81 mg PO DAILY
4. Levothyroxine Sodium 250 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 10 mg PO DAILY
7. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation daily
8. Tiotropium Bromide 1 CAP IH DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) [**12-26**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-26**] Tablet(s) by mouth
every 6 hours Disp #*10 Tablet Refills:*0
10. Calcium Carbonate 500 mg PO DAILY
11. Cephalexin 500 mg PO Q8H Duration: 2 Days
RX *cephalexin 500 mg one Capsule(s) by mouth three times a day
Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Complete Heart Block
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had complete heart block and passed out at home. The EP team
reviewed your strips and placed a temporary wire, then a
permanant pacemaker, the make and model is listed below. You
have recovered well. Your creatinine increased to 1.5 after the
procedure, it is thought that you were slightly dehydrated and
received a fluid bolus. Your repeat creatinine is 1.5 and you
will have it checked as an outpatient. Please get your
creatinine checked on [**6-20**] when you see Dr. [**Last Name (STitle) 23239**]. A
prescription has been written for you to take to his office.
It was a pleasure caring for you at [**Hospital1 18**].
Followup Instructions:
.
Department: RADIOLOGY
When: MONDAY [**2131-2-19**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) **],[**First Name3 (LF) 1955**] W.
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 24047**]
Appointment: Tuesday [**2130-6-20**] 2:40pm
Department: CARDIAC SERVICES
When: MONDAY [**2130-6-19**] at 11:00 AM
With: DEVICE CLINIC [**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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36
| 165,660
|
7414
|
Discharge summary
|
report
|
Admission Date: [**2134-5-10**] Discharge Date: [**2134-5-20**]
Date of Birth: [**2061-8-17**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1430**]
Chief Complaint:
Recurrent ventral herniation with omentum up in the anterior
chest
Major Surgical or Invasive Procedure:
Ventral hernia repair, placement of SurgiMend and omentectomy.
Sternal plate removal.
History of Present Illness:
Mr. [**Known lastname 27218**] is a 72 y.o. male with PMH significant for CAD s/p
CABG ([**2131-5-4**]), COPD, HTN who presents with recurrent ventral
hernia.
Approximately three years ago ([**2131-5-18**]), the patient had a
sternal repair done with plates. He had an omental transfer and
at that time a ventral hernia repair to the anterior fascia at
the bottom of sternotomy lead to a hernia. This was actually
repaired primarily and reinforced with mesh. A separate new hole
was made through the diaphragm for the omental transfer. Over
time omentum and bowel has protruded up through this hole in the
diaphragm, as evidenced on a recent CT. He now comes in for
repair of this defect. In addition was planning on removal of
his plates as he was having some discomfort. He understood we
could not guarantee success and further intervention may be
required.
Past Medical History:
Coronary artery disease s/p 5 vessel CABG
Bladder cancer
BPH
Anxiety
COPD
History of DVT and PE (in [**2131**] treated with ? 6 months of
coumadin)
Social History:
He smoked one pack per day for over 59 years, active until
[**2134-5-10**], drinks alcohol socially ( 1 drink per month). No
illicits. Retired truck driver. Lives with wife independent in
ADLs.
Family History:
Father lung ca
brother throat ca
sister leukemia
brother colon CA
sister pancreatic ca
Physical Exam:
GENERAL: Comfortable and in NAD
HEENT: NCAT, sclerae anicteric. MMM.
PULM: CTAB, no rales/rhonchi/wheezes
CVS: RRR with no murmur/gallop/rubs; s/p sternotomy. Hardware
palpable
ABD: Soft/NT/ND
EXT: No c/c/e
Pertinent Results:
Initial Labs:
[**2134-5-11**] 06:15AM BLOOD WBC-15.6*# RBC-5.01 Hgb-14.4 Hct-42.2
MCV-84 MCH-28.7 MCHC-34.1 RDW-14.6 Plt Ct-224
[**2134-5-11**] 06:15AM BLOOD Glucose-124* UreaN-19 Creat-1.0 Na-140
K-4.2 Cl-106 HCO3-25 AnGap-13
[**2134-5-11**] 06:15AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.9
Cardiac Enzymes:
[**2134-5-11**] 07:00PM BLOOD CK(CPK)-342* CK-MB-6 cTropnT-0.03*
[**2134-5-12**] 08:33AM BLOOD CK(CPK)-347* CK-MB-6 cTropnT-0.03*
ABG's:
Prior to Intubation - [**2134-5-12**] 03:22PM BLOOD Type-ART pO2-70*
pCO2-75* pH-7.22* calTCO2-32* Base XS-0
After Intubation - [**2134-5-12**] 06:48PM BLOOD Type-ART pO2-84*
pCO2-50* pH-7.36 calTCO2-29 Base XS-1
Prior to ICU Call-Out - [**2134-5-15**] 03:06PM BLOOD Type-ART pO2-64*
pCO2-41 pH-7.53* calTCO2-35* Base XS-10
[**2134-5-12**] 12:35PM BLOOD Lactate-1.0
[**2134-5-15**] 02:50PM BLOOD Lactate-1.7
Blood and sputum cx - No Growth to date.
ECG ([**2134-5-11**]) - Sinus rhythm. Normal tracing. Since the previous
tracing of [**2134-5-4**] sinus bradycardia is absent.
CXR ([**2134-5-11**]) - Mild bibasilar atelectasis documented on the CTA
performed subsequently, 8:00 a.m. on [**5-12**] and available at the
time of this dictation, in combination with pulmonary embolism
demonstrated on that study is sufficient to explain hypoxia.
There is no pulmonary edema. Heart size is probably normal and
unchanged. There is no pulmonary edema. Left pleural thickening
is chronic.
Echo ([**2134-5-12**]) - The left atrium is mildly dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There is no
ventricular septal defect. RV appears to have normal free wall
contractility (poor image quality). There is abnormal septal
motion/position. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2131-5-19**],
the RV funciton has probably improved. If indicated, a cardiac
MRI may better assess RV size and systolic function.
CXR ([**2134-5-12**]) - IMPRESSION: Asymmetric pulmonary edema, new since
one day prior.
CTA Chest ([**2134-5-12**]) - IMPRESSION:
1. Left upper lobe lobar pulmonary embolism.
2. Partial right lower lobe collapse due to a combination of
dependent secretions and bronchial wall thickening, with
associated surrounding peribronchial lymph nodes which are
probably reactive; however, a followup CT is recommended in four
to six weeks to ensure resolution.
3. Diffuse ground-glass opacities superimposed on centrilobular
emphysema are most likely infectious (such as viral in origin);
aspiration and asymetrical edema are less likely.
4. Large fatty lesion posterior to the left scapula contains
internal septations; considering large size and septations, a
dedicated MRI with contrast is recommended for further
evaluation to help distinguish a lipoma from a low grade
liposarcoma.
5. New ventral hernia mesh with postoperative changes in the
soft tissues of the anterior chest and upper abdomen.
6. Diffuse coronary artery calcification with CABG.
Bilateral LENIs ([**2134-5-13**]) - IMPRESSION: No evidence of DVT of
bilateral lower extremities.
Brief Hospital Course:
The patient was taken to the operating room for a joint
procedure between Dr. [**First Name (STitle) **] of plastic surgery and Dr. [**Last Name (STitle) **]
of general surgery. He [**Last Name (STitle) 1834**] the following procedures:
(1) Repair of chest wall hernia (Dr. [**Last Name (STitle) **]
(2) Ventral hernia repair, placement of SurgiMend and
omentectomy. Sternal plate removal (Dr. [**First Name (STitle) **]
.
The patient tolerated the procedure well and was transferred to
the floor for routine post operate care. He initially had poor
pain control and his PCA was titrated up. He was kept strictly
NPO until return of bowel function. Unfortunately, he developed
acute respiratory distress during the early morning hours of
[**2134-5-12**] that necessitated transfer to the medical intensive care
unit.
.
# Pulmonary: On POD 2, the patient was transferred to the ICU
for ongoing respiratory distress and hypoxia. He had been on 4L
NC since he was in the OR; however, he desaturated to the high
80's. Also, he had had ongoing difficulty with deep breaths
secondary to abdominal pain. CTA during this decompensation
showed pulmonary embolism. Imaging was also concerning for
underlying pneumonia as well as fluid overload. Shortly after
transfer to the ICU, the patient was noted to have worsening
hypercarbic respiratory failure and depressed mental status.
Ultimately, he was intubated on [**2134-5-12**]. The patient was started
on antibiotics to cover for his pneumonia (see below). Diuresis
was intially limited [**2-9**] hypotension; however, his blood
pressures improved and he was ultimately diuresed. After a few
days of antibiotics and diuresis, the patient's respiratory
status improved. His sedating medications were weaned and he was
ultimately extubated on [**2134-5-15**]. He was called out to the floor
on the day following his extubation and remained stable from a
pulmonary standpoint.
.
During the initial workup of his respiratory distress, a left
upper lobe lobar pulmonary embolism was noted on CTA. Of note,
patient does have a history of clots right femoral vein, left
IJ, superficial veins of the left and right cephalic veins,
superficial left basilic vein, and pulmonary embolism in setting
of surgery for cardiac tamponade s/p CABG [**5-14**]. Per Hematology
patient should have a minimum of 6 months of anticoagulation. In
2 months the patient will follow-up with hematology for
additional work-up and determination of total length of
anticoagulation. Mr. [**Known lastname 27218**] was initially on a conservative
heparin drip given he is recently post-operative. He was
continued on heparin until his INR was therapeutic.
.
He continued on oxygen via nasal cannula at a rate of 4 LPM for
the remainder of his admission and was maintaining an oxygen
saturation > 94%. He continued pulmonary toilet with incentive
spirometry. He responded well to intermittent doses of lasix
and was started on standing lasix 20mg by mouth daily.
.
Pneumonia - Patient with likely pneumonia based on imaging and
clinical history (reported approximately 1 week of cough during
the week prior to surgery). Large amount of secretions noted
during intubation. Pt started on levofloxacin on admission to
ICU. After intubation, ceftriaxone was added as double-coverage
to treat for severe CAP. Sputum and blood cx were sent but had
no growth to date at the time of transfer out of the ICU. On
transfer out of the ICU, the patient was continued on
levofloxacin / ceftriaxone with an end date of [**2134-5-21**].
.
# Neuro: Post-operatively, the patient received Dilaudid via PCA
initially with poor pain control that was then transitioned to
PO dilaudid with good effect and adequate pain control.
.
# CV: Patient had troponin leak in setting pneumonia and
pulmonary embolism felt to be demand. The patient was evaluated
by the cardiology service during this admission. They
recommended that the patient should discuss with his outpatient
cardiologist the utility of continuing plavix, given the
anticoagulation that will be started for his PE. Plavix was
restarted towards the end of the [**Hospital 228**] hospital admission.
.
Multiple EKGs were performed throughout this hospitalization
that did not detect any new ST or T wave abnormalities or any
other findings concerning for ischemia.
.
# GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Intake and output were
closely monitored, and urine output was noted to be marginal on
several occasions. The patient initially received boluses of
IVF with improvement in his urine output. After these boluses,
however, the patient was thought to be in fluid overload and
received lasix. His urine output increased with lasix, as well.
.
The patient was continued on his home dose of finasteride for
his BPH.
.
ID: The patient was started on antibiotics for hospital acquired
pneumonia as above.
The patient's temperature was closely watched for signs of
infection.
.
# Hematology: The patient's hematocrit did trend downwards
slightly after his transfer to the ICU. Hematocrit was followed
and remained stable thereafter. Of note, when patient was
intubated, OG tube was placed and moderate amount of brown
guaiac positive liquid was aspirated back; patient was kept on
heparin gtt and started on [**Hospital1 **] IV PPI. When his plavix was
restarted, his PPI was transitioned to an H2 blocker due to the
interaction between these two medications.
.
# Musculoskeletal: The patient had difficulty ambulating and
getting out of bed. This was thought to be due to
deconditioning. A PT consult was requested and the patient
[**Hospital1 1834**] vigorous physical therapy. He will require continued
physical therapy at rehab.
.
# Prophylaxis: The patient was maintained on subcutaneous
heparin after his operation. He was transitioned to heparin
drip at the time of his pulmonary embolism, and eventually was
started on coumadin. At the time of his discharge, his INR was
4.1 ([**2134-5-19**]). His INR from [**2134-5-20**] was still pending.
Medications on Admission:
Albuterol aerosol 4 puffs daily
Amlodipine 10 mg PO daily
Aspirin 81 mg daily
Atenolol 25 mg PO daily
Atrovent 4 puffs daily
Citalopram 60 mg PO daily
Lisinopril 40 mg PO daily
Folic acid 1 mg PO daily
Iron 65 mg PO daily
Vytorin 10/80 mg PO daily
Omeprazole 40 mg PO daily
Oxycodone 5-10 mg PO BID:PRN
Plavix 75 mg daily
Finasteride 5 mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever: Max 4000 mg Tylenol/day.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2
hours) as needed for sob, wheezing.
9. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: Two (2) Powder in Packet PO TID (3 times a day).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours).
12. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Levofloxacin 750mg PO daily: Last dose Friday [**2134-5-21**].
17. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours): Last dose Friday
[**2134-5-21**].
18. Warfarin 1 mg Tablet Sig: dose as necessary for INR [**2-10**]
Tablets PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1) Recurrent ventral herniation with omentum up in the anterior
chest
2) Pulmonary embolism
3) hospital acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Personal Care:
1. Leave your chest dressing in place until your follow up
appointment with Dr. [**First Name (STitle) **]. If your dressings get wet
underneath, you may remove them.
2. Clean around the drain site(s), where the tubing exits the
skin, with hydrogen peroxide.
3. Strip drain tubing, empty bulb(s), and record output(s) [**2-10**]
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may shower daily. No baths until instructed to do so by
Dr. [**First Name (STitle) **].
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. [**First Name (STitle) **].
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
4. Take prescription pain medications for pain not relieved by
tylenol.
5. Take your antibiotic as prescribed.
6. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softerner if you wish.
7. 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.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Separation of the incision.
4. Severe nausea and vomiting and lack of bowel movement or gas
for several days.
5. Fever greater than 101.5 oF
6. Severe pain NOT relieved by your medication.
.
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.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] on Tuesday, [**2134-5-25**] at 9AM
at his office.
.
You are scheduled to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], a hematologist,
on [**2134-7-16**] at 10:30 AM on [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**]
Clinical Center. Dr. [**Last Name (STitle) 27222**] will determine how long you
should remain on coumdin. Phone:[**Telephone/Fax (1) 22**]
Please follow-up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name (STitle) **] -
[**Doctor Last Name 15369**] to follow-up on your recent hospitalization and to
monitor your coumadin dose. Your goal INR is [**2-10**]. Your first INR
check out of the hospital will be on [**2134-5-21**].
Please follow-up with your cardiologist Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] discuss your
recent hospitalization and determine if you should re-start
plavix.
You should also call the Pulmonary Clinic as soon as possible
for the next availabe appointment. Their telephone number is
([**Telephone/Fax (1) 513**].
Completed by:[**2134-5-20**]
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|
1548, 1743
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,174
| 100,526
|
41199
|
Discharge summary
|
report
|
Admission Date: [**2151-12-10**] Discharge Date: [**2151-12-24**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Seizure and Increased Rt subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The information was provided by the patient's daughter and
son-in-law. The patient is a [**Age over 90 **]-year-old hypertensive diabetic
gentleman with a past medical history of Atrial fibrillation(not
on anticoagulation due to hemorrhagic stroke in [**2151-3-27**]),
PMR/RA, BPH, urinary retention/chronic foley after stroke in
[**4-4**], and prostate CA (on hormonal therapy, mets to pelvic bone)
who was transferred from [**Hospital3 **] to the neurosurgical
service for seizures and enlarging Right subdural hematoma (he
has bilateral chronic subdural hematoma).
He fell down on [**2151-12-6**] while he was hospitalized for UTI & PNA
(s/p Lt thoracentesis for para-pneumonic effusions) at [**Hospital1 **] that was treated with imipenem. He had a CT head the
same day that showed a bilateral chronic subdural hematoma. A
repeat CT head next day was done which showed no significant
change. On [**2151-12-10**] he was transferred to rehab, where he had a
generalized seizure, for which he was transferred back to [**Hospital1 2519**]. CT head at that time showed enlargement of the right
subdural hematoma, and CXR showed a fractured left clavicle. He
was brought to [**Hospital1 18**] for neurosurgical evaluation.
Past Medical History:
HTN, hemorrhagic stroke, NIDDM, PMR/RA, BPH and prostate CA.
AFIb (not on coumadin), chronic urine retention on chronic
foley's
Social History:
Lives with daughter at home
Family History:
NC
Physical Exam:
On admission:
*************
Vitals: 95.9, 116/73, 94 bpm irregular, RR 24, sat99%RA
GEN: Not in acute distress sitting comfortably in bed.
HEENT: Mucous membranes moist, no lesions noted. Sclerae
anicteric. No conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
CV: irregular rhythm with normal rate, no murmurs, rubs or
gallops
PULM: relatively good A/E bilaterally, harsh exp gurggling
sounds bilaterally and harsh end-insp "wheeze" like sounds are
heard, particularly midzone and lower zone while upper zones are
clear.
ABD: Soft, non-tender, non distended, bowel sounds present. No
hepatosplenomegaly
EXTR: No edema, Dorsalis pedis not palpable
NEURO: Alert, oriented to person, not time (something that has 0
and 1), not place. CN II-XII grossly intact. Motor power: [**2-28**]+/5
Lt UE, [**3-30**] Rt UE. lower limb power [**3-30**]. Wasn't capable of doing
finger-to-nose test or rapid-alternating test. Gait was not
assessed.
SKIN: No ulcerations or rashes noted.
On discharge:
*************
Vitals: T96, 135/90, 84 bpm irregular , RR 18, 94%sat on RA
GEN: Not in acute distress, lying flat with elevated bed head at
30 degrees.
HEENT: Mucous membranes relatively dry, no lesions noted.
Sclerae anicteric. No conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
CV: irregular rhythm with normal rate, no murmurs, rubs or
gallops
PULM: relatively good A/E bilaterally, faint insp crackles on
the right side, but no insp crackles could be appreciated on the
left side. no wheezes.
ABD: Soft, non-tender, non distended, bowel sounds present. No
hepatosplenomegaly
EXTR: No edema, Dorsalis pedis not palpable
NEURO: Alert, oriented to person, not place or time.
SKIN: grade I ulcer at the sacral area.
Pertinent Results:
On admission:
-------------
[**2151-12-10**] 08:36PM BLOOD WBC-15.5* RBC-3.75* Hgb-11.0* Hct-32.9*
MCV-88 MCH-29.2 MCHC-33.3 RDW-15.7* Plt Ct-293
[**2151-12-10**] 08:36PM BLOOD Neuts-92.3* Lymphs-5.3* Monos-2.3 Eos-0.1
Baso-0.1
[**2151-12-10**] 08:36PM BLOOD PT-14.1* PTT-27.1 INR(PT)-1.2*
[**2151-12-10**] 08:36PM BLOOD Glucose-226* UreaN-14 Creat-0.8 Na-135
K-4.4 Cl-98 HCO3-27 AnGap-14
[**2151-12-11**] 12:50AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.8
[**2151-12-10**] 08:44PM BLOOD Lactate-2.0
On discharge:
-------------
[**2151-12-22**] 05:06AM BLOOD WBC-8.5# RBC-2.82* Hgb-8.3* Hct-24.5*
MCV-87 MCH-29.4 MCHC-33.9 RDW-16.2* Plt Ct-203
[**2151-12-21**] 05:15AM BLOOD Glucose-111* UreaN-15 Creat-0.5 Na-138
K-3.6 Cl-100 HCO3-34* AnGap-8
[**2151-12-21**] 05:15AM BLOOD Mg-1.9 Iron-21*
[**2151-12-21**] 05:15AM BLOOD calTIBC-199* Ferritn-70 TRF-153*
Microbiology:
--------------
Blood Cultures 1/14 and [**12-14**]: No growth (finalized)
Urine Culture [**2151-12-10**]: (Final [**2151-12-11**]):
YEAST. >100,000 ORGANISMS/ML..
Imaging:
---------
CXR [**2151-12-10**]:
1. Left costophrenic angle not fully included.
2. Right base opacity raises concern for consolidation, such as
pneumonia or aspiration. PA and lateral views would be helpful
when/if patient able.
3. Non-displaced distal left clavicle fracture of indeterminate
age, but
which may be acute.
CXR [**2151-12-14**]:
As compared to the previous radiograph, there is a newly
appeared
retrocardiac opacity. The opacity is relatively homogeneous,
favoring
atelectasis over pneumonia. However, the presence of pneumonia
cannot be
excluded. The right lung base shows a minimal area of
atelectasis.
CT head [**2151-12-11**]
1. Essentially unchanged bilateral subacute-to-chronic subdural
hematomas
compared to outside hospital studies. No definite new foci of
acute
intracranial hemorrhage. No significant midline shift.
2. Chronic-appearing right frontoparietal and parietal infarcts.
CT Head [**2151-12-13**]:
Evaluation of the posterior fossa is slightly limited by motion
artifacts despite multiple scan acquisitions. Allowing for
differences in patient positioning, there is essentially no
change in bilateral hypodense subdural collections, right
greater than left. No new hemorrhage is identified. There is
unchanged minimal leftward shift of the anterior falx and septum
pellucidum. Parenchymal hypodensity and encephalomalacia in the
right posterior frontal and parietal lobes are again noted,
likely a chronic right MCA infarct. Scattered periventricular
and subcortical white matter hypodensities are also
again seen, likely due to chronic small vessel ischemic disease.
There is a small amount of fluid in the right maxillary sinus.
No osseous
abnormality is identified.
IMPRESSION: Bilateral hypodense subdural collections, right
greater than
left, appear similar to [**2151-12-11**], but larger than on [**2151-12-7**].
EEG [**2151-12-16**]:
IMPRESSION: Abnormal EEG in the waking and drowsy states due to
the
slow posterior and other background and due to the occasional
generalized slowing. These findings indicate a widespread
encephalopathy. They suggest a concomitant infectious,
metabolic, or
[**Last Name 89736**] problem as causing the encephalopathy. This
would
less likely derive from the subdural hematomas. With regard to
the
hematomas, there was no prominent loss of background voltage on
either
side though that is a very insensitive indicator of subdural
fluid.
There may have been a bit of slowing on the left, but nothing
persistent
or prominent. The single epileptiform sharp wave was likely
related to
movement artifact, and there were no similar findings in the
rest of the
tracing. An abnormal cardiac rhythm was noted.
Brief Hospital Course:
[**Age over 90 **] yo gentleman, DM, HTN, Afib (not on anticoagulation), BPH,
urine retention on chronic foley after stroke on [**2151-3-27**],
prostate Ca (mets to pelvic bone) was transferred to [**Hospital1 18**] for
evaluation of his very recent seizure on [**2151-12-10**] and enlarging
right subdural hematoma (has chronic bilateral subdural
hematomas).
.
# Goals of Care: Over the course of his hospitalization, the
patient had a substantial clinical decline. He was unable to
interact with family and medical team in a meaningful way, and
was unable to take oral nutrition and medications without
aspiration. Consequently, several family meetings were held,
and a decision was made to move from aggressive care to more of
a comfort-focused approach. The family and medical team decided
that the patient should be allowed to eat pureed foods despite
the risk of aspiration. Furthermore, per palliative care
discussion and note with his daughter [**Name (NI) **], the health care
proxy, the "Goal of care is optimal mental status so he can
interact with family in a meaningful manner. If pt continues to
improve goals of care should be continually readdressed and
modified. Family is aware that pt is still seriously ill and may
not regain function, and may not survive this event. If he is
improving, there should be discussion about treatment of next
infection ( resp or urine) with options to treat aggressively if
this is within keeping of goals/current status. If pt is
improving, option of intermittent catheterization, to reduce
chances of UTI, should be considered. This option will only be
favorable if pt does not experience discomfort with
catheterization. If he has not improved or is failing, options
for moving to hospice/care and comfort should be offered and
discussed. [**Doctor First Name **] is aware of hospice options and would like
to meet the hospice team. Family has made decision that
artificial feeding is not in keeping with overall goals of care.
No PEG placement desired. Pt is DNR/DNI but is not "Do Not
Hospitalize" - this should be discussed with his daughter. Pt
has had delirium- use of anticholinergics (scopolamine, levsin)
for secretions should be limited if possible and
positioning, good oral care and oral suction can be used in
place of medications. Use of end of life care medications to
manage respiratory distress should only be started after
discussion with daughter."
.
# Seizure & chronic subdural hematoma: Pt was thought to
possibly have a seizure focus from the previous stroke, subdural
hematoma, or significant lowering of seizure threshold secondary
to imipenem that he received in his admission on [**2151-11-30**] to
[**Hospital3 4107**] for UTI/PNA. He was evaluated by the
neurosurgeon who concluded that the patient was neurologically
stable and no interventions were indicated. He was also
evaluated by neurology who recommended that he continue Keppra
500 mg twice daily for seizure prophylaxis. If the patient does
have a seizure lasting more than several minutes, he can be
treated with crushed sublingual ativan, or rectal diazepam
(please see attached directions).
.
# Altered mental status: His mental status was noticed to
deteriorate dramatically following his seizure (according to the
daughter and son in law). During his stay, his mental status
gradually and slowly deteriorated. Possibly causes included
multiple intracranial co-morbidities, and infections (pneumonia
and UTI). He was agitated several times at night, and Seroquel
12.5 mg PO qhs was started with good effect. He was evaluated
by speech and swallow several times which revealed his poor
swallowing capability and high risk of aspiration. NG tube was
placed initially to deliver nutrition and medications. However,
NG tube was removed after a family decision was made to improve
the patient's comfort despite risk of aspiration. According to
the daughter's wishes, she would like her father to receive
speicific diet that might reduce the chance of aspiration, that
is pureed, nectar thickened diet.
.
# Pneumonia: The patient was admitted on [**2151-11-30**] to [**Hospital1 **] for complex UTI and pneumonia. CXR on admission showed
Rt lower zone infiltrate with blunting of Rt costophrenic angle.
The infiltrate improved compared to [**12-10**] CXR. It was felt to be
a new Rt sided pneumonia since from OSH his prior pneumonia was
on the left side. Aspiration was the most likely cause given his
poor speech and swallow function. He received a course of IV
Vancomycin and Cefipime that started on [**2151-12-14**] for 7 days for
Hospital acquired pneumonia. There was no growth on blood
culture.
.
# UTI: Culture grew significant yeast, however this is most
likely contamination from his indwelling foley. He received
fluconazole for 7 days starting on [**2151-12-14**] to treat possible
candidal UTI, and foley catheter was changed.
.
# Diabetes Mellitus: The patient was initially on fixed dose
lantus and humalog sliding scale with meals. However, when his
NG tube feeds were discontinued and the patient allowed to eat,
his lantus was significantly decreased and humalog stopped. At
discharge, he was on Lantus 8 units at night. However, his oral
intake should be carefully monitored and his finger sticks
checked at least once daily. If his intake of food and finger
sticks decline, his lantus should also be decreased and possibly
discontinued.
.
# Atrial fibrillation: Patient has been in atrial fibrillation
for the duration of his hospitalization. He had a few episodes
of HR in the 130's-140's along with agitation. These episodes
were dramatically reduced after his Toprol XL 50 mg was switched
to metoprolol 50 mg twice daily. Coumadin has been held since
[**2151-3-27**] due to recent hemorrhagic stroke.
.
Medications on Admission:
Ca Vit D
Glyburide 5mg OD
Toprol 50 mg OD
Humigan eye drops
Ferrous Sulface 325 BD
Colace BD
Senna OD
Vit C 500 OD
Ranitidine 150 mg OD
Discharge Medications:
1. levetiracetam 100 mg/mL Solution Sig: Five (5) ml PO BID (2
times a day).
2. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QPM (once a day
(in the evening)).
3. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QPM (once a day
(in the evening)) as needed for agitation: [**Month (only) 116**] give 1 hour after
standing dose for total of 25mg/night if agitated.
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold if SBP < 100 or HR < 60.
5. insulin glargine 100 unit/mL Solution Sig: Eight (8) unit
Subcutaneous HS (at bedtime).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain or fever.
8. diazepam 12.5-15-17.5-20 mg Kit Sig: 12.5 mg Rectal PRN:
q4-12 hours as needed for seizure: do not use for more than 5
episodes per month or more than one episode every 5 days.
.
9. Ativan 1 mg Tablet Sig: One (1) Tablet PO q15mins as needed
for seizure: Can crush and place sublingually for seizure. Use
either ativan or rectal diazepam, but not both.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay [**Hospital **] Nursing and Rehab.
Discharge Diagnosis:
Primary diagnoses:
chronic bilateral subdural hematoma
UTI
Pneumonia
Left Clavicle fracture
Secondary diagnoses:
Diabetes
Hypertension
Atrial fibrillation (not on coumadin)
metastatic prostate cancer
chronic urine retention with indwelling foley's
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
DNR - DNI
Discharge Instructions:
Dear Mr. [**Known lastname **] and family,
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] because of seizure and
increase in the size of blood around his brain on the right
side. He was evaluated by the brain surgeons on admission who
felt that there was no indication to intervene regarding the
blood around his brain. During his stay, he was evaluated by
speech and swallow team several times that showed impaired
swallowing and high risk of aspiration. A tube was fixed that
goes from his nose to his stomach to deliver food and
medications. He became agitated a few times at night which made
it neccessary to give him a medication at evening time on
regular basis to control his agitation.
On admission, there was an infection in his right lower lung,
for which he was receiving an IV antibiotic. After few days of
hospitalization, he had another infection in his left lower
lung, most likely due to aspiration. Because of this, his IV
antibiotics was changed to two medications that he received for
a total course of 7 days. He also received an oral [**Doctor Last Name 360**] to
treat the fungus in his urine for 7 days.
His Toprol XL 50 mg was changed to metoprolol 50 mg orally twice
daily. Keppra 500 mg twice daily was added to prevent further
seizure.
Given his poor health status, a family meeting was held and it
was discussed with [**Doctor First Name **], the daughter and health care proxy
of Mr [**Name (NI) **] and her husband, [**Name (NI) **], regarding the long term
goals for Mr [**Known lastname **]. It was agreed to take him to a Hospice
care and move to comfort measures. His IV line and feeding tube
were removed, but his blood pressure, anti-seizure and insulin
was continued.
Followup Instructions:
None
|
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icd9cm
|
[
[
[]
]
] |
[
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"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
14462, 14555
|
7313, 10465
|
294, 301
|
14848, 14848
|
3556, 3556
|
16782, 16790
|
1767, 1771
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4062, 7290
|
212, 256
|
329, 1553
|
3570, 4048
|
14863, 15011
|
1575, 1705
|
1721, 1751
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,641
| 141,562
|
44904
|
Discharge summary
|
report
|
Admission Date: [**2196-5-11**] Discharge Date: [**2196-5-16**]
Date of Birth: [**2120-3-13**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: As per MICU Admission Note.
75 year old female with extensive past medical history, most
recently complicated by incarceration of a bowel at stoma
from prior colectomy for colon cancer. Recent admission in
[**2196-1-27**], with maroon stool and found to have the
incarcerated parastomal hernia and status post colectomy and
ileostomy. The patient also had a recent admit on [**2196-2-27**], with urinary tract infection and was sent to
rehabilitation and then readmitted in [**2196-3-26**], with
decreased p.o.'s, feculent emesis and also found to have
prerenal failure and urinary tract infection of that improved
significantly with hydration. The patient also has a past
medical history of severe depression and question of
Parkinsonism.
She was at rehabilitation when she started feeling nauseous
for a few days. A Chem 7 at rehabilitation revealed a
hyperkalemia to 7. She was sent by ambulance to [**Hospital6 1760**] and along the way became
unresponsive. She soon recovered respiration and pulse but
remained unresponsive and arrived at the [**Hospital6 1760**] EW without a pulse. The
patient was asystolic and CPR was initiated x one minute in
which the patient received Epinephrine, an amp of Atropine,
an amp of Calcium Chloride, 10 units of Insulin, D50
Bicarbonate then another amp of Epinephrine, another amp of
Calcium Chloride and more Bicarbonate. The patient was then
intubated for airway protection. The patient also became
hypotensive to a blood pressure of 69 and she was given four
to five liters of normal saline as a fluid rehydration. At
this time her potassium was found to be 8.9 and her
Bicarbonate was 10 and a blood gas demonstrated pH of 7.2;
PO2 of 128; PCO2 of 20. During this CPR, the patient had
various runs of brady and tachy cardias, all with wide
complex QRS.
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Parastomal hernia, status post emergent colectomy for
incarceration.
3. Colon cancer.
4. Breast cancer, status post left lumpectomy in XRT.
5. Type II diabetes mellitus
6. Depression.
7. Anxiety.
8. Hypertension.
9. History of tremor.
10. Orthostatic hypotension.
11. Urinary tract infections.
12. Osteopenia.
13. Multiple cardiac catheterizations at outside hospitals
reporting clean coronary arteries.
MEDICATIONS ON ADMISSION:
1. Metoprolol 25 b.i.d.
2. Tylenol 325 to 650 prn.
3. Paroxetine 30 q d.
4. Colace 100 b.i.d.
5. Regular Insulin sliding scale.
6. Pantoprazole.
7. Neurontin 200 q hs.
8. Wellbutrin 75 q d.
9. Imodium two prn.
10. Seroquel 12.5 t.i.d.
11. Avandia 8 q d.
PHYSICAL EXAMINATION UPON ADMISSION TO THE MICU: Blood
pressure, 116/39; pulse, 146; 87% with a poor wave form. The
patient was intubated and sedated. Pupils were equal and
reactive. Sclera were anicteric. The patient had an
otherwise unremarkable examination with cool extremities.
LABORATORIES ON ADMISSION SHOWED: Sodium, 123; potassium,
8.9; chloride, 89; bicarbonate, 10. BUN, 99; creatinine,
4.8. Glucose, 309. Free calcium, 1.87. White blood count,
27.8. Hematocrit, 38.8. Platelets, 585. Calcium, 14;
magnesium, 2.8; phosphorus, 10.3. Arterial blood gases,
7.2/20/128.
The patient was admitted overnight to the MICU. She was
rehydrated aggressively with normal saline and her
electrolytes abnormalities self-corrected as well as her
renal failure. She was then transferred to the Floor.
EXAMINATION ON TRANSFER TO THE FLOOR: Afebrile; blood
pressure, 108/45; pulse, 75; respirations, 13; 100% on three
liter nasal cannula. Central venous pressure, 9 to 10. The
patient had had 2,026 of intravenous fluid in/2,020 of urine
out and only 200 of ostomy out. General, alert and oriented
x 2. Pleasant. Head, eyes, ears, nose and throat, pupils
are equal and reactive to light and accommodation. Anicteric
sclera. Mucous membranes, moist. Neck, no jugular venous
distention. Right IJ in place. Chest, clear to auscultation
bilaterally. Cardiac, regular rate and rhythm. S2, soft
systolic ejection murmur at the left upper sternal border.
Abdomen had normal active bowel sounds. Old ostomy site was
clean, dry and intact. The new ostomy bag showed dark stool.
Abdomen was nontender, nondistended with no organomegaly.
Extremities, no cyanosis, clubbing or edema. Neurological,
strength, [**5-30**], bilateral upper and lower extremities. There
was a tremor of initiation greater on the right than left
side.
White blood count, 13,000, down from 27,000. Hematocrit, 25,
down from 38 and stabilized at 25, status post large volume
hydration. Platelets, 319. Sodium, 143; potassium, 3.7,
down from 8.9; bicarbonate, 27; chloride, 105. BUN, 45, down
from 99; admission creatinine, 1.3, down from 4.8 on
admission. Glucose, 152. Troponin, 5.9; CK, negative x 3.
The troponin peak was 5.9; next one was 4.2 six hours later.
ALT, 11; AST, 17. Alkaline phosphatase, 43. Calcium, 9.3;
magnesium, 1.7; phosphorus, 3.4; amylase, 66; lipase, 185.
Electrocardiogram, initially on admission, showed sinus
rhythm with prolonged PR of 224; prolonged QRS of 142; large
R wave in V1 and V2 with poor R wave progression and T wave
depressions V1 through V5 that were new.
On [**2196-5-11**], the patient had an electrocardiogram with slow
atrial flutter with ventricular rate that was irregular at 25
beats per minute with peak T waves. This was her admission
electrocardiogram.
Renal ultrasound done showed kidneys of 10 and 11 cm with no
hydronephrosis. Incidentally, positive gallstones were
noted. A chest x-ray, initially on admission, showed
perihilar haziness consistent with mild congestive heart
failure and on the next day, [**2196-5-12**], showed improved
congestive heart failure.
HOSPITAL COURSE: This is a 75 year old female with ileostomy
and multiple abdominal surgeries, depression, who is admitted
with acute renal failure leading to hyperkalemia and acidosis
leading to cardiac arrest.
The patient improved dramatically with rehydration with
correction of her renal failure and electrolyte abnormalities
after less than 24 hours of rehydration. It was felt that
the patient, due to her depression, was not taking good p.o.
and also had some large ostomy output and became gradually
dehydrated, leading to prerenal failure and subsequent
hyperkalemia/acidosis.
1. Renal - Prerenal/Acute renal failure in the setting of
dehydration secondary to poor p.o.'s and large ostomy output
likely. This was improved with intravenous fluids. Negative
renal ultrasound. The renal failure rapidly corrected with
intravenous hydration and was stable throughout the remainder
of the admission. On day of discharge, her creatinine was
0.6 with a BUN of 9.
2. Cardiology - The patient was status post PEA arrest in
the setting of acidosis and hyperkalemia of 8.9. After
correction of her potassium and acidosis and intravenous
hydration, the patient was revived and remained stable for
the remainder of the hospitalization.
3. Electrophysiologic - The patient had one episode of
atrial fibrillation, status post her cardiac arrest that was
electrically cardioverted. The patient remained in sinus
rhythm after cardioversion. She did have a troponin of 5.9
status post cardioversion that was likely the result of
shock. Her TSH was normal.
4. Pump - The patient had some mild congestive heart failure
after her PEA arrest that was likely due to pump dysfunction
corrected status post resumed sinus rhythm. She has no
further episodes of congestive heart failure.
Regarding the Troponin, this is most likely secondary to
cardiac arrest and electrocardioversion and resolved after
these interventions.
5. Fluids, Electrolytes and Nutrition - The patient, on
admission, had severe hyperkalemia secondary to acute renal
failure that was corrected upon admission with calcium,
Insulin, intravenous fluid hydration and resolution of her
acute renal failure. She also had an anion gap acidosis
likely also secondary to her acute renal function and also
resolve after intravenous fluid hydration and bicarbonate
issued during the code.
The patient has a history of poor p.o. intake that is likely
secondary to her depression. During this admission, she had
fairly good p.o. intake and this should be encouraged as an
outpatient. It is likely that at the current time she does
not need a percutaneous endoscopic gastrostomy tube for
nutrition, however, this may be considered if the patient
cannot eat to keep up with ostomy output in the future.
6. Gastrointestinal - The patient has had multiple
gastrointestinal surgeries in the past for colon cancer and
herniated parastomal hernia and has from 200 to 250 cm of
small bowel left as per her latest Operative Note. She
likely has some increased ostomy output from short bowel
syndrome. However, her ins and outs during this
hospitalization have not been consistent with large ostomy
output. She had less than one liter per day while on the
Floor and on the day of discharge, she had 1,350 from her
ostomy. She can be currently symptomatically managed with
Loperamide prn for ostomy outputs greater than 500 or 1,000
per day. Her Clostridium Difficile and stool studies were
negative.
7. Dermatologic - The patient had ecchymotic areas on her
right forearm. These were 4 to 5 in number and anywhere from
1 to 5 cm in diameter. The largest had bullous bullae
overlying. A Dermatology consult was called and Dermatology
did a biopsy of this lesion. The biopsy currently is
pending. The lesions have been stable throughout the
hospitalization and currently do not show any signs of
infection or worsening. The patient should follow up with
Dermatology one week after discharge for re-evaluation and
for the results of the biopsy. Question as to whether these
lesions were due to hypotensive episodes during her code
versus pressure on her arm during the code versus any type of
embolic event.
8. Depression - The patient's mood was noted to be better
during this admission by the Geriatrics Fellow who knows the
patient from the last admission. She was continued on her
current antidepressants.
9. Hematologic - The patient hematocrit went from 38 to 25
after a large volume fluid rehydration. She had no signs of
blood loss and has guaiac negative stool. It is likely that
she has some degree of anemia of chronic disease. She was
transfused two units of packed red blood cells with an
appropriate bump in her hematocrit and this has been stable
throughout her hospitalization and is now at 33.4.
DISPOSITION: The patient will be discharged to [**Hospital1 **] Rehabilitation Center. There her p.o. intake and
output should be watched carefully and she should have her
ostomy output recorded. She has not had a high ostomy output
here while an inpatient. This may change with a change in
her diet at the rehabilitation. She should follow up with
Dermatology and perhaps Gastroenterology if her ostomy output
is shown to be high.
DISCHARGE DIAGNOSIS:
1. Dehydration.
2. Depression.
3. Acute renal failure.
4. Hyperkalemia.
5. Anion gap acidosis which is resolved.
6. Depression.
MEDICATIONS ON DISCHARGE:
1. Loperamide prn ostomy output between 500 and 1,000 cc per
day.
2. Neutra-Phos one packet t.i.d.
3. Bacitracin b.i.d. to open bullae on right arm with dry
dressings.
4. .................... 12.5 mg p.o. b.i.d.
5. Multi-vitamin 1 p.o. q d.
6. Bupropion 150 mg p.o. q d.
7. Protonix 40 mg p.o. q d.
8. Paroxetine 30 mg p.o. q d.
9. Regular Insulin sliding scale.
10. Magnesium Oxide 500 mg p.o. b.i.d.
11. The patient can be restarted on her Avandia 8 mg p.o. q d
although her blood sugars were fairly well controlled with
diet with a range of 134 to 210.
FOLLOW UP: The patient should follow up with her Primary
Care Doctor in one to two weeks and with Dermatology at [**Hospital6 1760**] within one week for removal
of her stitches from her biopsy and follow up of her right
arm ecchymotic and bullous areas.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], M.D. [**MD Number(1) 16133**]
Dictated By:[**First Name3 (LF) 96059**]
MEDQUIST36
D: [**2196-5-16**] 14:28
T: [**2196-5-16**] 14:35
JOB#: [**Job Number **]
|
[
"427.5",
"427.31",
"285.29",
"556.9",
"276.5",
"428.0",
"276.7",
"584.9",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"38.93",
"96.71",
"96.04",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
11107, 11242
|
11268, 11834
|
2461, 5852
|
5870, 11086
|
11846, 12340
|
160, 1973
|
1995, 2435
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,821
| 120,310
|
47653
|
Discharge summary
|
report
|
Admission Date: [**2136-12-10**] Discharge Date: [**2136-12-11**]
Date of Birth: [**2075-7-13**] Sex: M
Service: MEDICINE
Allergies:
Pravastatin / Atenolol / Colchicine
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Bradycardia/Weakness
Major Surgical or Invasive Procedure:
ICD pacemaker placement
History of Present Illness:
61 yo male with history of CAD s/p CABG '[**18**], HTN, obesity, COPD,
being followed by Dr. [**Last Name (STitle) **] comes in today with worsening
lightheadedness, SOB on exertion. He recently had a holter
monitor placed by Dr. [**Last Name (STitle) **] and was found to have episodes of
bradycardia. Betablockers and lisinopril were stopped (on
[**11-29**]). However, his symptoms persisted, with him feeling worse
for the past 3-4 days. He has had intermittent chest discomfort
as well, had trouble walking in the kitchen. He called his PCP
who recommended for him to go to the ED for bradycardia.
In the ED, initial VS were 98.2 30 150/65 18 100% RA. EKG
revealed complete heart block. Labs unremarkable. External
pads were placed. EP saw the patient in the ED, plan for pacer
placement today. VS on transfer were 32 133/59 17 99% on 2L.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for chest "pressure", but
absence of chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY: CAD
-CABG: CABG (LIMA-diagonal, SVG-LAD) in [**2118**] after failed
angioplasty
-PERCUTANEOUS CORONARY INTERVENTIONS: S/P RCA stent [**2122**],
ostial and mid-SVG-LAD Tetra stent in [**2126**]
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
. obesity, OSA home CPAP [**12-6**], COPD, herpes zoster
ophthalmicus, osteoarthritis, pseudogout, chronic back pain,
depression, DJD, and hypothyroidism
Social History:
SOCIAL HISTORY
-Tobacco history: Smokes 1.5 packs per day, smoker for 45 years.
-ETOH: on occasion, had 3 drinks yesterday at a party
-Illicit drugs: denies
Family History:
Father, Mother, uncle, and multiple cousins with [**Name2 (NI) **]. No
diabetes or hypertension in the family members.
Physical Exam:
On admission:
VS: T=97 BP=139/64 HR= 26-33 RR=18 O2 sat=98% 2L O2.
GENERAL: Obese man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
wears glasses.
NECK: JVP not appreciated due to obesity.
CARDIAC: Distant heart sounds. PMI located in 5th intercostal
space, midclavicular line. slow heart rate, S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, Obese. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Scars on lower
extremities (CABG graft).
PULSES:Right:DP 2+
Left:DP 2+
On discharge:
Pertinent Results:
Admission labs:
[**2136-12-10**] 12:00PM PT-13.6* PTT-24.9 INR(PT)-1.2*
[**2136-12-10**] 12:00PM NEUTS-71.2* LYMPHS-20.6 MONOS-4.5 EOS-2.4
BASOS-1.2
[**2136-12-10**] 12:00PM WBC-10.2 RBC-4.25* HGB-13.6* HCT-40.5 MCV-95
MCH-32.0 MCHC-33.6 RDW-14.3
[**2136-12-10**] 12:00PM cTropnT-<0.01
[**2136-12-10**] 12:00PM estGFR-Using this
[**2136-12-10**] 12:00PM GLUCOSE-121* UREA N-18 CREAT-1.1 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
[**2136-12-10**] 12:09PM O2 SAT-48 CARBOXYHB-6*
[**2136-12-10**] 12:09PM K+-4.1
[**2136-12-10**] 12:09PM COMMENTS-GREEN TOP
CXR:
Brief Hospital Course:
61 yo male with history of CAD s/p CABG '[**18**], HTN, obesity, COPD,
being followed by Dr. [**Last Name (STitle) **] admitted with worsening symptoms and
bradycardia. In the ICU for Pacemaker Placement.
.
# RHYTHM: On arrival to the ER, patient was bradycardic to 30's
though asymptomatic and normotensive EKG revealed complete heart
block with previous showing RBB with Left Anterior fascicular
block. Labs unremarkable. External pads were placed and the
patient underwent transcutaneous pacing. He was seen by
electrophysiology who recommended pacer placement. On HD2,
patient had a biventricular [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] pacer placed. He was
restarted on bisoprolol 2.5mg daily and lisinopril 5mg daily. He
was discharged the same day with a plan for a total of three
days of kefflex for antibiotic prophylaxis and followup with EP
in 1 week.
.
# CORONARIES: s/p CABG in 93 (Lima-Diag, SVG to LAD), s/p
stents, most recently in [**2126**]. He was continued on ASA 325
daily, Rosurvastatin 10 daily and Clopidogrel 75mg.
.
# PUMP: On admission, patient was not on a beta blocker or and
ace given history of bradycardia. Last [**11/2136**] ECHO showed EF
45-54%, with an akinetic LV apex
.
# COPD - Continued home inhalant therapy as needed
.
# Hyperlipidemia: Continued rosurvastatin 10mg daily
.
#OSA - he was continued on CPAP which he uses at home.
.
#Chronic Back Pain - oxycodone Q4hrs 5mg PRN for back pain.
.
# Depression - Continued citalopram home dose
Medications on Admission:
MEDICATIONS (confirmed with patient):
1. BISOPROLOL FUMARATE - (On Hold from [**2136-11-29**] to unknown
for
bradycardia) - 5 mg Tablet - [**12-24**] Tablet(s) by mouth once a day
2. CITALOPRAM - 40 mg Tablet - 1.5 Tablet(s) by mouth once a day
3. CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth
once a
day
4. FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2
puffs
twice a day
5. FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
6. HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s)
by
mouth at bedtime as needed for pain
7. IPRATROPIUM-ALBUTEROL [COMBIVENT] - 103 mcg-18 mcg/Actuation
8. Aerosol - 2 puffs four times a day as needed for sob
9. LEVOTHYROXINE [LEVOXYL] - 137 mcg Tablet - 2 Tablet(s) by
mouth
once a day
10. LISINOPRIL - (Prescribed by Other Provider: [**Name Initial (NameIs) 2000**]; Dose
adjustment - no new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth
once
a day
11. NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually every 5 minutes as needed for chest pain (max 3)
12. ROSUVASTATIN [CRESTOR] - 10 mg Tablet - 1 Tablet(s) by mouth
once
a day
13. ASPIRIN - (OTC) - 325 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
14. OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other
Provider;
OTC) - 1,000 mg Capsule - 1 Capsule(s) by mouth daily
.
Discharge Medications:
1. citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO at bedtime as needed for pain.
6. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-24**]
Puffs Inhalation Q6H (every 6 hours) as needed for Shortness of
breath.
7. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. levothyroxine 137 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
12. bisoprolol fumarate 5 mg Tablet Sig: 0.5 Tablet PO once a
day.
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Complete heart block
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 a dangerous heart rhythm
called complete heart block. You had a pacemaker placed without
complication. You tolerated the procedure well.
.
Some of your medications were changed during this admission:
RESTART bisoprolol 2.5mg daily (you already have these pills)
RESTART lisinopril 5mg daily (you already have these pills)
START cephalexin 500mg every 6 hours for 2 days (8 pills total)
.
You should continue to take all of your other medications as
prescribed.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2136-12-19**] at 10:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: WEDNESDAY [**2136-12-19**] at 3:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: FRIDAY [**2137-1-25**] at 3:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"414.00",
"244.9",
"272.4",
"401.9",
"496",
"426.0",
"311",
"338.29",
"V45.81",
"724.5",
"305.1",
"278.00",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
7952, 7958
|
3972, 5483
|
320, 345
|
8025, 8025
|
3348, 3348
|
8699, 9639
|
2504, 2624
|
6873, 7929
|
7979, 8004
|
5509, 6850
|
8175, 8676
|
2639, 2639
|
1909, 2124
|
3329, 3329
|
260, 282
|
373, 1778
|
3365, 3949
|
2653, 3314
|
8040, 8151
|
2155, 2312
|
1822, 1888
|
2328, 2488
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,472
| 163,951
|
8795
|
Discharge summary
|
report
|
Admission Date: [**2124-10-14**] Discharge Date: [**2124-10-27**]
Date of Birth: [**2066-4-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
Endotracheal intubation
Tracheostomy
PEG tube placement
History of Present Illness:
58 yo M with history of CML treated with allogeneic stem cell
transplant in [**2121**] and complicating graft versus host disease
presents from rehab following an episode of hypoxia to the 70s
earlier today. Patient was discharged from the ICU to the high
level rehab facility on [**2124-10-11**]. Patient notes that he was
doing all prescribed pulmonary hygiene, including inexsufflator
and was at his baseline until early on day of admission when he
felt acutely dyspneic and was noted to have an oxygen saturation
in the 70s. (ED resident originally reported that patient's
[**Year (4 digits) 30712**] was measured on room air; however, patient cannot
corraborate this information. Patient was discharged with
instructions to remain on 4L supplemental oxygen at all times.)
Upon presentation to the ED: T 100.1, HR 76, BP 114/74, RR 22,
O2Sat 100% NRB. Patient was assessed as having a worsened CXR
and was given prednisone 60 mg, albuterol and ipratropium neb,
acetaminophen, Zosyn, and tobramycin. Vitals prior to transfer
to the ICU were: HR 84, BP 112/71, RR 14, O2Sat 98% NRB.
ROS:
(+)ve: productive cough, dyspnea, back pain (baseline),
abdominal pain (baseline)
(-)ve: fever, chills, sweats, constipation, diarrhea, orthopnea,
paroxysmal nocturnal dyspnea, sore throat, myalgias, coughing
with meals or drinking
Past Medical History:
1) CML s/p allogeneic stem cell transplant [**2121**] c/b GVHD
2) Chronic graft vs host disease on immunosuppressants
-has had chronic abdominal discomfort since transplant that is
thought to be associated with GVHD
-bronchiectasis and bronchiolitis obliterans related to GVHD of
the lung
3) h/o resistant pseudomonas ([**2124-6-8**]), ESBL E coli ([**2124-5-21**]),
stenotrophomonas ([**2123-12-23**]) in sputum
4) Linezolid for VRE bacteremia ([**2124-4-24**]) which he contracted
during a hospitalization for cellulitis (see d/c summary
[**2124-5-4**])
5) Chronic RUQ pain since [**2113**] (?in addition to GVH-related
pain)
- work up unrevealing
- on narcotics
6) GERD w/ Barrett's esophagus
7) Hypertension
8) h/o pulmonary embolism in [**5-8**]; DVT [**12-27**]
9) Compression fractures since the beginning of [**2122**] at T8, T9,
T11, L1, and L3
Social History:
Lives with his sister and her husband, although being admitted
from rehab. Previously worked as a manufacturing manager, is now
on disability.
Tobacco: quit > 12 years ago; 10 pack-year history
EtoH: Denies
Illicits: Denies
Family History:
Father with diabetes mellitus, BPH, alive at 85 yrs
Mother with h/o breast cancer; d. TIAs and CVD at 75 yrs
Sister with h/o breast cancer in her 50s, atrial fibrillation
Two brothers with h/o melanoma
Physical Exam:
VITAL SIGNS: T 96.9, HR 103, BP 110/68, RR 15, O2Sat 95% 5L NC
GENERAL: Patient in fetal position on bed, appears fatigued
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. Oral mucosa dry with thick
secretion, oropharynx benign
NECK: Supple, no [**Doctor First Name **]
CARDIAC: RR, nl S1, nl S2, nl M/R/G
LUNGS: Scattered coarse crackles with rhonchi and expiratory
pleural rub.
ABDOMEN: +BS. distended. Tender across lower abdomen. No
rebound.
EXTREMITIES: BLE with 2+ pitting edema halfway up shins.
Bilaterally 2+ DP pulses. 2+ radial pulses.
SKIN: Dry skin throughout and multiple wounds with scabs
NEURO: A&Ox3. Somnolent with delayed response to direct
questions. CN II-XII grossly intact. Preserved sensation
throughout grossly. 5/5 strength UE And LE.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
[**2124-10-14**] 07:20PM WBC-6.6 RBC-3.16*# HGB-10.0*# HCT-31.3*#
MCV-99* MCH-31.6 MCHC-31.8 RDW-20.1*
[**2124-10-14**] 07:20PM PLT COUNT-247
[**2124-10-14**] 07:20PM GLUCOSE-181* UREA N-18 CREAT-0.6 SODIUM-139
POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-42* ANION GAP-8
[**2124-10-14**] 07:20PM CK(CPK)-23*
[**2124-10-14**] 07:20PM CK-MB-NotDone cTropnT-0.21*
[**2124-10-14**] 07:20PM LACTATE-1.7
[**2124-10-14**] 08:50PM TYPE-ART PO2-143* PCO2-79* PH-7.36 TOTAL
CO2-46* BASE XS-15 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2124-10-14**] 11:16PM TYPE-ART PO2-57* PCO2-70* PH-7.40 TOTAL
CO2-45* BASE XS-14 INTUBATED-NOT INTUBA
Discharge Labs:
WBC 5.6, H/H 7.2/22.7, Plts 31.6, MCV 101
RENAL & GLUCOSE-------Gluc BUN Creat Na K Cl HCO3 AnGap
[**2124-10-27**] 03:41AM 102 9 0.6 145 4.1 104 36* 9
Ca 8.0, Phos 2.3, Mg 2.0
.
===============
Microbiology:
===============
Blood Culture [**10-14**] No growth to date
Rapid Respiratory Viral Screen & Culture [**10-15**] Negative (final)
SPUTUM [**10-15**] Source: Endotracheal.
**FINAL REPORT [**2124-10-17**]**
GRAM STAIN (Final [**2124-10-15**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2124-10-17**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**10-20**] Fecal Cx and C diff neg
[**2124-10-24**] 10:00 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2124-10-25**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
.
=============
Studies:
=============
[**2124-10-14**]: ECG: Sinus rhythm. Compared to the previous tracing of
[**2124-9-28**] there is no change
.
[**2124-10-14**]: Chest Xray: Markedly limited study as above. There has
been interval opacification of the retrocardiac left lower lung
which is presumably in part due to atelectasis and large
effusion although a concurrent pneumonia cannot be excluded.
Mild edema.
.
[**2124-10-15**]: CT Chest w/o Contrast:
1. Stable left pleural effusion with dependent consolidation.
Interval
increase in size of right pleural effusion and dependent
consolidation at the right lung base. New opacities at the right
lung in a dependent distribution, likely atelectasis, though a
component of aspiration is possible.
2. Secretions/mucus in the right mainstem bronchus.
3. Stable centrilobular emphysema and basilar bronchiectasis.
4. Multilevel compression fractures throughout the thoracic
spine, not
significantly changed compared to prior study.
5. Nonobstructibe nephrolithiasis.
.
[**2124-10-17**] Chest Xray:
Greater opacification at the base of the right lung is probably
worsening
atelectasis. Severe atelectasis in the left lower lobe and small
bilateral
pleural effusions are stable. Lungs elsewhere are grossly clear
though
pulmonary and mediastinal vascular congestion suggests volume
overload. Of
note, recent chest CT scan showed abundant bronchial secretions
which may be playing a role in the persistent atelectasis.
Moderate cardiomegaly is
stable.
.
[**2124-10-23**] TTE: IMPRESSION: poor technical quality due to patient's
body habitus. Left ventricular function is normal, a focal wall
motion abnormality cannot be fully excluded. The right ventricle
is not well seen. Diastolic function is probably normal. Mild
mitral and aortic regurgitation. Mild pulmonary artery systolic
hypertension. Compared with the prior study (images reviewed) of
[**2124-4-24**], mild aortic regurgitation is seen on the current
study. This was present on the prior study although not reported
as such, likely due to suboptimal image quality.
.
[**2124-10-25**] CXR portable AP: As compared to the previous
examination, the monitoring and support devices are in unchanged
position. The pre-existing left pleural effusion has not changed
in extent. The extent of the retrocardiac atelectasis is also
unchanged. Unchanged perihilar haziness, small right-sided
pleural effusion, and bilateral signs indicative of
mild-to-moderate pulmonary edema. No newly appeared focal
parenchymal opacity suggesting pneumonia.
Brief Hospital Course:
58 year old male with history of CML treated with allogeneic
stem cell transplant in [**2121**] and complicating graft versus host
disease who presented from an LTAC following an episode of
hypoxia with O2 sats in the 70's. Patient was discharged from
the ICU to the high level rehab facility on [**2124-10-11**] and
returned three days later for hypoxia.
.
#. Hypoxia: He has underlying bronchiolitis and bronchiectasis
related to GVHD that causes persistent respiratory compromise
requiring 4L NC of oxygen at baseline. On admission it was felt
that he may have also developed a healthcare-associated
pneumonia given his recent prolonged hospitalizations. He was
treated with Vancomycin and Zosyn empirically, which was then
stopped after a 7 day course ([**Date range (1) 12917**]). Consideration was
given to organisms likely to infect immunocompromised hosts;
however, patient has been on prophylaxis with acyclovir,
bactrim, voriconazole, and tobramycin. He was maintained on 4L
nasal cannula and required deep suctioning to maintain his O2
sats. He was continued on 30mg of prednisone daily, and tapered
to 20mg po prednisone on [**2124-10-20**]. He was ruled out for
influenza and sputum culture and viral culture were negative.
Blood cultures had no growth at the time of discharge. He was
also trialed on BiPap which he did not tolerate as his O2 sats
decreased to low 80's. The patient's respiratory function
continued to decline, and on [**10-23**] was intubated. A tracheostomy
was performed on [**10-24**] and the patient maintained on a ventilator
thereafter. Currently, the patient is maintained on Pressure
Support at 5/5 with FiO2 at 40%. He had a 2 hour SBT on [**10-26**]
with trach mask. He should be weaned off of the ventilator to
trach mask as tolerated. Continue aggressive suctioning,
atrovent and albuterol MDIs.
.
#. CML s/p BMTs, complicated by chronic GVHD: He was continued
on mycophenolate mofetil and continued on prednisone, which was
tapered to 20mg po daily as above. Additionally, he continued
on his home prophylaxis with bactim, voriconazole, tobramycin
and acyclovir. He was started on azithromycin for Mac
prophylaxis and completed a week of 500 mg daily, and was
switched to 250 mg three times weekly on [**10-27**].
.
#. Chronic abdominal pain and back pain: He has chronic pain
thought to be attributable to GVHD after negative prior work-up.
He initially continued on his home regimen of fentanyl patch,
methadone, morphine, lidocaine patches, and pregabalin. A pain
management consult was obtain, and it was felt that the patient
was likely not absorbing his fentanyl scondary to skin tears and
generalized edema. Consequently, his fentanyl patch was
discontinued and he was started on a dilaudid PCA with
improvement in his pain control. He should continue on the
dilaudid PCA with both a basal and bolus rate. The basal rate
has been set at 0.6 mg/hour, with a bolus of 0.37 mg every 10
minutes. Both the basal and bolus rates can be increased for
better pain control. Additionally, he was started on
amytriptiline for improvement in neuropathic pain control. Per
pharmacy, lyrica can be dispensed by opening capsules and
administering through G-tube, although this is off-label.
.
# Risk for Serotonin syndrome: The patient is currently on
various drugs that can precipitate serotonin syndrome
(amytriptiline, citalopram, dilaudid). He should be monitored
for signs of this syndrome, which may include clonus, agitation,
diaphoresis, tremor, hyperreflexia, and fever.
.
#. Hx of PE, DVT: He has had multiple prior thrombotic events.
He was continued on enoxaparin 40 mg Q12H, which is a reduced
dose because of a prior episode of profuse bleeding when on a
higher dose.
.
# Atrial fibrillation: Patient has a history of paroxysmal
Atrial fibrillation, which occurred again this admission, likely
triggered by hypoxia and increased catecholamine surge. His
rate was more responsive to diltiazem than metoprolol, and his
medications were adjusted accordingly. He should be continued
on diltiazem for rate control, although he is in sinus rhythm at
the time of discharge.
.
# Depression: The patient has appeared withdrawn since
admission, which worsened after intubation and tracheostomy. He
was started on citalopram on [**2124-10-25**].
.
# Hypotension: Intermittently hypotensive to 80s systolic,
likely related to administration of sedating medications.
Mentating well with stable urine output at time of admission,
although SBP in the 80-90s systolic.
.
#. Anemia: Hct slowly trended down over the course of his
admission, likely combination of anemia of chronic disease and
recent procedures. Transfused 1U PRBCs on day of discharge.
Repeat Hct should be checked on evening of [**10-27**] or morning of
[**10-28**] to confirm adequate response to transfusion.
Pre-transfusion Hct was and 22.7. The patient remained guaiac
negative.
.
#. FEN: A PEG was placed on [**10-25**] and the patient began receiving
tube feeds for nutrition.
.
#. Code Status: He was full code during this hospitalization.
#. Communication: His emergency contact was [**Name (NI) **] [**Name (NI) 23227**]
(sister) [**0-0-**].
cell: ([**Telephone/Fax (1) 30718**] or [**Telephone/Fax (1) 30719**] home [**Telephone/Fax (1) 30720**], office
[**Telephone/Fax (1) 30721**].
Medications on Admission:
1. Enoxaparin 40 mg/0.4 mL Syringe [**Telephone/Fax (1) **]: Forty (40) mg
Subcutaneous Q12H (every 12 hours).
2. Fentanyl 100 mcg/hr Patch 72 hr [**Telephone/Fax (1) **]: Two (2) patches
Transdermal every seventy-two (72) hours.
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Telephone/Fax (1) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to left side of back for 12 hours daily, then remove for 12
hours.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Telephone/Fax (1) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to right side of back for 12 hours daily, then remove for 12
hours.
5. Methadone 5 mg Tablet [**Telephone/Fax (1) **]: Three (3) Tablet PO BID (2 times a
day)
6. Methadone 10 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO QHS (once a day
at bedtime)
7. Pregabalin 75 mg Capsule [**Telephone/Fax (1) **]: Two (2) Capsule PO QID (4 times
a day)
8. Morphine 30 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
9. Lorazepam 0.5 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Amylase-Lipase-Protease 30,000-10,000- 30,000 unit Capsule,
Delayed Release(E.C.) [**Telephone/Fax (1) **]: Two (2) Capsule, Delayed
Release(E.C.) PO three times a day: with meals.
12. Multi-Vitamin W/Minerals Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO
once a day.
13. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Telephone/Fax (1) **]: Two (2)
Tablet PO DAILY (Daily)
14. Acyclovir 200 mg Capsule [**Telephone/Fax (1) **]: Two (2) Capsule PO Q12H (every
12 hours)
15. Voriconazole 200 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q12H
(every 12 hours)
16. Calcium Carbonate 500 mg Tablet, Chewable [**Telephone/Fax (1) **]: Two (2)
Tablet, Chewable PO three times a day
17. Budesonide 3 mg Capsule, Sust. Release 24 hr [**Telephone/Fax (1) **]: One (1)
Capsule, Sust. Release 24 hr PO Q 8H (Every 8 Hours)
18. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day)
19. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Telephone/Fax (1) **]: One (1)
Tablet PO DAILY (Daily)
20. Polyethylene Glycol 3350 17 gram/dose Powder [**Telephone/Fax (1) **]: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation
21. Docusate Sodium 100 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO BID
(2 times a day)
22. Mycophenolate Mofetil 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
QAM once a day (in the morning)
23. Mycophenolate Mofetil 250 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO
QPM once a day (in the evening)
24. Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO every six
(6) hours as needed for fever or pain
25. Combivent 18-103 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing
26. Tobramycin 300 mg/5 mL Solution for Nebulization [**Telephone/Fax (1) **]: Five
(5) ml Inhalation [**Hospital1 **] (2 times a day): 4 weeks on, 4 weeks off:
started on [**10-7**] to end [**11-4**], to restart on [**12-3**]
27. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) nebulization [**Month/Year (2) **]:
Three (3) ml Inhalation Q2H (every 2 hours) as needed for
wheeze.
28. Ondansetron 4 mg IV Q8H:PRN nausea
29. 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.
30. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID
(2 times a day)
31. Oxygen 2-4 liters/min by nasal cannula at all times
32. Cough assist please dispense on mechanical
insufflator-exsufflator cough assist use: at least twice daily
settings: inspiratory pressure 26, expiratory rpessure 32, pause
dialt at 2, AUTO mode, pressures depend on seal of mask which is
small
33. Respiratory Therapy Requires frequent deep suctioning at
least twice a day; [**Hospital1 **] use of acapella PEP device (at bedside);
hourly use of incentive spirometer (at bedside); at lease twice
daily use of
insuffllator/exsufflator
34. Diphenhydramine HCl 50 mg/mL Solution [**Hospital1 **]: 12.5 mg Injection
x1 PRN as needed for prior to Gammagard.
35. Tylenol 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO x1 PRN as
needed for prior to Gammagard.
36. Gammagard S/D 10 gram Recon Soln [**Hospital1 **]: as directed
Intravenous once a month: next dose [**2124-10-17**]; premdicate with
Tylenol 650mg PO and Benadryl 12.5mg IV.
37. Prednisone 10 mg Tablets, Dose Pack [**Month/Day/Year **]: Four (4) Tablets,
Dose Pack PO once a day: Until [**10-11**], switch to 30 mg
daily until [**10-19**]. Cont. Then, prednisone at 20mg daily
indefinitely
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month (only) **]:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month (only) **]:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
3. Lorazepam 0.5 mg Tablet [**Month (only) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2)
Tablet, Chewable PO TID (3 times a day).
7. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day): hold for loose stools or diarrhea.
8. Polyethylene Glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) PO
DAILY (Daily) as needed for constipation.
9. Tobramycin 300 mg/5 mL Solution for Nebulization [**Last Name (STitle) **]: One (1)
Inhalation [**Hospital1 **] (2 times a day).
10. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for to peri area.
11. Prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**11-19**]
Drops Ophthalmic PRN (as needed) as needed for eye irritation.
13. Diltiazem HCl 30 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QID (4
times a day).
14. Guaifenesin 100 mg/5 mL Syrup [**Month/Day (2) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for secretions.
15. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension [**Month/Day (2) **]:
Ten (10) ML PO DAILY (Daily).
16. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Month/Day (2) **]: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing
or dyspnea.
17. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (2) **]: 1-2 MLs Mucous
membrane [**Hospital1 **] (2 times a day).
18. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day): Hold for loose stools or diarrhea.
19. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO
DAILY (Daily).
20. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
21. Enoxaparin 40 mg/0.4 mL Syringe [**Hospital1 **]: One (1) Subcutaneous
Q12H (every 12 hours).
22. Methadone 5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2 times
a day): hold for sedation or hypotension.
23. Methadone 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QHS (once a
day (at bedtime)): hold for sedation or hypotension.
24. Mycophenolate Mofetil 200 mg/mL Suspension for
Reconstitution [**Hospital1 **]: 2.5 PO QAM (once a day (in the morning)):
(please dispense total of 500 mg qAM).
25. Mycophenolate Mofetil 200 mg/mL Suspension for
Reconstitution [**Hospital1 **]: 1.25 PO QPM (once a day (in the evening)):
(please dispense total of 250 mg qPM).
26. Voriconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours).
27. Pregabalin 75 mg Capsule [**Hospital1 **]: Two (2) Capsule PO QID (4
times a day).
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.
29. Ondansetron 4 mg IV Q8H:PRN nausea
30. Azithromycin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
31. Amitriptyline 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO at
bedtime.
32. Acyclovir 200 mg/5 mL Suspension [**Hospital1 **]: 2.5 PO Q12H (every 12
hours).
33. Hydromorphone (PF) 4 mg/mL Solution [**Hospital1 **]: see instructions
Injection ASDIR (AS DIRECTED): HYDROmorphone (Dilaudid) 0.37 mg
IVPCA Lockout Interval: 10 minutes Basal Rate: 0.6 mg(s)/hour
1-hr Max Limit: 2.82 mg(s)
.
34. Morphine 30 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain: [**Month (only) 116**] uptitrate as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Brochiolitis obliterans, Chronic Graft vs. Host
Disease, CML
Secondary: Vertebral Fractures
Discharge Condition:
Vitals stable, oxygen saturation of 95%, Not ambulatory but up
to chair with assistance.
Discharge Instructions:
You have a diagnosis of CML and GVHD causing severe lung disease
and were admitted to the hospital because of low oxygen and
difficulty breathing. While in the hospital, you were treated
with antibiotics for a possible pneumonia, as well as oxygen and
respiratory therapy. You were intubated due to respiratory
distress and had a tracheostomy placed. You also were give a
feeding tube (PEG) in your stomach to help with your nutrition.
He tolerated trach collar trials well and may not need very much
ventilatory support after discharge. He should be liberated
from the ventilator as tolerated after discharge.
Followup Instructions:
You have follow-up appointment with your Pulmonologist Dr.
[**Last Name (STitle) **] as follows:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2124-11-2**] 2:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2124-11-2**] 3:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2124-11-2**] 3:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,436
| 122,275
|
2259
|
Discharge summary
|
report
|
Admission Date: [**2192-3-10**] Discharge Date: [**2192-3-19**]
Date of Birth: [**2121-8-17**] Sex: F
Service: GOLD SURGERY
HISTORY OF PRESENT ILLNESS: This is a 70-year-old female
with a history of hypertension, chronic renal insufficiency,
gastroesophageal reflux disease who is status post childhood
head injury who presented to the Emergency Room with 12 hours
of multiple episodes of projectile vomiting. She is a
resident of [**Hospital 2670**] Nursing Home and there at that facility
was started on intravenous fluids. A nasogastric tube was
also placed which returned approximately 1500 cc of
questionable bilious material with reported coffee grounds
and was also reported heme positive. In the Emergency Room,
a KUB was done which showed air fluid levels and dilated
small bowel loops consistent with a small bowel obstruction.
She was admitted to the medical service, was made NPO,
started on intravenous fluids and her nasogastric tube was
kept to low wall suction. Her nasogastric was putting out
about 150 to 350 cc per day, however the patient continued to
complain of diffuse abdominal pain with distention. There
was no report of flatus or bowel movements, although the
patient was somewhat unreliable. Due to the patient's
failure to improve, a CT scan was obtained which showed
dilated loops of small bowel with free fluid in the abdomen
and the possibility of a closed loop obstruction. A surgical
consultation was called at that time and it was, upon review
of the CT scan, thought that the patient had a complete small
bowel obstruction. She was then taken to the Operating Room
for exploratory laparotomy.
PAST MEDICAL HISTORY:
1. Hypertension
2. Chronic renal insufficiency
3. Congestive heart failure with an ejection fraction of 25%
to 30%.
4. She is status post appendectomy.
5. Hypothyroidism
6. Degenerative joint disease
7. Anemia
8. Gastroesophageal reflux disease
9. History of diverticulitis in [**2191-6-22**]
10. Status post total knee replacement in [**2185**]
SOCIAL HISTORY: No alcohol or tobacco.
ALLERGIES: BIAXIN
MEDICATIONS:
1. Prevacid 30 mg po qd
2. Lopressor 12.5 mg po bid
3. Hydrochlorothiazide 12.5 mg po bid
4. Senokot 200 mg po q hs
5. Levoxyl 25 mcg po qd
6. Colace 100 mg po bid
7. Iron supplement
8. Ambien 10 mg po q hs
9. Pamelor 10 mg po q hs
10. Tums
11. Celebrex
12. Multivitamins
13. Niferex 150 mg po bid
LABORATORY AND IMAGING STUDIES: White blood cell count 5.9,
hematocrit 32.5, platelet count 198. Chemistries: Sodium
140, potassium 4.2, chloride 106, CO2 26, BUN 44, creatinine
1.5, glucose 121. Initial CK was 31. KUB from [**2191-3-11**] showed dilated small bowel with air fluid levels, no
clear transition point. Abdominal CT from [**2191-3-13**]
showed dilated loops of small bowel with free fluid in the
abdomen. No free air.
BRIEF HOSPITAL COURSE: The patient postoperatively was then
transferred to the general surgical service. She underwent,
on the [**3-12**], [**First Name3 (LF) **] exploratory laparotomy with lysis of
adhesions under general endotracheal anesthesia.
Intraoperatively, a complete small bowel obstruction with a
closed loop and multiple adhesions were found. There were no
complications. She was transferred to the Surgical Intensive
Care Unit intubated and sedated where she stayed secondary to
her cardiac history, history of congestive heart failure and
prolonged preoperative illness. She was extubated that
evening in the PACU and remained stable from a respiratory
standpoint. Her nasogastric continued with minimal output.
She was at her baseline mental status. She was placed on a
rule out myocardial infarction protocol secondary to her
history. She also required placement of a Swan-Ganz catheter
for accurate assessment of her fluid status. She was also
kept on Lopressor, cardioprotective as well as to manage her
heart rate and blood pressure. She continued NPO. Her urine
output was initially low. She received multiple fluid
boluses and the Swan-Ganz catheter as previously mentioned.
She was also placed on Venodynes, subcutaneous heparin and
Protonix for prophylaxis. She remained in the Intensive Care
Unit until postoperative day #3, during which time she ruled
out for a myocardial infarction and remained hemodynamically
stable.
On postoperative day #4, she remained afebrile,
hemodynamically stable. The patient reported passing flatus
and her abdomen was soft and flat. She was started on sips.
PT consult and rehabilitation screen were done. Her home
medications were restarted. On postoperative day #5, the
patient was tolerating sips well and she was advanced to
clears with aspiration precaution. She did well on this and
in addition her Foley catheter was removed secondary to not
needing to follow her urine output as closely. She continued
to do well, was advanced to a regular diet on postoperative
day #6 and was deemed stable for discharge back to her
rehabilitation facility on postoperative day #7. She
remained afebrile throughout her hospital course was and was
hemodynamically stable both in and out of the unit. She
continued to make good urine, tolerating a regular diet and
was accepted at her previous living facility.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: The patient is discharged to the [**Hospital3 11911**] Facility to continue her postoperative care.
DISCHARGE DIAGNOSES:
1. Status post exploratory laparotomy with lysis of
adhesions for a complete close loop small bowel obstruction.
2. Hypertension
3. Chronic renal insufficiency
4. Congestive heart failure
5. Hypothyroidism
6. Degenerative joint disease
7. Anemia
8. Gastroesophageal reflux disease
9. History of diverticulitis
DISCHARGE MEDICATIONS:
1. Prevacid 30 mg po qd
2. Lopressor 50 mg po bid
3. Hydrochlorothiazide 12.5 mg po bid
4. Senokot 2 tablets po q hs
5. Levoxyl 25 mcg po qd
6. Colace 100 mg po bid
7. Pamelor 10 mg po q hs
8. Tums 300 mg po bid
9. Niferex 150 mg po bid
10. Tylenol 650 mg po q 4 to 6 hours prn
DISCHARGE INSTRUCTIONS: The patient is to resume a regular
diet. She is to continue on tid ambulation. Bowel regimen
with stool softeners, Colace and Senokot as needed. Her
Steri-Strips are to be left in place until they fall off on
their own. Wound is to be checked for redness.
FOLLOW UP: She is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2192-3-19**] 09:09
T: [**2192-3-19**] 09:17
JOB#: [**Job Number 11912**]
|
[
"428.0",
"401.9",
"414.01",
"276.5",
"560.81",
"593.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"54.59",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
2884, 5241
|
5263, 5391
|
5412, 5732
|
5755, 6043
|
6068, 6329
|
6341, 6727
|
174, 1660
|
1682, 2038
|
2055, 2435
|
2453, 2860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,782
| 152,810
|
50254+59239
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-4-9**] Discharge Date: [**2116-4-22**]
Date of Birth: [**2041-10-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Hypopharyngeal mass biopsy
Tracheostomy
History of Present Illness:
74M esophogeal adenocarcinoma in situ (no nodes) s/p
esophagogastrectomy and feeding jejonostomy [**8-25**] (c/b
pseudomonal pna, and trach [**9-25**]) admitted from OSH with 24 hrs
of worsening SOB, productive cough and stridor. Patient has had
progressively worsening stridor and dysphagia - evaluated in [**Hospital **]
clinic ([**Hospital 64107**]) in [**Month (only) 547**] and sent for CT of neck [**4-3**] that
showed a large soft tissue neck mass.
.
In [**Name (NI) **], pt was hypoxic requiring 3L NC; WBC 12.3 with a L shift
and had a CXR showing RML PNA. At that time, treated with
flagyl, cefepime, levaquin, dexamethasone. ENT saw pt in ED and
on laryngoscope he had diffuse edema of B/L vocal cords but not
epiglottitis with marked airway narrowing. He was intubated for
respiratory distress/airway protection.
.
At NH had been noted to have increasing lethargy, confusion on
[**4-8**] with increasing cream colored sputum. Pt denied
CP/n/v/constipation/ diarrhea.
.
During his MICU course, he was followed closely by ENT and
thoracic surgery regarding this large soft tissue neck mass. It
was unclear if it was recurrence of his cancer or a complication
of his surgery several months ago. Underwent rigid bronchoscopy
and biopsy [**4-10**] to obtain tissue of this mass, which showed
squamous mucosa with fibrosis and perivascular acute and chronic
inflammation, no malignancy identified. Also had EGD at the
same time, which showed a widely patent anastomosis, no masses,
multiple gastric polyps. Had CT chest to assess of new lymph
nodes/metastatic disease, which showed CHF/new ascites, but no
metastases, LAD. Did show partial mass as seen on CT from [**4-3**].
.
On [**4-13**], went to OR again for tracheostomy, direct
laryngoscopy/biopsy of hypopharyngeal mass as it was felt they
did not get enough tissue the first time, pathology still
pending. Had multiple episodes of hypotension, decreased UOP.
Underwent echo which showed new decreased EF 30-35%, moderately
dilated LA/moderate regional LV systolic dysfunction with HK of
basal wall. Mild 1(+) MR/AR. Moderate pulmonary HTN.
.
Was treated with 7 day course zosyn for pneumonia. Has afib,
anticoagulation held given multiple procedures, now restarted on
warfarin. Evaluated by cardiology given new echo findings/WMA;
needs cardiac work up including stress mibi once acute medical
issues are resolved. Now transferred to the floor.
Past Medical History:
1. Esophageal adenocarcinoma in situ s/p esophagogastrectomy
with pull up 11/04 c/b 50 day hospital course for psuedomonal
PNA, pleural effusions, trach, J-tube
2. Afib s/p pacemaker on coumadin
3. "HOCM" Echo [**10-25**]: mild symmetric LVH; EF>60%, min AS,
[**11-24**]+MR, 2+TR
4. Prostate Cancer
5. HTN
6. OSA
7. Hypothyroid
Social History:
Retired truck driver. Lives at [**Location **]. No tobacco/EtOH/IVDU.
Family History:
NC
Physical Exam:
PE: T 98.7 P 80 BP 132/73 RR 22 Pox 98% FM
General pleasant, NAD
HEENT EOMI, PERRL, OP clear, trach in place
Heart irregularly irregular with no murmurs
Lungs CTA B
Abd soft, NT, ND, BS(+)
Ext warm, no edema; 2(+) DP pulses
Neuro grossly non-focal
Skin no rashes
Brief Hospital Course:
A/P: 74M esophageal adenocarcinoma admitted with SOB, stridor
found to have new hypopharngeal mass, now s/p tracheostomy for
airway protection.
.
Hospital course is as per the HPI.
.
To summarize:
.
1. Hypopharyngeal mass/tracheostomy-At this point, the etiology
is still not clear. Had an initial biopsy which did not show
evidence of malignancy. Given the rapid growing nature of the
mass and his h/o esophageal adenocarcinoma, malignancy was high
on the differential. He underwent a second biopsy for more
tissue in hopes of a more definitive diagnosis; however, the
pathology also did not show malignancy. He had a tracheostomy
placed during his second biopsy as there was concern of the mass
compromising his airway. The patient will follow up with Dr.
[**Last Name (STitle) 64107**] of ENT at which time they will discuss how to treat the
mass and how long he will need to have his trach.
.
2. Cardiomyopathy-Patient has a h/o HOCM and now new (since
[**2114**]) decreased EF 30-35% with LV HK, etiology unclear. [**Name2 (NI) **]
further cardiac work up (wtih stress mibi) once acute issues are
resolved. He was continued on ASA 81 mg po qd, captopril 25 mg
po TID, lopressor 25 mg po bid and digoxin 0.125 mg po qd as
well as atorvastatin 10 mg po qd for h/o hypercholesterolemia.
.
3. Patient has a h/o atrial fibrillation-His coumadin was held
for all his biopsies, but was restarted after consultation with
ENT. He needs to have daily INRs checked until he is
therapeutic on his coumadin, with goal INR [**12-26**]. Please adjust
his dose accordingly.
.
4. Anemia-Patient appears to have an Fe deficiency anemia, and
would benefit from iron therapy. He was started on iron sulfate
and was given one unit pRBC transfusion. He should discuss age
appropriate cancer screening including colonoscopy with his PCP.
.
5. FEN-J tube feedings for now. Video swallow exam showed
aspiration after swallowing thick and thin liquids. Although
nutrition felt he could take a PO diet with special precautions,
ENT did not feel patient should eat because he is aspirating.
PO meds should be crushed via his J tube. Continue current J
tube feedings.
.
6. OF NOTE, patient does not have h/o hypothyroidism prior to
his recent hospitalizations. Was evidently placed on levoxyl
prior to admission at rehab. Was not on levoxyl during his
hospitalization. His TSH was checked and was WNL. Needs to
have his TSH checked after his acute medical issues are
resolved.
.
7. Trach care-Patient currently has a cuffed tracheostomy (to
help prevent aspiration, as he is aspirating per swallow study).
He should have a repeat swallow study in 2 weeks. If at that
time he is not aspirating, he can be switched to a non-cuffed
tracheostomy. He can continue with PMV trials as tolerated.
The tracheostomy cuff should be taken down when he has these
trials. Trach skin care as per usual regimen.
Medications on Admission:
Meds on Admission from OSH records:
Digoxin 0.125 mg qd
Lopressor 100 mg po BID
Flomax 0.4 mg qd
Prevacid 30 mg [**Hospital1 **]
Coumadin 3/2.5 mg alternating
Ativan prn
.
Meds on transfer from MICU:
colace 100 mg po bid prn
heparin 5000 units SC TID
albuterol 2 puffs IH Q6h prn
RISS
ASA 81 mg po qd
Lansoprazole 30 mg qd
Atorvastatin 10 mg PO qd
Metoprolol 50 mg PO/NG [**Hospital1 **]
Bisacodyl 10 mg PR HS:PRN
Captopril 25 mg PO TID
Digoxin 0.125 mg NG DAILY
Warfarin 5 mg PO HS
.
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
9. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Hypopharyngeal mass
Tracheostomy
Discharge Condition:
Patient is urinating, having bowel movements. He is getting
tube feeds. He should have a swallow evaluation to determine if
he can take anything by mouth. He needs to work with physical
therapy to get his strength back.
Discharge Instructions:
Patient should seek medical attention if he develops fevers,
shortness of breath or any other symptom of concern.
He needs to have his INR checked to maintain a level between 2
and 3. His coumadin dose should be adjusted accordingly.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Where: [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2116-6-10**] 11:00
.
Patient should call Dr. [**Last Name (STitle) 64107**] ([**Telephone/Fax (1) 6213**] to make an
appointment for NEXT week. He needs to follow up with him
regarding his hospitalization and to have a follow up CT scan.
At that appointment they can discuss a long term plan for his
tracheostomy and management of his mass.
.
Please call Dr. [**Last Name (STitle) 120**], your cardiologist, at ([**Telephone/Fax (1) 10085**] to
schedule a follow up appointment, stress test.
Completed by:[**0-0-0**] Name: [**Known lastname **],[**Known firstname 1500**] Unit No: [**Numeric Identifier 17027**]
Admission Date: [**2116-4-9**] Discharge Date: [**2116-4-22**]
Date of Birth: [**2041-10-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 211**]
Addendum:
On the day of discharge, patient was having intermittent
episodes of ventricular tachycardia. He did not have any
symptoms of chest pain or SOB. He was evaluated by the
electrophysiologists, who felt that he is not a candidate for an
ICD given his other comorbidities. In addition, it is unclear
if he has ischemic or non-ischemic cardiomyopathy, which is part
of the criteria to determine whether he would qualify for an
ICD. He will be following up with his cardiologist for further
work up of this new cardiomyopathy as recommended.
.
FOR NOW:
Plan is to d/c is his DIGOXIN
Start TOPROL XL 150 mg PO QD
.
Give patient a dose of metoprolol 75 mg [**4-22**] p.m.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**]
Completed by:[**0-0-0**]
|
[
"244.9",
"482.1",
"427.1",
"V45.01",
"416.8",
"478.20",
"518.81",
"530.89",
"427.31",
"478.6",
"V58.61",
"V44.4",
"280.9",
"V10.03",
"425.1",
"428.0",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"99.04",
"45.13",
"38.93",
"31.42",
"96.04",
"31.1",
"29.12"
] |
icd9pcs
|
[
[
[]
]
] |
10264, 10485
|
3590, 6486
|
334, 376
|
7914, 8138
|
8422, 10241
|
3283, 3287
|
7022, 7742
|
7858, 7893
|
6512, 6999
|
8162, 8399
|
3302, 3567
|
275, 296
|
404, 2827
|
2849, 3179
|
3195, 3267
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,668
| 181,297
|
36027
|
Discharge summary
|
report
|
Admission Date: [**2156-12-1**] Discharge Date: [**2156-12-4**]
Date of Birth: [**2098-7-8**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
diplopia, headache, memory loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 32126**] is a 58 year old right handed male presenting with
diplopia, headache and memory loss. He was well until afternoon
of [**2156-12-1**] when after returning from his morning bible study
session and working out in his yard to cut down trees damaged in
the recent [**State 32926**] ice storm... he does not
remember much else of the morning. According to his wife, she
returned home at 5:30pm to find the house dark and that her
husband had slept most of the day, which was quite unusual. At
that point her husband reported horizontal diplopia, resolved by
closing one eye. He was unable to recall the events of the
morning in detail. His wife called EMS and he was taken to [**First Name8 (NamePattern2) 1495**]
[**Hospital3 6783**] Hospital in [**Hospital1 1559**]. There a head CT revealed a
2.1x1.3cm hemorrhage in the left posterior temporal lobe. He was
noted to have a low grade temperature to 100.4. An MRI/A/V was
performed which did not reveal any venous sinus thrombosis or
acute infarct. While at the OSH, the patient noted severe neck
pain and a rash on the posterior aspect of his neck. He was
given
Acyclovir IV, Ceftriaxone 2g IV, Decadron 10mg IV and
transferred
to [**Hospital1 18**] for further care.
On arrival at [**Hospital1 18**] the patient was given vancomycin 1g,
ampicillin, temperature was 100.4. The patient reports a left
sided headache that only occurs when rotating his head. Subsides
when still. He denies any dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denied difficulties
producing or comprehending speech. His wife comments on a
clearly
new and prominent short term memory deficit. "he is very
confused." He denies focal weakness. He has chronic (several
years) numbness, parasthesias of his left great toe. No bowel or
bladder incontinence or retention. Denied difficulty with gait
although he has not walked since EMS picked him up yesterday
afternoon.
On review of systems, the pt denied recent fever or chills or
other illness. No night sweats or recent weight loss or gain.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Denied rash. No known sick contacts. There are no pets in the
home. No recent hunting/fishing expeditions. No recent travel in
or outside the U.S. Their home is on city water supply.
Past Medical History:
1) Migraine headache- experiences visual aura of blurred vision,
followed by throbbing headache. experiences these on a weekly
basis, but no longer has headaches since he takes excedrin
migraine the earliest symptom.
2) Chronic left great toe paresthesias- has seen neurologist
regularly for this in the past, pt unsure of the dx.
3) Ascending aortic aneurysm- noted by PCP from routine EKG on
[**2155-10-21**]. Unclear of the dimensions/extent.
GERD
No known hypertension, DM2, hyperlipidemia
Social History:
Married, has a daughter at bedside, self employed in
entrepreneurial sales from his home, lives in [**Hospital1 1559**], MA.
Never smoker, no ETOH, no illicit or IV drug use.
Family History:
Father- prostate cancer
Mother- died of liver cancer
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T 100.4, HR 90, BP 150/100-->113/67 on repeat, R 18, Sat
99% RA, Height: 6'2"
General: obese, ill appearing, pleasant and cooperative however,
NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: marked nuchal rigidity, no JVD or carotid bruits
appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: obese soft, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: trace bilateral LE edema, 2+ radial, DP pulses
bilaterally. Negative Kernig's, + Brudzinski
Skin: petechial rash over posterior neck.
Neurologic:
Mental Status: oriented to hospital, person, city is difficult
to
place, unsure if he's in [**Location (un) 86**], takes unable to name that he
was
just transferred from [**Hospital1 **]. He is unable to relate his
recent history, has difficulty providing details of his work and
home life. He is inattentive, unable to name [**Doctor Last Name 1841**] backwards,
skipping several months witout noticing. Difficulty switching
sets. Language is fluent with intact repetition and
comprehension of complex phrases. Normal prosody. He makes
occaional paraphasic errors. Patient had difficulty naming both
high and low frequency objects and would substitute incorrect
names for common objects. PAtient made frequent paraphasic
errors while trying to read simple sentences. He is able to
write
"the boat was very big." Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects, but unable to recall any of the 3 at 5
minutes despite cues. No neglect based on interpretation of NIH
cookie theft picture.
Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and brisk.
VFF to confrontation. There is no ptosis bilaterally.
Funduscopic exam revealed papilledema of the left optic disc, no
exudates, or hemorrhages. He has a pure left CN VI palsy, unabel
to abduct his left eye past the midline. Otherwise EOMI without
nystagmus. Normal saccades aside from L CN VI. Facial sensation
intact to pinprick. No facial droop, facial musculature
symmetric. Hearing intact to finger-rub bilaterally. Palate
elevates symmetrically. 5/5 strength in trapezii and SCM
bilaterally. Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No adventitious movements
noted. No asterixis noted.
No pronator drift bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
Gait: deferred.
Pertinent Results:
[**2156-12-1**] 03:50PM GLUCOSE-123* CREAT-1.1 SODIUM-141
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2156-12-1**] 03:50PM CALCIUM-9.3 PHOSPHATE-3.4# MAGNESIUM-2.3
[**2156-12-1**] 03:50PM WBC-12.0* RBC-4.39* HGB-13.5* HCT-37.8*
MCV-86 MCH-30.7 MCHC-35.7* RDW-13.7
[**2156-12-1**] 03:50PM PLT COUNT-216
[**2156-12-1**] 01:39PM PTT-22.0
[**2156-12-1**] 01:39PM PT-14.1* PTT-29.2 INR(PT)-1.2*
[**2156-12-1**] 01:39PM PTT-22.0
[**2156-12-1**] 01:39PM ACA IgG-3.0 ACA IgM-6.9
[**2156-12-1**] 01:39PM AT III-96 PROT C AG-97 PROT S AG-93
[**2156-12-1**] 01:39PM LUPUS-NEG
[**2156-12-1**] 12:07PM ALT(SGPT)-34 AST(SGOT)-39 LD(LDH)-433*
CK(CPK)-616* ALK PHOS-81 TOT BILI-1.5
[**2156-12-1**] 12:07PM CK-MB-4 cTropnT-<0.01
[**2156-12-1**] 12:07PM ALBUMIN-4.4
[**2156-12-1**] 12:07PM HOMOCYSTN-7.2
[**2156-12-1**] 09:40AM HOMOCYSTN-7.5
[**2156-12-1**] 09:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2156-12-1**] 09:40AM ACA IgG-3.4 ACA IgM-7.2
[**2156-12-1**] 09:40AM AT III-96 PROT C FN-123 PROT S FN-62
[**2156-12-1**] 09:20AM URINE HOURS-RANDOM
[**2156-12-1**] 09:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2156-12-1**] 09:05AM CEREBROSPINAL FLUID (CSF) PROTEIN-248*
GLUCOSE-73
[**2156-12-1**] 09:05AM CEREBROSPINAL FLUID (CSF) WBC-111 RBC-[**Numeric Identifier 81778**]*
POLYS-60 LYMPHS-40 MONOS-0
[**2156-12-1**] 09:05AM CEREBROSPINAL FLUID (CSF) WBC-167 RBC-[**Numeric Identifier 81779**]*
POLYS-100 LYMPHS-0 MONOS-0
[**2156-12-1**] 05:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2156-12-1**] 05:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2156-12-1**] 05:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2156-12-1**] 03:30AM GLUCOSE-138* UREA N-11 CREAT-1.0 SODIUM-141
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
[**2156-12-1**] 03:30AM estGFR-Using this
[**2156-12-1**] 03:30AM CALCIUM-9.4 PHOSPHATE-1.5* MAGNESIUM-2.2
[**2156-12-1**] 03:30AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2156-12-1**] 03:30AM WBC-12.3* RBC-4.63 HGB-14.4 HCT-39.3* MCV-85
MCH-31.2 MCHC-36.7* RDW-13.6
[**2156-12-1**] 03:30AM NEUTS-92.4* LYMPHS-5.8* MONOS-1.4* EOS-0.4
BASOS-0.1
[**2156-12-1**] 03:30AM PLT COUNT-223
[**2156-12-1**] 03:30AM PT-14.0* PTT-31.6 INR(PT)-1.2*
Brief Hospital Course:
Mr. [**Known lastname 32126**] is a 58 year old right handed male who presented with
diplopia, headache, low grade fever and neck pain, found to have
a small left posterior temporal hemorrhage after having
sustained head and upper back from a chainsaw accident. He was
also found to have spinous process and endplate fracture in the
cervical and thoracic spines, respectively. On admision, his
examination was notable for nuchal rigidity, inattention and
perseveration,
paraphasic errors, mild anomia, short term memory deficit, left
cranial nerve VI palsy, left eye papilledema.
CSF:
WBC RBC Polys Lymphs Monos
1111 [**Numeric Identifier 81778**]*2 603 40 0
TUBE # 4
1[**Numeric Identifier 81780**]*2 1004 0 0
Patient was treated with acyclovir; HSV PCR result negative.
Blood preassure was controlled maintaining SBP bellow 160
Serial head CT showed that the intracranial bleed was stable.
Orthopedic spine specialists evaluated his spinal fractures and
recommended wearing a hard cervial collar and back brace until
follow-up with them as an outpatient in 10 days. He was also
started on a anti-seizure medication (Dilantin) which he should
be continued until follow-up in [**Hospital 4038**] clinic. Aspirin was held
until next appointment.
He was also found to have a patent foramen ovale on
echocardiogram.
He should have anti-coagulation profile followed-up in clinic:
anticariolipin antibody, factor V leiden and prothrombin.
Medications on Admission:
Aspirin daily
Prilosec
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*2*
3. Tylenol Ex Str Arthritis Pain 500 mg Tablet Sig: One (1)
Tablet PO every six (6) hours as needed for pain. Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
traumatic left temporo-parietal intracranial hemorrhage
fracture of C7 spinous process
fracture of inferior endplate of T10
left cranial nerve VI palsy (lateral rectus)
patent foramen ovale
secondary diagnosis:
migraine headache
chronic left great toe paresthesias
ascending aortic aneurysm
GERD
Discharge Condition:
Stable. In hard cervical collar and
thoracic-lumbar-spine-orthotic (back brace) when out of bed.
Discharge Instructions:
You sustained trauma to the back of your head and upper back
from a chainsaw accident and was found to have an intracranial
bleed, spinous process and endplate fracture in your cervical
and thoracic spines, respectively. You also have retrograde and
anterograde amnesia of events surrounding the accident.
Serial head CT showed that the intracranial bleed was stable.
Orthopedic spine specialists evaluated your spinal fractures and
recommended wearing a hard cervial collar and back brace until
follow-up with them as an outpatient in 10 days. You were
started on a anti-seizure medication (Dilantin) which should be
continued until follow-up in [**Hospital 4038**] clinic.
Aspirin was held and should not be resumed until you follow-up
in [**Hospital 4038**] clinic.
Wear the eye patch alternating every 8 hours for your double
vision. If your double vision persists, then you should be
referred to Dr. [**Last Name (STitle) 81781**] [**Name (STitle) **] in [**Hospital 13279**] clinic
(Phone: [**Telephone/Fax (1) 253**]).
You were incidientally found to have a patent foramen ovale
which did not change your medical management.
You also had some tests that were pending at discharge that
should be reviewed at your follow-up appointemnts: CSF HSV PCR,
anticariolipin antibody, factor V leiden and prothrombin. These
tests were obtained prior to obtaining a clearer history of
trauma as the cause of your injuries and so were ultimately not
needed pertinent.
Please keep your follow-up appointments.
Please take your medications as prescribed.
If you have any worsening or worrying symptoms, please call your
PCP or return to the emergency room.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**], MD Phone: [**Telephone/Fax (1) 3573**]
Please follow-up in [**Hospital **] clinic within 10 days of discharge.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 2174**] [**Doctor Last Name 59104**], MD Phone: [**Telephone/Fax (1) 54771**]
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone: [**Telephone/Fax (1) 2574**]
Please follow-up in [**Hospital 4038**] clinic with 1-2 months of discharge.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2156-12-11**]
|
[
"378.54",
"427.89",
"530.81",
"V12.59",
"805.07",
"780.39",
"E884.9",
"368.2",
"853.00",
"346.00",
"782.0",
"805.2",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
11156, 11162
|
9261, 10702
|
346, 353
|
11522, 11622
|
6777, 9238
|
13331, 14057
|
3617, 3671
|
10775, 11133
|
11183, 11183
|
10728, 10752
|
11646, 13308
|
3686, 3686
|
3708, 4341
|
275, 308
|
381, 2891
|
5420, 6758
|
11414, 11501
|
11202, 11393
|
4356, 5404
|
2913, 3408
|
3424, 3601
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,403
| 104,048
|
34842
|
Discharge summary
|
report
|
Admission Date: [**2129-10-6**] Discharge Date: [**2129-10-15**]
Date of Birth: [**2050-12-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
new onset angina
Major Surgical or Invasive Procedure:
[**2129-10-7**] cardiac catheterization
[**2129-10-11**] AVR ( 21mm CE pericardial)/ cabg x1 (LIMA to LAD)
History of Present Illness:
78 yo male awakened from sleep with sharp chest spasm that
radiated down right arm. It lasted approx. 30 seconds and then
he had multiple episodes over 10 minutes. Has had several
episodes per day. Also noted to have left sided twitching over
precordial area. Had associated nausea.
Past Medical History:
severe PVD with multiple aneurysms in LE
COPD- in pulm. rehab
OSA on CPAP
CHF [**5-10**]
multiple PNAs
AS
carotid stenosis
elev. chol.
PSH: bil. LE bypass procedures x 6; last bypass with goretex due
to unusable vein
eye surgery as a child
Social History:
lives with wife
100 pack-year history-quit 22 years ago
12 beers a month/ one shot of sambuca per week
drives school bus
Family History:
son with MI at 46
Physical Exam:
5'3" 74.8 kg
SR 83 RR 15 123/78
NAD
diminshed BS bilat.;increased AP diameter
RRR 2/6 harsh SEM heard best at left axilla
soft NT, ND + BS
warm, well-perfused, trace edema, several well-healed scars BLE
no varicosities noted
1+ bil. fems
trace to 1+ right DP/PTs
dopplerable left DP/PTs
2+ bil. radials
no carotid bruits
Pertinent Results:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated one-vessel coronary artery disease. The LMCA, LCX,
and RCA
were all free of angiographically-appareny flow-limiting
stenoses. The
LAD had a proximal eccentric and likely ulcerated 70% stenosis.
2. Resting hemodynamics demonstrated moderate aortic stenosis
with a
gradient of 19 mmHg. Right- and left-sided filling pressures
were
high-normal with an RVEDP of 8 mmHg and a PCWP a-wave of 10.
There was
mild pulmonary hypertension with an RVSP of 36 mmHg.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate aortic stenosis.
3. Mild pulmonary arterial hypertension.
ATTENDING PHYSICIAN: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] B.
[**Last Name (LF) **],[**First Name3 (LF) **]
ATTENDING STAFF: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J.
([**Numeric Identifier 79780**])
Conclusions
PREBYPASS
A patent foramen ovale is present with left-to-right shunt at
rest. Left ventricular wall thicknesses and cavity size are
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is mildly dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is moderate to severe aortic valve
stenosis (area ~1.2 cm2 Mild to moderate ([**2-2**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits).
POSTBYPASS
Patent has poor windows post bypass, LV function appears to
remain good with EF 55% but segmental motion hard to identify.
The aortic contour is smooth post decannulation. An prostetic
aortic valve is well seated in the aortic annulus. Trace
perivalvular leak is seen. Mitral regurgitation is seen post
bypass but remains unchanged from prior study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Known firstname **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician
Radiology Report CHEST (PORTABLE AP) Study Date of [**2129-10-13**] 3:06
PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2129-10-13**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79781**]
Reason: ? ptx s/p mt removal
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? ptx s/p mt removal
Provisional Findings Impression: IPf [**Doctor First Name **] [**2129-10-13**] 4:53 PM
No pneumothorax.
Final Report
PROCEDURE: Portable AP chest radiograph.
Comparison done with chest radiograph from [**10-13**] at 1:27
p.m.
78-year-old man with status post CABG, questionable pneumothorax
status post
mid thoracic chest tube removal.
_____: Mid thoracic chest tube removed. No pneumothorax. The
rest of the
lungs appear unchanged.
IMPRESSION: No pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2129-10-13**] 5:26 PM
Imaging Lab
?????? [**2124**] CareGroup IS. All rights reserved.
[**2129-10-15**] 08:20AM BLOOD WBC-14.9* RBC-3.47* Hgb-9.9* Hct-29.1*
MCV-84 MCH-28.6 MCHC-34.1 RDW-14.7 Plt Ct-180#
[**2129-10-6**] 11:50PM BLOOD WBC-9.0 RBC-4.87 Hgb-13.6* Hct-39.4*
MCV-81* MCH-28.0 MCHC-34.6 RDW-14.0 Plt Ct-275
[**2129-10-13**] 02:02AM BLOOD PT-12.8 PTT-25.0 INR(PT)-1.1
[**2129-10-6**] 11:50PM BLOOD PT-13.2 PTT-25.1 INR(PT)-1.1
[**2129-10-15**] 08:20AM BLOOD Glucose-140* UreaN-20 Creat-0.9 Na-135
K-4.1
[**2129-10-6**] 11:50PM BLOOD Glucose-134* UreaN-23* Creat-1.3* Na-139
K-4.0 Cl-98 HCO3-30 AnGap-15
[**2129-10-12**] 02:05AM BLOOD Type-ART pO2-100 pCO2-42 pH-7.37
calTCO2-25 Base XS-0
Brief Hospital Course:
Admitted [**10-6**] and had a cardiology consult done. Cath the next
day showed AS and LAD dz. Carotid US showed [**Country **] 60-69%. Vein
mapping,echo, and pulm consult also done pre-op. Underwent CABG
x1/AVR (#21mm [**Doctor Last Name **]) with Dr. [**First Name (STitle) **] on [**10-11**]. Please refer to
Dr[**Doctor First Name **] operative report for further details. Transferred to
the CVICU in stable condition on titrated phenylephrine and
propofol drips. Extubated late that night and steroid taper
started. Aggressive pulmonary toilet done. POD#1 he was
transferred to the SDU for further telemetry monitoring ans
recovery. The remainder of his postoperative course was
essentially unremarkable.POD#3 small serous drainage seen on
his sternotomy incision. Prior to discharge his sternum was
stable, C/D/I. He continued to progress and on POD#4 was
discharged to home with VNA. He was advised on all followup
appointments.
Medications on Admission:
prednisone 5 mg every other day
singulair 10 mg daily
dyazide 25/37.5 mg dialy
xopenex nebulizer TID
lovastatin 40 mg daily
ECASA 81 mg daily
plavix 75 mg daily
spiriva one daily
advair 250/50 2 puffs [**Hospital1 **]
albuterol prn ( uses 2-3x /day)
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
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:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for PVD.
Disp:*30 Tablet(s)* Refills:*0*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
continuous doses.
Disp:*30 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
Two (2) Disk with Device Inhalation [**Hospital1 **] ().
Disp:*120 Disk with Device(s)* Refills:*0*
13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
AS/CAD s/p AVR/CABG x1
COPD (in pulm. rehab)
OSA on BiPAP
CHF [**5-10**]
multiple PNAs
carotid stenosis
severe PVD with multiple aneurysms in bil. LE s/p 6 bypass
procedures
elev. chol.
Discharge Condition:
good
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams or powders on any incision
no driving for one month AND until off all narcotics
call for fever greater than 100.5, redness, or drainage
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
see Dr. [**Last Name (STitle) 79782**] in [**2-2**] weeks
see Dr. [**Last Name (STitle) 7659**] in [**3-6**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2129-10-15**]
|
[
"440.20",
"458.29",
"327.23",
"440.4",
"285.8",
"414.01",
"518.0",
"493.20",
"518.82",
"433.10",
"272.4",
"424.1",
"416.8",
"V58.65",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"35.21",
"88.72",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8748, 8797
|
5823, 6762
|
310, 420
|
9028, 9035
|
1533, 2080
|
9320, 9632
|
1154, 1173
|
7062, 8725
|
4264, 4294
|
8818, 9007
|
6788, 7039
|
2097, 4224
|
9059, 9297
|
1188, 1514
|
254, 272
|
4326, 5800
|
448, 733
|
755, 999
|
1015, 1138
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,083
| 198,330
|
36119
|
Discharge summary
|
report
|
Admission Date: [**2112-5-28**] Discharge Date: [**2112-6-7**]
Date of Birth: [**2057-11-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 4679**]
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
pericardiocentesis
pericardial window
History of Present Illness:
The patient is a 54-yo man with hypertension, esophageal cancer
(dx [**11-22**], s/p 1 cycle of 5-FU and cisplatin and 6 wks XRT, s/p
esophagectomy [**2112-5-4**]), and recently-diagnosed moderate left
pleural effusion s/p thoracentesis [**2112-5-22**] and pericardial
effusion with tamponade s/p pericardiocentesis [**2112-5-23**], who was
admitted to the [**Hospital1 1516**] service on [**2112-5-28**] with tachycardia and was
found to have a recurrent pericardial effusion. He was initially
admitted to the Thoracic Surgery service on [**2112-5-22**] for dyspnea
and underwent thoracentesis for left pleural effusion, which
yielded 1200cc of dark serous fluid and exudate. He was
transferred to the CCU when found to have a large
circumferential pericardial effusion with early tamponade
physiology, and underwent pericardiocentesis with initial
drainage of 400cc of serosanguinous fluid, followed by an
additional drainage of 270cc over the remainder of his course
prior to removal of the pigtail catheter. He was discharged home
with VNA services on [**2112-5-25**], but was found to be tachycardic to
the 130s by his VNA and was sent to the ED for evaluation.
.
He had been feeling fine at home. He was eating very poorly at
home due to low appetite and slowly progressing diet. He was
drinking [**12-18**] cups of water per day. He denies any fever, chills,
rigors, SOB, cough, edema, swelling, changes in weight from
discharge, changes in activity. He has been very sedentary after
the surgery, only being able to go a flight of stairs very
slowly. He also reports a mass in his right thorax, close to the
thoracosentesis site, which has been mildly bothersome to him
intermittently.
.
In the ED: VS - Temp 99.1F, BP 150/99, HR 131, R 18, SpO2 99%
RA. He received 1L NS with improvement of his heart rate and
decrease in his blood pressure. Cardiology was consulted and
bedside TTE showed a pericardial effusion without signs of
tamponade. His SBP was 130s and pulsus was 10, so he was
admitted to the [**Hospital1 1516**] service, for observation and further
work-up. Thoracic surgery was consulted as well, who felt that
he may need a pericardial window on Monday.
.
Overnight on the floor, the patient developed an episode of
diaphoresis. Bedside TTE at the time revealed little change in
his pericardial effusion. SBPs were 110s-120s, and pulsus
remained at 10. He is being transferred to the CCU for closer
monitoring and with a plan for pericardiocentesis in the
morning.
.
On arrival to the CCU, the patient continues to feel "lousy". He
has developed dyspnea again since feeling diaphoretic on the
floor. It feels the same as his prior admission, and he also
feels as though there is "fluid on the lungs" as well. He notes
shallower breathing and mild chest discomfort, as well as low
back pain.
.
He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. Cardiac review of systems is notable for absence of
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
ankle edema, palpitations, syncope or presyncope. All of the
other review of systems were negative.
.
Past Medical History:
Hypertension
Esophageal cancer, locally advanced: s/p 1 cycle 5-FU and
cisplatin [**1-25**], cycle 2 held [**1-18**] thrombocytopenia, s/p radiation
[**2112-1-18**] to [**2112-2-22**]. s/p esophagectomy [**2112-5-4**].
Social History:
-Tobacco history:none
-ETOH: no ETOH for 7 months, previously drank 4-6 beers several
nights a week.
-Illicit drugs: None
Previously worked as an autobody mechanic.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
T: 97.6 HR: 90 SR BP: 130/76 Sats: 97% RA
General: 54 year-old in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: Supple no lymphadenopathy
Card; RRR, normal S1,S2. no murmur. Pigtail site clean
Resp; clear breath sounds throughout
GI: bowel sounds positive abdomen soft non-tender/non-distended.
J-tube site clean no discharge
Extr: warm no edema
Neuro: non-focal
Pertinent Results:
[**2112-6-2**] HCT 23.4
[**2112-5-28**] WBC-10.4 RBC-4.18* Hgb-10.3* Hct-32.0* MCV-77*
MCH-24.6* MCHC-32.0 RDW-14.7 Plt Ct-144*
[**2112-5-28**] Neuts-88.6* Lymphs-7.0* Monos-3.9 Eos-0.3 Baso-0.2
[**2112-5-28**] PT-14.0* PTT-26.4 INR(PT)-1.2*
[**2112-5-28**] Glucose-164* UreaN-14 Creat-0.9 Na-140 K-3.6 Cl-102
HCO3-24
[**2112-5-28**] ALT-12 AST-12 LD(LDH)-148 AlkPhos-88 TotBili-0.4
================================
IMAGING:
ECHO
[**2112-5-30**] Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is abnormal
septal motion/position. There is a small to moderate sized echo
filled pericardial effusion most prominent around the distal
right ventricle and left ventricular apex, but also extending to
the base of the right ventricle and right atrium. No right
atrial or right ventricular diastolic collapse is seen, but
there is abnormal septal motion suggestive of constriction.
Left ventricular wall thickness, cavity size and global systolic
function are normal (LVEF >55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. There is a small/echodense primarily anterior
pericardial effusion without suggestion of diastolic collapse. A
prominent left pleural effusion with atelectasis is present.
Compared with the prior study (images reviewed) of earlier in
the day, the effusion is smaller
[**2112-5-29**] The estimated right atrial pressure is 0-10mmHg.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). The
right ventricular cavity is small. There is a moderate to large
sized pericardial effusion. There is right ventricular diastolic
collapse, consistent with impaired fillling/tamponade
physiology.
Compared with the findings of the prior study of [**2112-5-28**],
the size of the pericardial effusion has increased.
[**2112-5-28**]: The estimated right atrial pressure is 10-20mmHg. The
left ventricular cavity is small. Regional left ventricular wall
motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is small.
with normal free wall contractility. There is a moderate sized
pericardial effusion. Stranding is visualized within the
pericardial space c/w organization. No right atrial or right
ventricular diastolic collapse is seen.
Compared with the findings of the prior study of [**2112-5-24**],
the size of the pericardial effusion has increased
CXR
[**2112-5-28**]:Increasing moderate left pleural effusion. The remainder
of the
study appears unchanged.
[**2112-5-31**] the right hemidiaphragmatic
contour is somewhat sharper. Retrocardiac opacification
persists.
[**2112-6-7**] In comparison with earlier study of this date, there
has been
removal of the chest tube. No convincing evidence of
pneumothorax.
[**2112-6-7**] loculated pleural effusions on the right and with
possible residual tiny left apical pneumothorax and small left
pleural effusion.
C.Cath [**2112-5-29**]:
1. Pericardiocentesis was performed using the subxyphoid
approach, with
removal of 220 cc of serous fluid.
2. Limited pericardial hemodynamics demonstrated a fall in
pericardial
pressure after pericardiocentesis, from 23 mm Hg to 5 mm Hg
Post-Cath ECHO [**2112-5-29**]:
Compared with the prior study (images reviewed) of [**2112-5-29**],
the effusion is significantly diminished. There are no signs of
tamponade
Fluid: [**2112-5-30**] 5:10 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final [**2112-5-30**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2112-6-2**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2112-6-5**]): NO GROWTH.
ACID FAST SMEAR (Final [**2112-5-31**]): NO ACID FAST BACILLI SEEN
ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final [**2112-5-31**]):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Blood Cultures: [**2112-5-29**] no growth
Brief Hospital Course:
Mr. [**Known lastname 81936**] was admitted on [**2112-5-28**] for recurrent
pericardial effusion confirmed by echocardiogram. Overnight on
the floor the patient developed shortness of breath and
diaphoresis. He was transferred to the CCU for further
monitoring. A bedside echocardiogram showed a large sized
pericardial effusion with early tamponade physiology. On
[**2112-5-29**] he was taken to the cath lab and drained 220cc serous
fluid with a pigtail placement with an additional 130cc drainage
overnight.
Thoracic surgery was consulted and on [**2112-5-30**] proceeded with a
Left thoracoscopy, drainage of pleural effusion and creation of
pericardial window. Removal of left subclavian chemotherapy
port. He was transferred back to the CCU with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain to
water seal draining moderate amounts of serous fluid. His was
hypotensive requiring fluid challenges with improved
hemodynamics. His HCT remained stable. He was started on
Indocin for pericardial serositis. Followed by serial chest
films with improving effusion.
On [**2112-6-1**] he transferred to the floor. His dyspnea improved.
His pericardial effusion slowly improved to < 100cc/24hrs. On
[**2112-6-7**] the [**Doctor Last Name 406**] drain was removed. The J-tube was removed.
He tolerated a regular diet. His pain was well controlled. He
was seen by physical therapy and discharged to home. He will
follow-up with Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
Acetaminophen (Tylenol) 650 mg PO Q6hrs PRN pain
Ferrous Sulfate 325 mg PO BID
Atenolol 50mg PO daily, held since last admission
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Indocin SR 75 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Pericardial effusion
Secondary: Esophageal cancer
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience: fever or
chills.
Increased shortness of breath or cough.
Chest tube dressing & J-tube site dressing remove Thursday
morning and cover with a bandaid until healed
You may shower Thursday. No tub bathing or swimming for 4
weeks.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**6-14**] at 10:00 am on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Report to the [**Location (un) **] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Completed by:[**2112-6-8**]
|
[
"511.9",
"401.9",
"423.3",
"V10.03",
"285.9",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"37.12",
"37.0",
"34.06"
] |
icd9pcs
|
[
[
[]
]
] |
10884, 10890
|
8785, 10296
|
332, 371
|
10993, 11002
|
4609, 8568
|
11358, 11678
|
4067, 4182
|
10476, 10861
|
10911, 10972
|
10322, 10453
|
11026, 11335
|
4197, 4590
|
8604, 8664
|
8697, 8762
|
281, 294
|
399, 3624
|
3646, 3868
|
3884, 4051
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,629
| 190,964
|
7265
|
Discharge summary
|
report
|
Admission Date: [**2159-7-30**] Discharge Date: [**2159-8-29**]
Date of Birth: [**2086-5-29**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
R Lung Adenocarcinoma
Major Surgical or Invasive Procedure:
1. s/p RUL/RML lobectomy with mediastinoscopy for Lung
Adenocarcinoma
2. Tracheostomy
3. Direct Current Cardioversion
History of Present Illness:
73M with CAD, s/p CABG, CHF, COPD, xfered to MICU for failure to
wean off vent, resp failure. Pt originally admitted [**7-30**],
underwent RUL/RML lobectomy with mediastinoscopy for lung adeno
CA. Extubated same day, went to floor on IVF. On [**8-3**]: AF with
[**Hospital 26875**] transfered to SICU, found to be in CHF. Diuresed, started
on Vitamin L, but worsenng SOB, and reintubated [**8-6**]. Underwent
DCCV [**8-7**]-->NSR, loaded on Amio, started on steroids for ?
adrenal Insufficiency [**8-11**].
Difficult to wean b/c of agitation: anxiety, issues with chronic
pain management. Ativan taper begun, haldol started for acute
delerium.
Past Medical History:
Secondary Diagnoses:
1. CHF (EF < 20%)
2. CAD s/p CABG
3. Abdominal Aortic Aneursym
4. Hepatitis B
5. GERD
6. s/p Pacemaker insertion
7. HTN
8. Dyslipidemia
9. Chronic Obstructive Pulmonary Disease
10. Atrial Fibrilation
11. Right Lung Adenocarcinoma
Social History:
Non-contributory
Family History:
Non-contributory
Physical Exam:
Initial Physical Exam upon Presentation to MICU:
AF VSS
Gen: NAD
HEENT: ET tube in place
CV: irreg irreg
Pulm: Coarse (B) BS in anterior lung fields
Abd: soft, NABS
Extrem: no edema
Pertinent Results:
[**2159-8-28**] 01:49PM BLOOD Hct-24.5*
[**2159-8-28**] 02:59AM BLOOD WBC-8.0 RBC-2.90* Hgb-7.8* Hct-23.8*
MCV-82 MCH-26.9* MCHC-32.8 RDW-17.6* Plt Ct-172
[**2159-8-28**] 02:59AM BLOOD Glucose-121* UreaN-37* Creat-1.0 Na-144
K-3.4 Cl-110* HCO3-26 AnGap-11
[**2159-8-27**] 02:44AM BLOOD CK(CPK)-23*
[**2159-8-24**] 02:51AM BLOOD ALT-31 AST-26 AlkPhos-243* TotBili-0.5
[**2159-8-27**] 02:44AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2159-8-28**] 02:59AM BLOOD Calcium-7.6* Phos-2.7 Mg-2.2
Brief Hospital Course:
This is a 73yo M admitted initially with complaint of R shoulder
pain. Following negative cardiac w/u in this patient with
significant cardiac history, pt was found to have a R upper lobe
nodule and subsequently found to be adenoca. Pt is now s/p RUL
and RML lobectomy - pod #18. [**Hospital 1094**] hospital course is significant
for transfer to the ICU 2nd to worsening SOB, desaturation, new
onset Afib with ventricular rate 120's-130's. Pt since that time
is reportedly rate controlled and had been later cardioverted.
Pt
was reintubated [**8-6**] 2nd to noted increase work of breathing.
Since that time other issues have included noted worsening
heart failure. Per chart, pt has been increasingly agitated,
disoriented, sedated. These sxs have been in an escalating
course
since transfer to ICU and [**Name8 (MD) **] RN notes have increased around
[**8-15**],
[**8-16**]. Pt was intubated on exam this am and minimally response to
exam. Trached on [**8-17**].
Breifly, patient transfered to MICU for eval of MS
changes/Failure to wean from Vent. Sedatives and opiods weaned
without change in mental status. Spiked fevers without obvious
source, but likely line infection. Had intermittent GI
bleeding, ?source. Episodes of occasional hypotension which at
times required pressors. After d/w family members, because of
patients underlying dieseases, failure to wean off vent, and
lack of significant change in mental status, decision was made
to make patient Comfort Measures Only. DNR/DNI.
Medications on Admission:
Lasix 40 mg qd
Imdur 100 mg qhs
Norvasc 5 mg qd
Atenolol 50 mg qd
Aldactone 12.5 mg qd
Lipitor 20 mg qd
Prilosec 40 mg qam, 20 mg qhs
Trandolapril 2 mg qd
ASA 325 mg qd
Coumadin
Discharge Medications:
1. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal every seventy-two (72) hours.
Disp:*3 Patch 72HR(s)* Refills:*0*
2. Ativan 2 mg Tablet Sig: One (1) Tablet PO 1-2 hours as needed
for agitation or nausea.
Disp:*48 Tablet(s)* Refills:*0*
3. Morphine Sulfate 20 mg/mL Solution Sig: .75 ml PO every four
(4) hours: Please make a 50 mg/ml solution.
Disp:*9 ml* Refills:*0*
4. Morphine Sulfate 20 mg/mL Solution Sig: .25 ml PO q 2 hours
as needed for pain, restlessness: please make a 50 mg/ml
solution.
Disp:*2 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA and Hospice
Discharge Diagnosis:
Principal Diagnoses
1. s/p RUL/RML lobectomy with mediastinoscopy for Lung
Adenocarcinoma
2. Altered Mental Status
3. Failure to wean from Ventilator
Secondary Diagnoses:
1. CHF (EF < 20%)
2. CAD s/p CABG
3. Abdominal Aortic Aneursym
4. Hepatitis B
5. GERD
6. s/p Pacemaker insertion
7. HTN
8. Dyslipidemia
9. Chronic Obstructive Pulmonary Disease
10. Atrial Fibrilation
Discharge Condition:
Critical; Comfort Measures Only/Home with Hospice
Discharge Instructions:
Patients family should use Morphine, Ativan, and Scopolamine
patch as necessary to provide the patient with as much
comfortable as possible.
The patient should be maintained on continuous 2-4L of oxygen
via Tracheal Mask.
Followup Instructions:
N/A
|
[
"197.2",
"578.1",
"285.1",
"162.8",
"428.0",
"584.5",
"496",
"427.31",
"518.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"99.04",
"96.72",
"34.22",
"99.62",
"96.04",
"40.11",
"00.13",
"38.93",
"32.4",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
4507, 4570
|
2203, 3707
|
332, 455
|
4999, 5051
|
1695, 2180
|
5321, 5328
|
1453, 1471
|
3935, 4484
|
4591, 4745
|
3733, 3912
|
5075, 5298
|
1486, 1676
|
4766, 4978
|
271, 294
|
483, 1129
|
1151, 1151
|
1419, 1437
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,172
| 179,293
|
49114
|
Discharge summary
|
report
|
Admission Date: [**2111-10-16**] Discharge Date: [**2111-10-21**]
Date of Birth: [**2055-11-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Ibuprofen / Ciprofloxacin
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
hypoxia and feeding tube replacement
Major Surgical or Invasive Procedure:
intubation on [**10-17**]
Bronchoscopy
History of Present Illness:
55-year-old male who is s/p orthotropic liver [**Month/Year (2) **] in [**Month (only) 205**]
[**2108**] for alcoholic cirrhosis, history of colon cancer s/p
colectomy, on rapamune who was discharged from the ICU on
[**2111-9-22**] after an admission for sepsis, pneumonia, and severe
malnutrition. He required intubation during that admission and
sats were still low. He was bronched and suctioned for large
mucus plugs. Given his mucus plugging he was ultimately trached.
He then had an NG tube placed for his poor nutrition. The
decision was made not to place a feeding tube due to the liver
team's concerns of infection.
.
Per report from his nurse at rehab he weaned off the ventilator
well. He was decanulated last week and tolerated it well. His NG
tube had remained in place until earlier this week when it came
out. 2 days ago there was an attempt to place a dubhoff but it
could not be passed beyond the nasopharynx into the oropharynx.
The catheter would repeatedly enter the trachea. He was
supposed to have it placed under guidance yesterday but no
anesthesiologist was available so he was sent back to Spauling
without the dubhoff placed. He has received no TF or po
medications since [**10-13**] with the exception of sirolimus which he
has been allowed to take po. He's had no witnessed aspiration
events. He's been on D5 1/2 NS at 80cc/hr.
.
Yesterday evening when he became very anxious about not getting
the dubhoff placed and said that he felt like he would die. He
dropped his sats to the 70s and was placed on a NRB and it took
almost an hour for his sats to normalize. His o2 sats increased
when he finally fell asleep. He was maintained on the NRB
overnight. He was weaned to NC of 2L this Am but his sats
dropped to 70s when at the side of the bed working with PT.
Earlier this week he was satting fine on 0-2L.
.
His most recent set of vitals at rehab were afebrile, BP 148/104
(generally 130-low 140s), HR 85, RR24 and 97% on 2L NC. He has
been taking ice chips. He has been getting ativan 0.5mg IV q
6hrs and morphine 2mg q3hrs. HCT was approx 29 on the 14th and
15th. Then on [**10-14**] and [**10-15**] HCT was 22. He received 2 units of
blood and his HCT increased to 37.5. He was A & O x3 prior to
transfer.
.
On arrival to the ICU, vital signs were 97.9 99 151/89 RR22 93%
on 100% high flow face mask. He reports pain at the head of his
penis and pain with urination. He also reports that over the
last few days he has experienced spurts of SOB that occur
suddenly. He then begins to feel anxious like he is going to
die. This occurs on and off. He was decanulated last week and
says that his cough has improved over this time. His cough is
productive of bloody mucusy sputum but only after traumatic
dubhoff placement. He denies fevers or chills.
.
Review of systems:
(+) Per HPI , + for nausea, + for diarrhea less now that he has
not taken po x several days. Last week had between [**1-30**] BMs a
day. + for coughing up some blood since the attempts to place
dubhoff.
(-) Denies fever, chills. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies chest pain, chest pressure,
palpitations, or weakness. Denies vomiting, constipation,
abdominal pain, no blood in stool, no black stool. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
#. Alcoholic cirrhosis, s/p Liver [**Month/Day (1) **] [**2109-6-6**], [**2109-6-23**]
exploration for hematoma and fluid collection, last liver biopsy
[**2110-3-14**] no acute cellular rejection, but [**Month/Day/Year 65**] for increased iron
deposition.
-H/o malnutrition
-Prior ESLD c/b ascites, hepatorenal syndrome, grade II
esophageal varices and portal gastropathy, candidal and
bacterial (SBP) peritonitis
Post-[**Month/Day/Year **] course has been complicated by diarrhea and
malnutrition s/p extensive workup that has not found a cause.
This diarrhea is controlled with cholestyramine, Imodium,
tincture of opium, and he has [**12-31**] bowel movements a day.
#. Recurrent UTIs: Most recent cultures ([**2110-5-7**]) grew pan
sensitive kleb pnemonia and corynebacterium, but in the past has
grown out resistant strains of pseudomonas sensitive only to
meropenem ([**3-6**]), to amikacin ([**2-3**]).
#. History of Torsades while on ciprofloxacin.
- Of note: recent hospitalization [**4-5**] w/ multiple episodes of
VT/torsades s/p magnesium & cardioversion x2. At that time
thought [**12-30**] to meds (Reglan, celexa, lyrica and Bactrim) and
contribution from congenital long QTc. QTc was 499-536 despite
holding meds and given daily magnesium and potassium.
- Cardiology evaluated him ad thought not a candidate at that
time for implantable device given recent infections. Followed as
outpatient by cardiology thought pt stress cardiomyopathy,
recommended avoiding zofran.
#. Anemia with baseline Hct 27-30
#. Hydroureteroephrosis/Urinary retention: Seen by [**Month/Day (2) **] as
outpatient. Most recent OMR note: secondary to recurrent
infections and that intermittent catheterization led to
hydronephrosis. Managed w/ indwelling foley.
#. Colorectal cancer (stage unknown) s/p colectomy in [**11/2108**]
#. Cervical stenosis
#. History of C Diff colitis
#. History of depression
#. BPH
#. Chronic pancytopenia
.
PSH:
s/p colectomy in [**11/2108**]
s/p OLT [**2109-6-6**],
s/p exlap for hematoma and fluid collection [**2109-6-23**]
s/p exlap/LOA [**8-5**]
s/p exlap/LOA/washout, temp closure [**8-5**]
s/p exlap/abd closure, cmpt separation [**8-5**]
s/p trach [**8-5**]
s/p R hip fx [**2110-1-23**]
Social History:
Lives with daughter. Wife died 4 weeks ago. Has not had any ETOH
use in "years." Smoking history: 1/2ppd for 20 yrs, quit over 5
years ago. No illicit drug use.
Family History:
Non-contributory
Physical Exam:
Admission PE:
VS: Temp: afebrile, BP 148/104 (generally 130-low 140s), HR 85,
RR24 and 97% on 2L NC
GEN: Emaciated, chronically ill appearing man, alert and
interactive
HEENT: PERRL, EOMI grossly, anicteric, MMM, op without lesions.
Trach site well healed.
RESP: diffuse rhonci L lung> R
CV: RR, S1 and S2 wnl, no m/r/g
ABD: severly cachectic, decreased b/s, soft, nt, no masses or
hepatosplenomegaly, + suprapubic tenderness
EXT: mildly cold, thin extremities, DP and radial pulses intact,
no edema or clubbing
SKIN: no rashes/no jaundice/no splinters
NEURO: A & O x3, UE and LE strength 5/5
Pertinent Results:
[**2111-10-16**] 09:21PM BLOOD WBC-7.7# RBC-4.00*# Hgb-12.4*# Hct-36.0*#
MCV-90 MCH-30.8 MCHC-34.3 RDW-15.2 Plt Ct-151
[**2111-10-17**] 02:36AM BLOOD WBC-8.2 RBC-4.03* Hgb-12.6* Hct-36.2*
MCV-90 MCH-31.4 MCHC-35.0 RDW-15.3 Plt Ct-157
[**2111-10-18**] 04:08AM BLOOD WBC-4.4 RBC-3.06* Hgb-9.4*# Hct-27.0*#
MCV-88 MCH-30.6 MCHC-34.7 RDW-15.0 Plt Ct-123*
[**2111-10-19**] 05:11AM BLOOD WBC-3.0* RBC-3.10* Hgb-9.7* Hct-28.0*
MCV-90 MCH-31.3 MCHC-34.6 RDW-15.1 Plt Ct-105*
[**2111-10-20**] 04:18AM BLOOD WBC-3.7* RBC-3.24* Hgb-10.0* Hct-28.7*
MCV-89 MCH-30.7 MCHC-34.7 RDW-14.9 Plt Ct-105*
.
[**2111-10-16**] 09:21PM BLOOD Neuts-79.8* Lymphs-14.2* Monos-3.4
Eos-2.1 Baso-0.5
[**2111-10-18**] 04:08AM BLOOD Neuts-70.6* Lymphs-18.7 Monos-4.0
Eos-6.4* Baso-0.3
.
[**2111-10-16**] 09:21PM BLOOD PT-14.5* PTT-37.5* INR(PT)-1.3*
[**2111-10-18**] 04:08AM BLOOD PT-14.5* PTT-37.0* INR(PT)-1.3*
[**2111-10-19**] 05:11AM BLOOD PT-14.3* PTT-41.7* INR(PT)-1.2*
[**2111-10-20**] 04:18AM BLOOD PT-13.8* PTT-37.8* INR(PT)-1.2*
.
[**2111-10-16**] 09:21PM BLOOD Glucose-72 UreaN-47* Creat-1.2 Na-140
K-5.2* Cl-108 HCO3-23 AnGap-14
[**2111-10-17**] 02:36AM BLOOD Glucose-79 UreaN-52* Creat-1.3* Na-139
K-5.4* Cl-107 HCO3-20* AnGap-17
[**2111-10-17**] 12:51PM BLOOD Glucose-122* UreaN-46* Creat-1.2 Na-134
K-5.4* Cl-103 HCO3-21* AnGap-15
[**2111-10-19**] 05:11AM BLOOD Glucose-81 UreaN-30* Creat-1.1 Na-133
K-3.7 Cl-105 HCO3-22 AnGap-10
[**2111-10-20**] 04:18AM BLOOD Glucose-102* UreaN-26* Creat-1.1 Na-137
K-3.7 Cl-106 HCO3-23 AnGap-12
.
[**2111-10-16**] 09:21PM BLOOD ALT-46* AST-41* LD(LDH)-174 AlkPhos-147*
TotBili-0.5
[**2111-10-17**] 02:36AM BLOOD ALT-45* AST-47* LD(LDH)-211 AlkPhos-147*
TotBili-0.6
[**2111-10-18**] 04:08AM BLOOD ALT-32 AST-30 LD(LDH)-153 AlkPhos-121
TotBili-0.4
.
[**2111-10-16**] 09:21PM BLOOD Albumin-3.1* Calcium-9.1 Phos-3.5 Mg-1.9
[**2111-10-18**] 04:08AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.7
[**2111-10-20**] 04:18AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.6
.
[**2111-10-18**] 04:08AM BLOOD rapmycn-17.6*
[**2111-10-19**] 05:11AM BLOOD rapmycn-7.8
.
[**2111-10-18**] 04:55AM BLOOD Type-[**Last Name (un) **] Temp-36.4 pO2-43* pCO2-47*
pH-7.33* calTCO2-26 Base XS--1 Intubat-INTUBATED
[**2111-10-18**] 10:45AM BLOOD Type-[**Last Name (un) **] Temp-36.0 Rates-/20 Tidal V-450
FiO2-40 pO2-34* pCO2-47* pH-7.34* calTCO2-26 Base XS-0
Intubat-INTUBATED
[**2111-10-18**] 12:37PM BLOOD Type-[**Last Name (un) **] Rates-/22 pO2-34* pCO2-45
pH-7.34* calTCO2-25 Base XS--1 Intubat-NOT INTUBA Comment-50%
OPEN F
.
[**2111-10-17**] 01:50AM URINE RBC-21-50* WBC->50 Bacteri-FEW Yeast-NONE
Epi-0
[**2111-10-17**] 01:50AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2111-10-17**] 01:50AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025
.
[**2111-10-17**] 03:53PM BAL Polys-91* Lymphs-4* Monos-0 Eos-1* Macro-4*
.
[**2111-10-17**] 1:50 am URINE Source: Catheter.
**FINAL REPORT [**2111-10-19**]**
URINE CULTURE (Final [**2111-10-19**]):
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
GRAM NEGATIVE ROD(S). ~4000/ML.
.
[**2111-10-17**] 5:54 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2111-10-17**]**
GRAM STAIN (Final [**2111-10-17**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
.
[**2111-10-17**] 3:53 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2111-10-17**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2111-10-20**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. ~7000/ML. OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES PERFORMED ON CULTURE # 310-5543S
[**2111-10-17**].
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2111-10-17**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies is
strongly suspected, contact the Microbiology Laboratory
(7-2306).
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2111-10-18**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2111-10-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
.
Cardiology Report ECG Study Date of [**2111-10-16**] 11:16:10 PM
Normal sinus rhythm. Moderate baseline artifact. Low voltage in
the limb leads.
Poor R wave progression. Diffuse T wave flattening. Compared to
the previous
tracing of [**2111-9-12**] there was moderate baseline artifact in that
tracing as
well. There is probably no diagnostic interval change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 152 76 370/419 72 45 78
.
Chest xray portable [**10-16**]
IMPRESSION: AP chest compared to [**9-21**]:
Large scale consolidation in the right lung has worsened
appreciably since
[**9-21**], while less pronounced consolidation in the left mid
lung has
improved. Left lung is markedly emphysematous. Small right
pleural effusion has increased. No nasogastric tube is in place,
but I cannot assess the caliber of the stomach. Patient has had
tracheostomy in the past. These recurrent severe pneumonias
suggest either free reflux or tracheoesophageal fistula. Heart
size normal. No pneumothorax.
.
Brief Hospital Course:
55-year-old male who is s/p orthotropic liver [**Month (only) **] in [**Month (only) 205**]
[**2108**] for alcoholic cirrhosis, history of colon cancer s/p
colectomy, on sirolimus who presents with need for placement of
Dobhoff tube and with hypoxia of 90% on 100% face mask.
.
#. Hypoxia: Infiltrates in his right lung on CXR are concerning
for PNA. On admission, he required non-rebreather to maintain
his sats. It was decided to electively intubate the patient for
placement of his NJ tube endoscopically. A bronch was also
performed which revealed RLL mucous plugging that was easily
suctioned. His sputum was sent for culture from the BAL. He
was started on vanco/meropenem for HAP coverage given his past
respiratory isolates of pseudomonas sensitive only to meropenem.
He was given aggressive chest PT and suctioning for thick
secretions. After bronchoscopy, secretion burden lessened and
he was easily extubated. He was transferred to the general liver
wards for further management. Abx were continued for presumed
HAP. He was mid 90s on RA and occasionally wearing NC O2 for
comfort. Cough productive of yellow/white sputum reported per
pt. No longer on O2 supplement at time of discharge.
Plan to monitor vanco troughs daily and dose per level w goal
15-20 for total of 14 days, started on [**10-16**]. Dose needs to be
adjusted to his renal function despite normal serum cr, pt is
cachectic and has likely renal failure unaccounted for in normal
labs.
Cont meropenem as well.
.
#. Malnutrition: Pt without any po access at time of admission.
Lost NG tube earlier this week and pt came to [**Hospital1 **] 2 days ago and
they were unable to place dubhoff as it was coming out through
trach site. Unfortunately pt returned to [**Hospital1 **] for guided placement
of dobhoff but no anesthesiologist was available so pt
unfortunately did not get it placed. NJ tube was placed in the
ICU under endoscopic guidance. He was started on tube feeds per
nutrition recs on [**10-19**]. Phos levels monitored for refeeding
syndrome and repleted as needed. Plan for LTAC to monitor levels
daily and replete as needed in acute refeeding period.
.
#. Normocytic Anemia: Baseline HCt per old notes 26-28. Likely
anemia of chronic disease [**12-30**] liver failure. B12 and folate have
been normal/high in the past also. [**First Name8 (NamePattern2) **] [**Hospital1 **] signout HCT was
approx 29 on the 14th and 15th. Then on [**10-14**] and [**10-15**] HCT was
22. He received 2 units of blood and his HCT increased to 37.5
at rehab. HCT here 36. Unclear whether low HCT could have been
secondary to traumatic placement of dubhoff. Increased HCT
likely secondary to hemoconcentration in the setting of NPO
although his platelets are not hemoconcentrated. Hct had been
stable on the general wards and at his baseline. He did not
require transfusion of any blood products during his stay.
.
#. Alcoholic cirrhosis s/p liver [**Month/Year (2) **] in [**2108**]: AST/ALT/Alk
ph all elevated from baseline. Post-[**Year (4 digits) **] course has been
complicated by diarrhea and malnutrition s/p extensive workup
with no obvious cause. This diarrhea in the past was controlled
with cholestyramine, Immodium, tincture of opium. Sirolimus was
restarted when PO access became available. He was restarted on
2mg daily w drug levels followed. Dosing based on labs.
.
#. Irritation at urethral meatus/pain with urination: Lidocaine
was used for comfort. Pt with long h/o UTIs. Urine culture did
not suggest acute UTI - inconclusive results. Pt afebrile w
resolved leukocytosis on vanco and meropenem for HAP.
.
#. Depression/anxiety: Home antidepressants were held until
dobhoff in place. Psychiatry to follow at [**Name (NI) **] - pt would
benefit from therapy and acute grief counseling. Would consider
adding antidepressant if clinically appropriate. uptitrated
remeron for incr'd appetite.
.
#. Chronic pancytopenia: Relative leukocytosis w left shift WBC
7.7 on admission, likely indicating infection. This fell with
treatment of pneumonia. Cell counts at baseline at time of
discharge.
.
#. Pain control: Lidocaine patch, fentanyl patch, po oxycodone
and IV morphine were continued.
.
#. Comm: [**Name (NI) 4489**] [**Name (NI) 102989**] (mother) [**Telephone/Fax (1) 103052**]; [**Doctor Last Name **]
(daughter) [**Telephone/Fax (1) 103053**]
Medications on Admission:
--amitriptyline 50 mg po qhs
--mirtazapine 15 mg PO HS
--sirolimus 3 mg PO DAILY (1mg/ml oral solution)
--ferrous sulfate 300mg/5ml TID
--calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet
1 tab twice a day.
--multivitamin PO DAILY
--thiamine HCl 100 mg po daily
--albuterol 90mcg inhaler 4 puffs q4hrs
--fentanyl patch 12mcg/hr q72hrs (last changed on [**10-15**])
--fondaparinux 2.5mg/0.5ml 2.5mg sq daily
--guaifenesin 600mg [**Hospital1 **]
--omeprazole 20mg daily
--protein supplement- beneprotein resource instant protein 2
scoops [**Hospital1 **]
--trazodone 12.5mg qhs
--xenaderm ointment TP TID
--ativan 0.5mg IV q6hrs prn anxiety
--morphine 2mg IV every 3 hrs
--compazine 10mg q6hrs prn nausea
--oxycodone 7.5mg q3hrs prn pain
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection TID (3 times a day): for dvt prophylaxis to
be continued while bedbound and at rehab.
2. lidocaine HCl 2 % Gel [**Hospital1 **]: One (1) Appl Mucous membrane PRN
(as needed) as needed for pain at urethral meatus .
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. fentanyl 12 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): last change [**10-18**].
5. therapeutic multivitamin Liquid [**Month/Year (2) **]: Five (5) ML PO DAILY
(Daily).
6. amitriptyline 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at
bedtime).
7. mirtazapine 15 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO HS (at
bedtime).
8. sirolimus 1 mg/mL Solution [**Month/Year (2) **]: Two (2) ml PO DAILY (Daily).
9. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Month/Year (2) **]: Five (5)
ml PO TID (3 times a day).
10. oxycodone 5 mg/5 mL Solution [**Month/Year (2) **]: 7.5 ml PO Q4H (every 4
hours) as needed for pain: hold for sedation.
11. thiamine HCl 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
12. guaifenesin 100 mg/5 mL Syrup [**Month/Year (2) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Year (2) **]:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for SOB,
wheezing.
14. heparin, porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
15. lorazepam 0.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
16. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Month/Year (2) **]: One
(1) Tablet, Chewable PO BID (2 times a day).
17. prochlorperazine Edisylate 5 mg/mL Solution [**Month/Year (2) **]: Ten (10) mg
Injection Q6H (every 6 hours) as needed for nausea.
18. morphine 100 mg/4 mL Solution [**Month/Year (2) **]: Two (2) mg Intravenous
q3h as needed for pain: hold for sedation or RR<12.
19. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
20. meropenem 1 gram Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous every twelve (12) hours for 9 days.
21. potassium & sodium phosphates 280-160-250 mg Powder in
Packet [**Last Name (STitle) **]: Two (2) Packet PO once a day: consider dc at follow
up at hepatology [**10-28**].
22. vancomycin 1,000 mg Recon Soln [**Month/Day (4) **]: dose by level
Intravenous dose by level for 9 days: goal trough 15-20. please
follow daily levels, dose by level. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Hospital acquired pneumonia
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital from rehab for low oxygen and
pneumonia. You were started on antibiotics that must be
continued through your PICC line. You also required replacement
of your feeding tube. You required intubation for your breathing
and for stability while your tube was replaced.
Tubefeeds were restarted on [**10-19**]. You were restarted on your
home medications as well.
.
The following changes were made to your medications:
STARTED Vancomycin IV antibiotic for 2 week course (day 1 [**10-16**])
STARTED Meropenem IV antibiotic for 2 week course (day 1 [**10-16**])
RESTARTED tubefeeds
STARTED Phosphate supplement during initial restart of tubefeeds
to prevent refeeding syndrome/hypophosphatemia
INCREASED Remeron for better appetite
.
We recommend that you continue to see psychiatry at [**Hospital1 **] to
see if you require an antidepressant or additional therapy.
Continued on sirolimus, vitamin supplements, home
anti-depressants
.
Please follow up with your physicians as stated below.
Followup Instructions:
Department: [**Hospital1 **]
When: WEDNESDAY [**2111-10-28**] at 8:40 AM
With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital Ward Name **]
When: WEDNESDAY [**2111-11-4**] at 1:20 PM
With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
[
"788.99",
"934.8",
"V42.7",
"V10.05",
"V15.82",
"284.1",
"E915",
"486",
"261",
"300.4",
"305.03",
"600.00",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"96.71",
"96.56",
"38.91",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
20817, 20888
|
12871, 17224
|
350, 391
|
20973, 20973
|
6826, 11536
|
22147, 22829
|
6180, 6198
|
18022, 20794
|
20909, 20952
|
17250, 17999
|
21108, 22124
|
6213, 6807
|
11776, 12848
|
11569, 11743
|
3234, 3741
|
274, 312
|
419, 3215
|
20988, 21084
|
3763, 5986
|
6002, 6164
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,825
| 154,415
|
48376
|
Discharge summary
|
report
|
Admission Date: [**2166-12-8**] Discharge Date: [**2166-12-14**]
Service: MEDICINE
Allergies:
Vasotec / Niacin
Attending:[**First Name3 (LF) 14145**]
Chief Complaint:
Diarrhea, Delirium.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is an 86 year old male with ischemic cardiomyopathy
(ejection fraction 17%), prior ST-elevation myocardial
infarction (STEMI), peripheral vascular disease (PVD), who
presented with worsening fatigue and diarrhea. His family noted
worsened malaise, fatigue, diarrhea, over past week, also with
loose, non-bloody stools over the prior 3 days, then with
decreased oral intake. His wife had noticed more sundowning at
night-time, worse than normal. Of note, he recently started
Digoxin and diuresed with Diuril from wt of 160lbs to admission
wt ~140lbs. Outpatient EKG showed lateral lead scooping on
[**12-2**].
In [**Hospital1 18**] ED, 95/50, 95% room air, HR 70, lungs clear
bilaterally, guaiac (-), otherwise benign exam. EKG showed
lateral lead scooping. He was given Aspirin 325, Lidocaine Jelly
2% (Urojet) 5mL Urojet. The patient dropped SBP to 70s, given 3
250cc boluses, with appropriate bump to 90s, asymptomatic. Out
of concern for Digoxin toxicity, Digibind was given, but then
stopped after Dig level returned at 1 (only half vial
administered). Toxicology was consulted. CXR showed trace bil
effusions, streaky atelectasis in RLL, final read possible
pneumonia. He was given Levaquin and ceftriaxone for CAP.
Cardiology consulted: recs for careful fluid resuscitation. 2
large bore pIVs. He was admitted to MICU for concern for
evolving pneumo-sepsis.
Past Medical History:
1. History of Colon cancer - last scope [**2162**] with polyp
2. Atrial fibrillation
3. History of Basal cell carcinoma
4. Mitral valve replacement [**1-/2164**] - (#29 Perimount Thermafix
pericardial valve).
5. Hypertension
6. Gout
7. Peripheral vascular disease (PVD)
8. Mild aortic stenosis
9. History of deep venous thrombosis - IVF filter placed [**2163**]
10. Hypercholesterolemia
11. Spinal stenosis
12. Familial hand tremor
13. Hernia repair, R-side inguinal
14. Cataract repair, last [**2165-8-14**]
15. Nephrolithiasis
16. Chronic kidney disease
Social History:
- Former orthodontist.
- Smoked until early 40s at 1-1.5 packs/day since age 22. Denies
smoking since.
Denies drinking.
- Lives with wife in [**Location (un) 55**].
Family History:
- Father had heart attack at age 60. "Four generations" of
"tremors," mother
had "head shake." Has two sons, one of which is affected by
the hand tremors.
- Denies history of CA, diabetes in family.
Physical Exam:
VITALS: T 97.7, BP 84/55, HR 84, RR 20, 96% on room air, I/O
1558/650(also incontinent)
Tm 98.2, 82-103/50-63, 80-87, 18-20
Gen: NAD. Oriented x3. Mood, affect appropriate, difficult to
understand
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: JVD to mid-neck
CV: irregular rhythm. systolic murmur, S1, S2, No thrills or
lifts.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. no wheezes or rhonchi.
Abd: Soft, NTND.
Ext: +LE tense edema, pitting, with erythema bil, appearance of
some stasis dermatitis.
Pertinent Results:
Labs on admission:
[**2166-12-8**] 03:50PM BLOOD WBC-6.6 RBC-4.31* Hgb-10.4* Hct-34.0*
MCV-79* MCH-24.0* MCHC-30.5* RDW-17.6* Plt Ct-278
[**2166-12-8**] 03:50PM BLOOD Neuts-63.4 Lymphs-23.7 Monos-7.9 Eos-4.5*
Baso-0.6
[**2166-12-8**] 03:50PM BLOOD PT-17.3* PTT-31.6 INR(PT)-1.6*
[**2166-12-8**] 03:50PM BLOOD Glucose-128* UreaN-98* Creat-4.6*# Na-139
K-4.2 Cl-91* HCO3-34* AnGap-18
[**2166-12-8**] 03:50PM BLOOD ALT-13 AST-28 CK(CPK)-83 TotBili-1.6*
DirBili-0.9* IndBili-0.7
[**2166-12-8**] 03:50PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 101894**]*
[**2166-12-8**] 03:50PM BLOOD Albumin-3.8 Calcium-9.6 Phos-5.5*#
Mg-3.3*
[**2166-12-8**] 03:50PM BLOOD TSH-3.1 Cortsol-16.3 Digoxin-1.0
[**2166-12-8**] 06:18PM BLOOD Glucose-95 Lactate-2.1* Na-138 K-4.2
Cl-87* calHCO3-32*
[**2166-12-9**] 03:19AM BLOOD freeCa-1.02*
Labs on discharge:
[**2166-12-14**] 06:45AM BLOOD WBC-10.4 RBC-4.21* Hgb-10.2* Hct-32.8*
MCV-78* MCH-24.2* MCHC-31.0 RDW-17.4* Plt Ct-277
[**2166-12-14**] 06:45AM BLOOD PT-15.5* PTT-34.0 INR(PT)-1.4*
[**2166-12-14**] 06:45AM BLOOD Glucose-89 UreaN-74* Creat-2.9* Na-136
K-3.8 Cl-96 HCO3-30 AnGap-14
[**2166-12-14**] 06:45AM BLOOD Mg-2.4
Chest x-ray [**2166-12-8**]:
AP view of the chest in upright position was obtained. The
patient is status post CABG and mitral valve replacement. The
cardiac silhouette is enlarged and unchanged. There is hazy
consolidation in the right lung base with associated pleural
effusion. The pulmonary vasculature is engorged without overt
pulmonary edema. There is no pneumothorax. The osseous
structures are unchanged.
IMPRESSION: Findings consistent with right lower lung pneumonia
and associated pleural effusion.
ECHO [**2166-12-9**]:
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. There is severe global left ventricular
hypokinesis (LVEF = 15-20% %). The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are moderately thickened. There is moderate to
severe aortic valve stenosis (area 0.8-1.0cm2). Mild to moderate
([**1-22**]+) aortic regurgitation is seen. A bioprosthetic mitral
valve prosthesis is present. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate to
severe tricuspid regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. The pulmonic valve leaflets
are thickened. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-4-22**], the
severity of aortic stenosis has progressed. The other findings
are similar.
Brief Hospital Course:
This is a 86 year old male with ischemic CMA, EF 20-25%, prior
STEMI, PVD, p/w worsening fatigue and diarrhea, admitted to MICU
with hypotension, now stable on floor:
In [**Hospital1 18**] ED, 95/50, 95% room air, HR 70, lungs clear
bilaterally, guaiac (-), otherwise benign exam. EKG showed
lateral lead scooping. He was given Aspirin 325, Lidocaine Jelly
2% (Urojet) 5mL Urojet. The patient dropped SBP to 70s, given 3
250cc boluses, with appropriate bump to 90s, asymptomatic. Out
of concern for Digoxin toxicity, Digibind was given, but then
stopped after Dig level returned at 1 (only half vial
administered). Toxicology was consulted. CXR showed trace
bilateral effusions, streaky atelectasis in RLL, final read
possible pneumonia. He was given Levaquin and ceftriaxone for
CAP. Cardiology was consulted with recommendations for careful
fluid resuscitation. 2 large bore pIVs were placed, and the
patient was admitted to the MICU for concern for evolving
pneumo-sepsis.
MICU course: BP 70/40, three 500cc bolus with good response.
Levo/ceftriaxone for pneumonia was continued initially. No
leukocytosis fever or tachycardia, no tachypnea. Digoxin,
Amiodarone and diuretics were initially held. He was in the unit
for two days. As patient was stable and infiltrate on CXR found
to be chronic, antibiotics were discontinued [**12-10**]. His Troponin
was measured at 0.21. Hypotension is considered, perhaps, an
element of his worsening AS with overdiuresis. The MICU did not
restart dig or diuretics. Metoprolol was restarted. New acute
renal failure was considered pre-renal in etiology.
On the floor, the patient's Cr continued to improve and
gradually, the patient was restarted on a diuresis regimen with
Torsemide. On discharge, the patient was started on low-dose
Coumadin for his afib and low EF.
Medications on Admission:
(some question about doses):
1. Lasix 20mg [**Hospital1 **]
2. Digoxin
3. Metoprolol 12.5mg XL
4. Amiodarone 200mg daily
5. Prilosec OTC 20mg daily
6. Docusate 100mg daily
7. Zolpidem 5mg qhs PRN
8. Aspirin 81 mg PO daily
9. Diuril
No coumadin for past 6 months.
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO Once Daily at 4 PM.
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family Services
Discharge Diagnosis:
Dehydration
Hypotension
Congestive Heart Failure
Atrial Fibrillation
Discharge Condition:
Stable, afebrile, chest pain free.
Discharge Instructions:
You were admitted for low blood pressure (hypotension). While
you were here, your diuretics were held until your blood
pressure recovered. Now that your blood pressure has improved,
you have been restarted on some new medications:
You were given the medication Torsemide, which can help remove
fluid from your body. This is to replace your Lasix. Please
discontinue taking Lasix. You should also take Metoprolol 12.5
by mouth twice a day and Lisinopril 2.5mg once a day. Please
also take Simvastatin 20mg once a day.
You were also started on the medication Coumadin. This
medication helps to keep your blood thin to prevent blood clots.
Please take 0.5mg every day for now. You will need to have your
INR checked to make further adjustments as necessary to your
Coumadin dosing.
You should follow up with Dr. [**Last Name (STitle) **] on Wednesday [**12-17**].
Please call his office ([**Telephone/Fax (1) 5768**]) to schedule a time.
Please resume taking your other medications as before.
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.
Please weigh yourself every morning, call your doctor if your
weight increases by more than 3 lbs. as this can be a sign of
fluid build-up.
Please also adhere to a 2 gm sodium diet.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] would like to see you on Wednesday [**12-17**]. Please call his office ([**Telephone/Fax (1) 5768**]) to schedule a time.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2166-12-15**] 3:30
Provider: [**Name10 (NameIs) 2975**] [**Name8 (MD) 2976**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2166-12-26**] 2:15
Completed by:[**2166-12-23**]
|
[
"V10.05",
"428.0",
"401.9",
"V42.2",
"V45.82",
"428.20",
"276.3",
"427.32",
"584.9",
"427.31",
"790.92",
"396.2",
"412",
"276.51",
"414.8",
"486",
"785.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9265, 9328
|
6138, 7950
|
246, 253
|
9441, 9477
|
3295, 3300
|
10943, 11474
|
2431, 2633
|
8263, 9242
|
9349, 9420
|
7976, 8240
|
9501, 10920
|
2648, 3276
|
187, 208
|
4139, 6115
|
281, 1652
|
3314, 4120
|
1674, 2231
|
2247, 2415
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,425
| 124,258
|
41026
|
Discharge summary
|
report
|
Admission Date: [**2200-12-4**] Discharge Date: [**2200-12-17**]
Date of Birth: [**2117-2-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
[**2200-12-5**] Cardiac catheterization
[**2200-12-10**] 1. Coronary artery bypass graft x3: Left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to obtuse marginal and posterior descending
arteries. 2. Endoscopic harvesting of the long saphenous vein.
3. Aortic valve replacement with size 21 St. [**Male First Name (un) 923**] tissue valve.
4. Aortic endarterectomy.
History of Present Illness:
Ms. [**Known lastname 89480**] is an 83 year old female with a history of coronary
artery disease s/p PCI [**2190**], Diabetes Mellitus, and Atrial
Fibrillation presented to OSH with pneumonia and mild CHF
exacerbation found to have positive biomarkers. A subsequent
cardiac catheterization revealed two vessel coronary artery
disease. Cardiac surgery consulted for coronary
revascularization.
Past Medical History:
Coronary Artery Disease s/p PCI to LAD in [**2190**]
Chronic Diastolic Congestive heart failure
Hypertension
Dyslipidemia
Diabetes mellitus type 2
Chronic atrial fibrillation
Osteoarthritis
Pneumonia (3 episodes this past year)
Social History:
Race:caucasian
Last Dental Exam:6 months ago, Dr. [**Last Name (STitle) 89481**] on High St, [**Hospital1 **]
Lives with:daughter or son, widowed
Occupation:retired secretary
Tobacco:denies
ETOH:rare
Family History:
Non-contributory
Physical Exam:
Admission PE:
Pulse:72 Resp:18 O2 sat: 96%
B/P 143/56
Height: 5'5" Weight:124lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [], scattered rales
Heart: RRR [] Irregular [x] Murmur II/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**2200-12-5**] Cath: Severe 90% LMCA stenosis, 70% RCA stenosis.
[**2200-12-8**] Carotid U/S: 1. 40-59% stenosis of the right internal
carotid artery. 2. Less than 40% stenosis of the left internal
carotid artery.
[**2200-12-10**] Echo: Pre bypass: The left atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is borderline moderate aortic valve
stenosis (valve area 1.3-cm2 on average, range 0.9- 1.6 cm2,
varies with atrial fibrillation, severe cad precludes dobutamine
stress echo) with poor mobility of left and non coronary cusps.
No aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
Post Bypass: Bioprosthetic Aortic valve in place peak gradient
5, mean 2 mm Hg. No perivalvular leaks. Preserved EF- 55%. MR
now trace to mild. Aortic contours intact. Remaining exam is
unchanged. All findings discussed with surgeons at the time of
the exam.
[**2200-12-15**] 07:53AM BLOOD WBC-8.1 RBC-3.36* Hgb-9.8* Hct-29.7*
MCV-89 MCH-29.1 MCHC-32.9 RDW-16.5* Plt Ct-124*
[**2200-12-4**] 11:05AM BLOOD WBC-11.0 RBC-4.32 Hgb-11.8* Hct-35.9*
MCV-83 MCH-27.2 MCHC-32.8 RDW-15.9* Plt Ct-355
[**2200-12-16**] 07:22AM BLOOD PT-30.4* INR(PT)-3.0*
[**2200-12-4**] 09:20PM BLOOD PT-16.1* PTT-26.3 INR(PT)-1.4*
[**2200-12-15**] 07:53AM BLOOD Glucose-148* UreaN-39* Creat-0.8 Na-134
K-4.4 Cl-98 HCO3-26 AnGap-14
[**2200-12-4**] 09:20PM BLOOD Glucose-131* UreaN-26* Creat-0.7 Na-135
K-4.3 Cl-100 HCO3-30 AnGap-9
[**2200-12-17**] 03:30AM BLOOD Hgb-9.7* Plt Ct-156
[**2200-12-17**] 03:30AM BLOOD PT-33.4* INR(PT)-3.4*
[**2200-12-16**] 07:22AM BLOOD PT-30.4* INR(PT)-3.0*
[**2200-12-15**] 07:53AM BLOOD PT-35.4* INR(PT)-3.6*
[**2200-12-17**] 03:30AM BLOOD UreaN-33* Creat-0.7
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2200-12-4**] for further
management of her myocardial infarction and known aortic
stenosis. She underwent a cardiac catheterization which revealed
severe left main and right coronary artery disease. An echo
demonstrated severe aortic valve stenosis. Given the severity of
her disease, the cardiac surgical service was consulted for
surgical management. She was worked-up in the usual preoperative
manner including a carotid ultrasound which showed 40-59%
stenosis of the right internal carotid artery and less than 40%
stenosis of the left internal carotid artery. Plavix was stopped
in anticipation of surgery. Dental clearance was obtained.
Heparin was continued given her chronic atrial fibrillation. On
[**2200-12-10**], Ms. [**Known lastname 89480**] was taken to the operating room where she
underwent coronary artery bypass grafting to three vessels and
an aortic valve replacement(Left internal mammary artery to left
anterior descending artery and saphenous vein grafts to obtuse
marginal and posterior descending arteries/ Aortic valve
replacement with size 21 St. [**Male First Name (un) 923**] tissue valve/Aortic
endarterectomy). Please see operative note for
details.Cardiopulmonary Bypass time=120 minutes. Cross Clamp
time= 103 minutes. On postoperative day one, she awoke
neurologically intact and was extubated without difficulty. Beta
blockade, aspirin and a statin were resumed. All lines and
drains were discontinued in a timely fashion. She continued to
progress and on postoperative day two, she was transferred to
the step down unit for further recovery. Physical therapy
service was consulted for evaluation of her strength and
mobility. She was gently diuresed towards her preoperative
weight. Coumadin was resumed for atrial fibrillation. She will
resume outpatient coumadin management as per preoperatively with
Dr. [**Last Name (STitle) 10543**]. She continued to make steady progress and was
discharged to home with VNA on postoperative day 7. All follow
up appointments were advised.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg
[**Last Name (STitle) 8426**] - 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg
[**Last Name (STitle) 8426**] - 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
ISOSORBIDE MONONITRATE [IMDUR] - (Prescribed by Other Provider)
- 30 mg [**Last Name (STitle) 8426**] Sustained Release 24 hr - 1 (One) [**Last Name (STitle) 8426**](s) by
mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 10 mg [**Last Name (STitle) 8426**] - 1
(One) [**Last Name (STitle) 8426**](s) by mouth once a day
AVAPRO 300 mg PO daily
METFORMIN - (Prescribed by Other Provider) - 500 mg [**Last Name (STitle) 8426**] - 1
(One) [**Last Name (STitle) 8426**](s) by mouth twice a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
[**Last Name (STitle) 8426**] - 1 (One) [**Last Name (STitle) 8426**](s) by mouth every twelve (12) hours
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg [**Last Name (STitle) 8426**],
Delayed Release (E.C.) - 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
WARFARIN - (Prescribed by Other Provider) - Dosage uncertain
.
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg [**Last Name (STitle) 8426**] - 1
(One) [**Last Name (STitle) 8426**](s) by mouth once a day
MAGNESIUM OXIDE - (Prescribed by Other Provider) - 400 mg [**Last Name (STitle) 8426**]
- 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
NIACIN - (Prescribed by Other Provider) - 500 mg [**Last Name (STitle) 8426**]
Sustained Release - 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
Discharge Medications:
1. atorvastatin 80 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY
(Daily).
Disp:*30 [**Last Name (STitle) 8426**](s)* Refills:*2*
2. lisinopril 10 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY (Daily):
Hold for SBP<90.
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*1*
3. metformin 500 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO twice a day.
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
4. metoprolol tartrate 50 mg [**Last Name (STitle) 8426**] Sig: 0.5 [**Last Name (STitle) 8426**] PO BID (2
times a day): Hold for HR<60, SBP<90.
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
5. pantoprazole 40 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One
(1) [**Last Name (STitle) 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*60 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*1*
6. magnesium oxide 400 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO once a
day.
Disp:*30 [**Last Name (STitle) 8426**](s)* Refills:*2*
7. niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. aspirin 81 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Last Name (STitle) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*2*
9. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 * Refills:*1*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
11. Lasix 40 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO once a day for 10
days.
Disp:*10 [**Hospital1 8426**](s)* Refills:*0*
12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. oxycodone-acetaminophen 5-325 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 [**Hospital1 8426**](s)* Refills:*0*
14. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day: INR
goal 2-2.5 for chronic AFib.
Disp:*150 [**Last Name (Titles) 8426**](s)* Refills:*2*
15. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication - Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2200-12-18**]
Results to phone fax Dr. [**Last Name (STitle) 10543**] [**Telephone/Fax (1) 4475**]
Discharge Disposition:
Home With Service
Facility:
vna [**Hospital3 **] vna
Discharge Diagnosis:
Coronary Artery Disease and Aortic Stenosis s/p Coronary artery
bypass graft x 3 and Aortic valve replacement
Myocardial infarction
Hypertension
chronic Diastolic congestive heart failure
Permanent atrial fibrillation
Dyslipidemia
Diabetes mellitus type 2
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema-Trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1504**] [**2200-12-29**] at 1:00PM
Cardiologist/PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] [**1-8**] at 11:30am [**Telephone/Fax (1) 4475**].
**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 - Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2200-12-18**]
Results to phone fax Dr. [**Last Name (STitle) 10543**] [**Telephone/Fax (1) 4475**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2200-12-17**]
|
[
"427.31",
"433.30",
"424.1",
"272.0",
"433.10",
"518.0",
"428.0",
"V45.82",
"998.12",
"428.32",
"410.71",
"250.00",
"285.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.23",
"36.12",
"36.15",
"35.21",
"38.97",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11043, 11098
|
4540, 6629
|
318, 725
|
11397, 11623
|
2319, 4517
|
12546, 13317
|
1632, 1650
|
8368, 11020
|
11119, 11376
|
6655, 8345
|
11647, 12523
|
1665, 2300
|
270, 280
|
753, 1148
|
1170, 1399
|
1415, 1616
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,706
| 141,443
|
43240
|
Discharge summary
|
report
|
Admission Date: [**2138-10-22**] Discharge Date: [**2138-10-27**]
Date of Birth: [**2070-6-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2138-10-22**] - CABGx3 (Left internal mammary artery->Left anterior
descending artery, vein->obtuse marginal artery, vein->posterior
desceding artery.)
[**2138-10-22**] - Cardiac Catheterization
History of Present Illness:
CC:[**0-0-**]
HPI: This is a 68-year-old former Merchant Marine who suffered
an AMI while at sea back in [**2120**]. He was hospitalized in Lima,
[**Location (un) **] for approximately 20 days. When he was discharged but he
experienced recurrent angina he describes as a terrible
heaviness in his chest. He returned to the area and underwent
cardiac catheterization here at [**Hospital1 18**] where he had a PTCA of the
LCx and OM-1 in [**2121-2-27**]. He returned sea and while in
[**Country 5881**] he again developed angina in [**2121-6-29**]. He was flown
home and underwent repeat balloon angioplasty of the LCx and
OM-1 here at [**Hospital1 18**]. He has done well since and has been
medically managed until approximately five months ago when he
developed an increase in his tinnitus and vertigo which was
worse than his usual discomfort. He saw his PCP who noticed he
had an irregular and increased heart beat and an increase in his
blood pressure. He saw Dr. [**Last Name (STitle) **] in cardiac consultation
complaining of episodes of chest heaviness with exertion,
feeling tired, as well as feeling very poorly. He has had his
medications adjusted several times over the last few months
without any improvement and is now
referred for a cardiac catheterization. In addition he reports
episodes of shortness of breath when lying down.
He underwent a nuclear stress echo on [**2138-6-2**] where he exercised
10 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol to a peak heart rate of 138 bpm
representing 91% of his age predicted maximum heart rate. He
was found to have ST-T abnormalities at rest. He had 1.[**Street Address(2) 93151**]
depression in lead III during recovery phase. He had occasional
couplets and was found to have inferior-apical dyskinesis,
inferobasal and septal hypokinesis. He had a mild reduction in
systolic function. He was reported as having multiple wall
motion abnormalities consistent with an old MI and multivessel
CAD.LVEF was 45-55% and he had trace MR, TR PPR and mild
thickening of the aortic valve but no AR.
Past Medical History:
Hyperlipidemia
HTN
CAD s/p PTCA/Stenting
Arthritis
Hypertension
Hyperlipidemia
Seasonal allergies
S/P Appendectomy
Bronchitis
BPH
Arthroscopic surgery to both knees
Meniere's syndrome
Social History:
CIG, quit 6 years ago, previously smoked [**2-1**] ppd x 42 years. He
is married with 4 grown children. He is a retired merchant
marine. He no longer smokes and rarely drinks.
Family History:
His father died of an MI at age 56.
Physical Exam:
70 SR 156/75 16 67" 179lbs
GEN: NAD
HEENT: No JVD, no carotid bruits
HEART: RRR, no murmur
LUNGS: CTA
ABD: Soft/NT/ND/NABS
EXT: Wram, dry, pulses intact. No varicosities
NEURO: Nonfocal
Pertinent Results:
[**2138-10-22**] 09:05AM PLT SMR-NORMAL PLT COUNT-219
[**2138-10-22**] 09:05AM PT-13.6* PTT-28.8 INR(PT)-1.2*
[**2138-10-22**] 09:05AM %HbA1c-6.3*
[**2138-10-22**] 09:05AM WBC-7.5 RBC-4.95 HGB-15.0 HCT-43.3 MCV-88
MCH-30.3 MCHC-34.6 RDW-13.6
[**2138-10-22**] 09:05AM ALT(SGPT)-27 AST(SGOT)-24 CK(CPK)-58 ALK
PHOS-44 AMYLASE-40 TOT BILI-0.8
[**2138-10-22**] 09:05AM GLUCOSE-247* UREA N-16 CREAT-0.8 SODIUM-125*
POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-23 ANION GAP-13
[**2138-10-22**] Cardiac Catheterization
1. Coronary angiography in this left dominant system
demonstrated a moderately calcified LMCA with an eccentric
proximal-mid
50% stenosis. The LAD was a heavily calcified "twin" system with
a
70-80% stenosis of the septal twin just after bifurcation of a
major
diagonal; the diagonal had 70% proximal and 80% mid-branch
stenosis. The
LCX as moderately calcifed with a complex mid-AV groove-segment
stenosis
of 80% involvine the origin of an OM; there was mild diffuse
disease in
the LPL and LPDA. The RCA was nondominant and moderately
calcified;
there were proximal 60% and mid 80% stenoses with diffuse distal
disease.
2. Limited resting hemodynamics revealed moderately elevated LV
filling
pressures.
3. Left ventriculography showed moderate LV systolic dysfunction
with
inferobasal akinesis and hypokinesis in other visualized
segments. The
aortic knob was calcified.
[**2138-10-22**] ECHO
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2. There is moderate regional left ventricular systolic
dysfunction with moderate hypokinesia of the mid and apical
portions of the inferior wall , inferolateral wall and inferior
septum. . Overall left ventricular systolic function is
moderately depressed (LVEF= 35 %).
3. There is focal hypokinesis of the apical free wall of the
right ventricle.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
Post Bypass
1. Patient is AV paced and receiving an infusion of
phenylephrine and epinephrine.
2. Biventricular systolic function is slightly improved.
3. Aorta intact post decannulation.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2138-10-22**] for a
cardiac catheterization. He was found to have severe left main
and three vessel disease. Please see cath note for details. As
he continued to have chest discomfort, the cardiac surgical
service was consulted for surgical management. He was taken
urgently to the operating room given his unstable angina where
he underwent coronary artery bypass grafting to three vessels.
Please see operative note for details. Postoperatively he was
taken to the cardiac surgical intensive care unit for
monitoring. Within 24 hours, he had awoke neurologically intact
and was extubated. Aspirin, a statin and beta blockade were
resumed. Later on postoperative day one, he was transferred to
the step down unit for further recovery. He was gently diuresed
towards his preoperative weight. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. He did well postoperatively, he had no preopblems with
atrial arrhtyhmias and was easily diuresed. He was ready for
discharge home on POD #5.
Medications on Admission:
Atenolol 25'', Norvasc 5', Ranexa 500', Crestor 10', Lisinopril
10', ASA 81', Ibuprofen 1000', Acetaminophen 1000', Clonazapam
0.25prn anxiety, Fexofenadine 180prn
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 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABG
Hyperlipidemia
HTN
Arthritis
Meniere's disease
BPH
Discharge Condition:
Good.
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns. [**Telephone/Fax (1) 170**]
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 12167**] in [**2-1**] weeks. [**0-0-**]
Follow-up with Dr. [**First Name (STitle) **] in [**2-1**] weeks. [**Telephone/Fax (1) 93152**]
Please call all providers for appointments.
Wound check appointment please schedule with RN [**Telephone/Fax (1) 3633**]
Completed by:[**2138-10-28**]
|
[
"300.4",
"412",
"V45.82",
"553.3",
"286.7",
"715.90",
"E934.8",
"496",
"272.4",
"V15.82",
"998.11",
"411.1",
"600.00",
"401.9",
"250.00",
"327.23",
"414.01",
"386.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"99.04",
"37.22",
"88.53",
"36.15",
"36.12",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
8022, 8080
|
5660, 6770
|
330, 530
|
8188, 8196
|
3342, 5637
|
8967, 9384
|
3081, 3118
|
6984, 7999
|
8101, 8167
|
6796, 6961
|
8220, 8944
|
3133, 3323
|
284, 292
|
558, 2662
|
2684, 2869
|
2885, 3065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,203
| 114,186
|
3461
|
Discharge summary
|
report
|
Admission Date: [**2171-6-1**] Discharge Date: [**2171-6-6**]
Date of Birth: [**2098-4-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC: L hand weakness
Major Surgical or Invasive Procedure:
[**2171-6-4**] right craniotomy for sdh evacuation
History of Present Illness:
This is a 73 year old man who hit his head while working in the
yard 3 weeks ago. He started steroids for PMR about 3 days ago
and noted transient
left hand weakness after steroids.
He was seen in the ED and CT head showed SDH.
Past Medical History:
HTN
Colon-rectal cancer w/ met to liver, s/p rsxn, no recurrence
Social History:
Married, lives with wife, former [**Name2 (NI) 1818**] > 30yrs ago, 3-4 beers
week
Family History:
Family Hx:
NC
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: 99.0 BP: 130/72 HR: 98 R 18 O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally.
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 [**6-8**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: L dysmetria, rapid alternating movements intact
Exam: AAOx3, PERRL, left facial droop at nasolabial fold, Motor
[**6-8**], sensory intact to light touch, no drift, incision with
staple c/d/i
Pertinent Results:
Sinus rhythm. Normal tracing. No significant change compared to
previous
tracings.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 188 82 340/396 47 -10 25
CT [**2171-6-1**]
FINDINGS: There is a large right frontal and parietal subdural
hematoma.
There are linear hyperattenuating lines mixed in with
lesser-attenuating
fluid. Suggest that there may be components of hemorrhage that
are old and
acute. There is a small subdural hematoma at the left frontal
lobe (2:13). There is no subarachnoid hemorrhage. There is a
trace suggestion of mass effect at the level of the right
frontal [**Doctor Last Name 534**] (2:12). There is 4 mm of leftward shift of the
third ventricle, which is normally midline. The basal cisterns
cisterns are patent. There is a tiny focus of hemorrhage in the
temporal [**Doctor Last Name 534**] of the right lateral ventricle (2:10).
IMPRESSION: Large right subdural and small left subdural
hematomas. The
heterogeneity of the right subdural hematoma suggests that there
may be an
older component of blood in addition to acute hemorrhage.
[**2171-6-1**] CXR
FINDINGS: PA and lateral views of the chest were obtained
demonstrating low lung volumes, though no focal consolidation,
effusion or pneumothorax. Cardiomediastinal silhouette is
normal. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
[**2171-6-4**] CT head
1. Status post evacuation of right subdural hematoma, with
expected
post-operative change, and subdural drain in situ. No
superimposed acute
process detected.
2. Unchanged appearance of chronic-appearing left frontal
subdural
collection
Brief Hospital Course:
Mr. [**Known lastname **] was admitted through the emergency room after
discovery of a right acute on chronic SDH. He was admitted and
placed on seizure prophylaxis. He was noted to have focal
seizure activity in the LUE and so he was bolused with Keppra
and his dosing increased. He remained neurologically intact
otherwise with just a left pronator drift. He was prepped for
surgery for Tuesday morning, CXR and UA were wnl. He was taken
to the OR on [**6-4**] and a drain was left after evacuation of the
hematoma CT showed expected post-op changes. He was observed in
the ICU overnight without neurologic decline. His drain was
removed on [**6-5**] and he was transferred to the floor.
He remained stable and was evaluated by PT and was deemed stable
for discharge. he was eating and ambulating appropriately and
was discharged home on [**6-6**]
Medications on Admission:
Cialis 20mg prn, HCTZ 25mg Qam, Prednisone 20mg Qd, Zolpidem 5mg
Qhs, Univasc 15mg
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: 0.5 Capsule PO DAILY
(Daily).
2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. moexipril 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
right sided subdural hematoma
focal motor seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
[**Street Address(1) 15947**] X 6 MONTHS
General Instructions
You have a staples at your drain site. This needs to be removed
on [**6-12**] at home or at rehab.
?????? 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.
?????? Dressing may be removed on Day 2 after surgery.
?????? If you have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? If your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. 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 discharged on Keppra (Levetiracetam),
you will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????All your staples need to be removed on [**2171-6-12**]. Please return to
the office or have them removed at rehab. Call([**Telephone/Fax (1) 88**] for
this appointment and to schedule an appointment with Dr. [**First Name (STitle) **],
to be seen in 4_weeks.
??????You will need a CT scan of the brain without contrast.
- You will need follow-up with neurology regarding your focal
motor seizures. Please call Dr. [**Last Name (STitle) 1274**] office to schedule
follow-up at [**Telephone/Fax (1) 8139**].
Completed by:[**2171-6-6**]
|
[
"401.9",
"852.21",
"V45.72",
"725",
"344.89",
"345.50",
"V10.05",
"E917.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
5489, 5495
|
3797, 4654
|
294, 347
|
5590, 5590
|
2059, 3774
|
7626, 8207
|
810, 826
|
4787, 5466
|
5516, 5569
|
4680, 4764
|
5741, 7603
|
870, 999
|
234, 256
|
375, 604
|
1251, 2040
|
855, 855
|
5605, 5717
|
626, 693
|
709, 794
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,263
| 191,390
|
54217
|
Discharge summary
|
report
|
Admission Date: [**2198-3-9**] Discharge Date: [**2198-3-16**]
Date of Birth: [**2132-7-5**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 65 year old female with past medical history
significant for diastolic heart failure, moderate aortic
stenosis with valve area of [**2-3**].2 cm2, bronchietasis and COPD
with stage II gold criteria and home oxygen 2-4L who was
recently admitted to [**Hospital1 18**] from [**2197-12-23**] - [**2198-1-2**] for
hypercarbic respiratory failure requiring intubation and
improvement with aggressive diuresis and treatment for hospital
acquired pneumonia/COPD exacerbation with prednisone and
Vancomycin/meropenem/azithromycin.
.
She was reports doing well at home since coming back from rehab
in [**2198-1-3**]. She reports being compliant with her diuretics
and diet with low salt. She does report occassional canned food
intake. She was noted to have diarrhea two days ago with
productive [**Year (4 digits) **] (different from her usual [**Year (4 digits) **]), shortness of
breath, hand tremors and occassional pleuritic left chest wall
pain yesterday. She reports her only sick contact is her
daughter who also had diarrhea but no pulmonary symptoms. She
was brought to [**Hospital1 18**] ED for evaluation of her shortness of
breath.
.
In the ED, her vitals were 97.0 122 145/106 100%6LNC. She was
noted to be tachypneic and oxygen saturation of 80% on home
oxygen. She was placed on CPAP with improvement in her
oxygenation. Her chest x-ray was concerning for new right lower
infiltrate. She was given solumedrol, ceftriaxone and levaquin
after blood and urine culture were drawn for presumed pneumonia.
She was not given IV lasix in the ED. She was transferred to
MICU for futher evaluation and management.
.
In the MICU, patient reported feeling better and less short of
breath.
Past Medical History:
- Asthma: (since childhood)/COPD s/p multiple intubations: 2L NC
(since [**2172**]) at baseline for spO2 91-95%, last PFT ~1 yr ago
at OSH, trach previously suggested but pt refused
- OSA: sleep study in [**2187**], recommended CPAP but has not
tolerated it well, unclear how compliant since last discharge
(made some progress on the fit of the mask). Of note, overnight
oximetry "better than expected" when measured at rehab.
- GERD
- Anemia (history of GI bleeding)
- Leukopenia, long standing, unclear etiology
- Hyperglycemia when previously on prednisone
- Diastolic heart failure, LVEF > 55%, [**8-/2197**]
- Aortic stenosis (valve area 1.0-1.2 cm^2)
- Moderate pulmonary HTN, PCWP > 18
- Atrial fibrillation (on dilt +/- beta blocker), no
anticoagulation due to history of GI bleeding
Social History:
-Smoking/Tobacco: quit smoking in [**2172**] (20 pack years)
-EtOH: None
-Illicits: None
-Lives at/with: sister (a nurse) in [**Name (NI) 4628**], was in rehab until
[**12-4**]; has 3 children, 1 died @ 27 in [**4-/2197**] from asthma
complication, has a daughter who's a CNA.
-Retired manager of a medical answering services
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
-Mother died of CVA
-Father died of lung CA
Physical Exam:
ON ADMISSION:
VS: 97.1 109/44 121 97% CPAP 10/5
GEN: Female in moderate distress. Alert and oriented to person,
place and time
HEENT: PERRLA. EOMI. CPAP in place.
NECK: Supple neck. Could not appreciate JVD
PULM: Poor air movement. Coarse breath sounds appreciated
bilaterally but no inspiratory crackles.
CARD: holosytolic murmur appreciated along the sternal border
ABD: Soft, nontender and nondistended. Normoactive bowel
sounds.
EXT: 2+ edema to knee.
SKIN: Statis dermatitis rash bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2198-3-9**] 04:40PM WBC-5.6 RBC-3.61* HGB-10.1* HCT-31.7* MCV-88
MCH-28.0 MCHC-31.9 RDW-16.1*
[**2198-3-9**] 04:40PM NEUTS-80.7* LYMPHS-13.7* MONOS-3.6 EOS-1.3
BASOS-0.6
[**2198-3-9**] 04:40PM PLT COUNT-186
[**2198-3-9**] 04:40PM PT-13.7* PTT-25.3 INR(PT)-1.2*
[**2198-3-9**] 04:40PM GLUCOSE-100 UREA N-27* CREAT-1.3* SODIUM-141
POTASSIUM-5.8* CHLORIDE-93* TOTAL CO2-39* ANION GAP-15
[**2198-3-9**] 04:40PM proBNP-3902*
[**2198-3-9**] 05:15PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2198-3-9**] 05:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2198-3-9**] 05:15PM URINE RBC-[**4-7**]* WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2198-3-9**] 05:48PM TYPE-[**Last Name (un) **] O2-100 PO2-211* PCO2-49* PH-7.52*
TOTAL CO2-41* BASE XS-15 AADO2-469 REQ O2-78 INTUBATED-NOT
INTUBA COMMENTS-CPAP
[**2198-3-9**] 09:55PM CK-MB-2 cTropnT-<0.01
MICRO:
[**2198-3-9**] URINE CULTURE (Final [**2198-3-11**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2198-3-9**] 9:55 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2198-3-10**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2198-3-10**]):
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
[**2198-3-9**] BLOOD CULTURE X 2: PENDING
[**2198-3-9**] URINE: Legionella Urinary Antigen (Final [**2198-3-10**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2198-3-10**] 5:00 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2198-3-10**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
[**2198-3-11**] 5:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final [**2198-3-13**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2198-3-12**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
STUDIES:
[**2198-3-9**] EKG: Atrial fibrillation with rapid ventricular response.
Diffuse baseline artifact with uninterpretable ST-T waves in
leads V1-V3. Rightward axis. Non-specific diffuse ST-T wave
changes. Compared to the previous tracing of [**2197-12-24**] the
ventricular response is faster. Otherwise, the findings are
similar.
[**2198-3-9**] CXR: Lower lung consolidations concerning for pneumonia,
possible small effusions. Please note technical limitations and
if needed a repeat with more optimized technique may be
performed to more clearly assess.
[**2198-3-13**] CXR: In comparison with the study of [**3-12**], there are lower
lung volumes. No change in the appearance of the right PICC
line. There is enlargement of the cardiac silhouette with mild
engorgement of pulmonary vessels that has improved since the
prior study.
Opacification at the left base again suggests volume loss or
superimposed
consolidation. The possibility of a central obstructing lesion
must again be considered. Prominence of central pulmonary
vessels again could reflect
pulmonary artery hypertension.
Brief Hospital Course:
65 year old female with past medical history significant for
diastolic heart failure, moderate aortic stenosis with valve
area of [**2-3**].2 cm2, bronchietasis and COPD with stage II gold
criteria and home oxygen 2-4L admitted with one day history of
shortness of breath, change in her productive [**Date Range **] and
pleuritic chest pain.
#. COPD exascerbation and decompensated dCHF: This was
attributed to elements of COPD exacerbation and her diastolic
heart failure. She was treated with BIPAP and started on
steroids, initially hydrocort 125mg IV Q8 which was gradually
tapered to 60mg PO prednisone daily by the time she was called
out to the floor. Then she was transitioned to 30mg of
prednisone prior to discharge. She was diuresed with lasix;
given a significant metabolic alkalosis she was briefly treated
with acetazolamide with continued diuresis. LOS fluid balance of
-5L. IV lasix was stopped and she was put on her home torsemide
dose of 40mg [**Hospital1 **]. Prior to discharge, we held one dose of
torsemide and prescribed half of a dose on the morning of
[**2198-3-16**], with resuming her home dose in the evening on [**2198-3-16**]
because of metabolic alkalosis. She remained on CPAP at night,
and her O2 saturations were titrated between 92-94% on 2-4L of
oxygen which is her home baseline.
#. Urinary tract infection: Grew out pan sensitive klebsiella in
her urine. She was started on levofloxacin (at the time for
empiric coverage of respiratory organisms when this was being
entertained on the SOB ddx) and then transitioned to cipro when
sensitivies grew out (and PNA was felt less likely) for a total
of a 3 day course. She had episodes of inconitnence in the
setting of a foley that was traumatically partially removed. It
was replaced, and then discontinued. She had improvement in her
incontinence prior to discharge.
#. Atrial fibrillation: Had episodes of RVR. Was amiodarone
loaded and given diltiazem as her pressures would tolerate,
which was gradually uptitrated to 90mg QID. He continued to have
episodes of RVR, and given her borderline blood pressures, we
started metoprolol 25mg [**Hospital1 **] and uptitrated to 37.5mg which
caused her to have mildly worse [**Last Name (LF) **], [**First Name3 (LF) **] we decreased it to
25mg [**Hospital1 **], with a decrease in incidence of RVR. Amiodarone was
discontinued as the risks were thought to outweight the
potential benefits in this patient. She was anticoagulated with
aspirin alone given a history of a prior GI bleed.
#. Access: Ms. [**Known lastname **] has a PICC line in her right brachial
vessel which terminates at the junction of the SVC and right
atrium. This is in good position and ok to use.
- Please remove PICC when no longer needed for access and draws
#. Anemia: Chronic and at baseline throughout admission. This
was a stable issue for her.
Medications on Admission:
1. Fluticasone-salmeterol 250-50 mcg/dose i puff [**Hospital1 **]
2. tiotropium bromide 18 mcg Capsule [**2-4**] inhalations daily
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) prn
4. montelukast 10 mg Tablet 10 mg po qdaily
5. Fexofenadine 60 mg po BID
6. Omeprazole 20 mg po BID
7. Vitamin D 400 units qdaily
8. Ferrous sulfate 300 mg po qdaily
9. Calcium carbonate 500 mg po TID with meals
10. docusate sodium 100 mg po BID
11. senna 8.6 mg po BID
12. torsemide 40 mg po BID
13. potassium chloride 20 meq po BID
14. metoprolol tartrate 25 mg po BID
15. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. diltiazem HCl 420 mg po qdaily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety: Please do not drive while on this
medication, it can make you drowsy.
9. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
12. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): Hold for SBP<90
Hold for HR<60.
13. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days.
14. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO three times a day: with meals.
15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
16. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) INH Inhalation twice a day.
17. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 doses: Morning of [**2198-3-16**].
18. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day:
Starting in the evening of [**2198-3-16**].
19. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary:
COPD exacerbation
acute on chronic diastolic congestive heart failure
Atrial fibrillation with rapid ventricular response
Urinary tract infection
Secondary:
Anemia of chronic disease
Depression
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:
Ms. [**Known lastname **],
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] because of difficulty breathing beyond your baseline. You
required a short stay in the ICU to control your breathing.
They treated your COPD with steroids and non-invasive
ventilation (BiPap) to help dampen the inflammation in your
lungs. We also found that you had fluid on your lungs and gave
you diuretics IV to help pull that fluid off (lasix). Your
breathing improved to your baseline.
Also, your abnormal heart rhythm, called atrial fibrillation was
abnormally fast. In the ICU they added a medication called
amiodarone to help with that. We transitioned you back to
metoprolol and diltiazem to help slow the rate down.
Over the course of your stay, you became weak because of your
illness, and will require a short stay in rehab to help you
transition home.
Finally, you had a urinary tract infection which we treated with
Cipro for three days.
We made the following changes to your medications:
-CHANGED diltiazem from 480mg daily to 60mg by mouth 4 times a
day
-CHANGED metoprolol to 37.5mg by mouth twice a day
-HELD your torsemide night time dose on [**2198-3-15**]. Please take
20mg in the morning on [**2198-3-16**] and restart your normal dose of
40mg twice a day in the evening on [**2198-3-16**]
-CONTINUE Prednisone 30mg by mouth daily for 2 more days (until
[**2198-3-17**])
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please Follow-up at the appointments below:
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: MONDAY [**2198-4-16**] at 10:45 AM
With: [**Month (only) 6436**] ([**Month (only) **]) [**Name8 (MD) **], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: ADULT SPECIALTIES
When: WEDNESDAY [**2198-5-9**] at 11:00 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1142**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: ADULT MEDICINE
When: THURSDAY [**2198-7-19**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2198-3-17**]
|
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51,237
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7009
|
Discharge summary
|
report
|
Admission Date: [**2108-4-10**] Discharge Date: [**2108-4-22**]
Date of Birth: [**2027-2-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / metformin
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Fever, cough, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 81M with HIV, last CD4 369 in [**Month (only) 404**], prostate CA
s/p chemo/XRT recently stopped for treatment failure (no PSA
response) who presented to his PCP [**Name Initial (PRE) 151**] 3 days of worsening
generalized fatigue and malaise and dyspnea. He also notes that
he and his partner had URTI about 2 weeks ago that improved and
he denied recent fever and cough. On admission, he required 0-2L
to maintain 02 >95%, he had WBC 13.6 (82%N, 0%B), acute on
chronic renal failure BUN/Cr 36/1.8. CXR showed a left lingular
PNA and he was started on Levofloxacin for presumed CAP.
.
The patient specifically denies chest pain, but does note some
dizziness. His dyspnea is not positional. Since his retirement
2 years ago he has traveled extensively to [**Location (un) **], [**Country 26231**],
[**Country 3396**], [**Country 651**], most of Europe. He denies any febrile
illnesses on any trip. He also denies history of TB or known
exposure to TB, and had a PPD several years ago that was
negative.
.
On the inpatient floor, the patient felt well other than
reporting continued generalized weakness/fatigue that is not his
baseline. No cough.
.
ROS: Denies headache, vision changes, rhinorrhea, congestion,
sore throat, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- HIV, diagnosed ~[**2089**], CD4 369 [**12/2107**]
- Prostate CA, s/p XRT/hormonal chemo (PSA unresponsive)
- HTN
- Hyperlipidemia
Social History:
Born in [**Country 26232**]. Has traveled extensively over past 2 years
to [**Location (un) **], [**Country 26231**], [**Country 3396**], [**Country 651**], most of Europe. Lives with
male partner who is a psychiatrist. Prior tobacco, quit 16y ago,
unclear pack-years. Denies ETOH. Former illicts, denies ever
IVDU, quit 18y ago.
Family History:
Mother deceased at [**Age over 90 **]yo; brother and sister alive at 82 and 83
with no medical problems.
Physical Exam:
ON ADMISSION:
VS - Temp 100.4F, BP 140/60, HR 78, R 26, O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate,
speaking full sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no wheezing or rhonchi, min crackles at
bilateral bases, good air movement, resp unlabored, no accessory
muscle use
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 (radials,
DPs), no crepitus
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait not tested
.
ON ADMISSION TO ICU:
GENERAL - well-appearing man using abdominal muscles, but
stating he feels comfortable speaking full sentences but
somewhat short of breath at the end of his sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS -
HEART - RRR, distant heart sounds, no rub appreciated
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait deferred
.
ON DISCHARGE:
VS: Tm 99.0 BP 95-141/74-90 HR 92-94 RR 18 94% on 3L
GENERAL: No acute distress, speaking full sentences without
accessory muscle use
HEENT: Sclerae anicteric and without injection, MMM, oropharynx
clear
NECK: Supple
LUNGS: Mild rhonchi in both bases, no wheeze
HEART: S1, S2, no murmurs auscultated
ABDOMEN: Soft, non-tender, no rebound/guarding, BS +
EXTREMITIES: WWP, no edema, 2+ radial/pedal pulses
NEURO: Awake, A&Ox3, CNs III-XII grossly intact, motor strength
grossly intact
Pertinent Results:
ADMISSION LABS:
[**2108-4-10**] 01:10PM BLOOD WBC-13.6* RBC-3.72* Hgb-12.2* Hct-34.6*
MCV-93 MCH-32.8* MCHC-35.3* RDW-12.5 Plt Ct-190
[**2108-4-10**] 01:10PM BLOOD Neuts-81.7* Lymphs-12.8* Monos-4.1
Eos-0.9 Baso-0.3
[**2108-4-10**] 01:10PM BLOOD Plt Ct-190
[**2108-4-12**] 06:45AM BLOOD WBC-12.6* Lymph-12* Abs [**Last Name (un) **]-1512 CD3%-79
Abs CD3-1193 CD4%-7 Abs CD4-112* CD8%-72 Abs CD8-1092*
CD4/CD8-0.1*
[**2108-4-10**] 01:10PM BLOOD Glucose-116* UreaN-36* Creat-1.8* Na-136
K-4.1 Cl-99 HCO3-26 AnGap-15
[**2108-4-11**] 07:10AM BLOOD ALT-32 AST-54* AlkPhos-72 TotBili-1.5
[**2108-4-11**] 07:10AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.7
[**2108-4-15**] 03:51AM BLOOD Vanco-7.9*
[**2108-4-13**] 05:45PM BLOOD Type-ART FiO2-96 O2 Flow-2 pO2-53*
pCO2-31* pH-7.49* calTCO2-24 Base XS-1 AADO2-615 REQ O2-98
[**2108-4-13**] 05:45PM BLOOD Lactate-1.8
[**2108-4-14**] 05:26AM BLOOD freeCa-1.07*
.
DISCHARGE LABS:
[**2108-4-21**] 05:21AM BLOOD WBC-12.0* RBC-2.91* Hgb-9.8* Hct-28.2*
MCV-97 MCH-33.5* MCHC-34.6 RDW-13.1 Plt Ct-402
[**2108-4-21**] 05:21AM BLOOD Glucose-111* UreaN-40* Creat-1.5* Na-140
K-3.7 Cl-101 HCO3-28 AnGap-15
.
MICRO:
Blood Culture, Routine (Final [**2108-4-16**]): NO GROWTH.
Blood Culture, Routine (Final [**2108-4-16**]): NO GROWTH.
URINE CULTURE (Final [**2108-4-12**]): <10,000 organisms/ml.
URINE CULTURE (Final [**2108-4-13**]): NO GROWTH.
URINE CULTURE (Final [**2108-4-16**]): NO GROWTH.
MRSA SCREEN (Final [**2108-4-16**]): No MRSA isolated.
.
Legionella Urinary Antigen (Final [**2108-4-13**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
HIV-1 Viral Load/Ultrasensitive (Final [**2108-4-13**]):
HIV-1 RNA is not detected.
.
[**2108-4-12**] 8:30 pm SPUTUM Source: Induced.
GRAM STAIN (Final [**2108-4-12**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2108-4-14**]):
MODERATE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2108-4-14**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
ACID FAST SMEAR (Final [**2108-4-13**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
[**2108-4-14**] 2:51 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2108-4-14**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2108-4-16**]):
MODERATE GROWTH Commensal Respiratory Flora.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2108-4-14**]):
SPECIMEN QNS FOR THIS TEST.
ACID FAST SMEAR (Final [**2108-4-16**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
This is only a PRELIMINARY result. If ruling out
tuberculosis, you
must wait for confirmation by concentrated smear.
DUE TO QUANTITY NOT SUFFICIENT concentrated smear not
available.
ACID FAST CULTURE (Final [**2108-4-14**]):
SPECIMEN QNS FOR THIS TEST.
.
[**2108-4-15**] 6:47 pm SPUTUM Source: Induced.
GRAM STAIN (Final [**2108-4-15**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
ACID FAST SMEAR (Final [**2108-4-16**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
RESPIRATORY CULTURE (Final [**2108-4-17**]):
SPARSE GROWTH Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2108-4-16**]): NEGATIVE for Pneumocystis jirovecii
(carinii).
.
NEGATIVE
- PCP x 2
- AFBs
- ASPERGILLUS GALACTOMANNAN ANTIGEN
- B-GLUCAN
- MYCOPLASMA PNEUMONIAE ANTIBODIES
.
IMAGING:
[**2108-4-10**] CXR
PA and lateral views of the chest were obtained. Low lung
volumes result in bronchovascular crowding. Focal consolidation
in the left hilar region is a pneumonia. The cardiac and
mediastinal silhouettes are normal. No pneumothorax.
IMPRESSION: Lingular pneumonia. Recommend repeat radiograph in
four to six weeks to document resolution.
.
[**2108-4-12**] CXR
As compared to the previous radiograph, the lung volumes have
slightly decreased. On the left, in both the lung periphery and
the perihilar areas, the pre-described massive pneumonia is
visible in unchanged manner.
No newly appeared focal parenchymal opacities. No pulmonary
edema. No pleural effusions. No pneumothorax. Unchanged size of
the cardiac silhouette.
.
[**2108-4-13**] CXR
Comparison is made to the CT scan performed on the same day as
well as prior chest radiograph from [**2108-4-12**].
There are again noted areas of consolidation within the left
lung. These have increased particularly in the left upper lobe.
Cardiac silhouette is upper limits of normal. Small area of
consolidation at the right base medially is also present. There
are no pneumothoraces or large pleural effusions.
.
[**2108-4-13**] CT CHEST
IMPRESSION:
1. Multifocal pulmonary consolidation involving both lungs,
worse in the left upper and lower lobes, concerning for
multifocal pneumonia. There is no evidence of airway
obstruction. Recommended follow up imaging after treatment to
assess resolution.
2. Mild ectasia of the ascending thoracic aorta measuring 4 cm.
3. Indeterminate adrenal nodules.
.
[**2108-4-15**] CXR
IMPRESSION: Widespread alveolar opacities, some of which have a
nodular configuration. In a patient with HIV infection, this is
most consistent with multifocal pneumonia. Bacterial and fungal
organisms should be considered. Infection complicated by
organizing pneumonia is also possible.
.
[**2108-4-16**] CXR
As compared to the previous radiograph, there is unchanged
evidence of diffuse left parenchymal opacity strongly suggestive
of pneumonia. The opacities show a slightly peripheral
predominance. No evidence of pleural effusions. No other
pathologies, the right lung is unremarkable, except for a spot
of increased lung density in the region of the right apex that
could be caused by a projection phenomenon.
Normal size of the cardiac silhouette.
.
Brief Hospital Course:
81M with HIV, prostate CA s/p chemo/XRT now presenting with 3
days of SOB, non-productive cough, fevers and CXR concerning for
pneumonia. He was initially admitted to the inpatient general
medicine service and empirically treated with levofloxacin for
empiric CAP treatment.
.
On the day after admission, the patient spiked fever up to 101.4
so Vancomycin was empirically started. A CD4 at that time was
112 and VL undetectable. CXR was repeated and was unchanged.
This morning, the patient was requiring 2L 02 and had another
fever so antibiotics were switched to
Vanco/Aztreonam/Azithromycin (Aztreonam because wanted to avoid
levofloxacin due to concern for TB and because he reports upper
airway swelling with PCN). Induced sputum was sent which was
AFB smear negative, had 2+GPCs and 1+GNRs with growth of only
commensal respiratory flora.
.
Late in the afternoon the patient was noted to be tachypneic to
the 30s and he was satting the the low 90s. ABG at this time
showed 7.49/31/53/24 and his 02 was increased to 6L. His sats
improved but he was still visibly dyspneic so was transferred to
the MICU for closer monitoring. The remainder of his hospital
course is outlined below by problem.
.
# Hypoxic respiratory distress/Multifocal pneumonia, bacterial:
Pt had a clinical decompensation requiring MICU, admission and
despite extensive infectious work up, there was no bacterial
source identified. Repeat imaging revealed diffuse multifocal
PNA. PCP stains were negative x 2. Induced sputum for TB was
negative x 3 for AFB and sputum Cx were positive for oral flora
only. Ultimately, pt developed a steady clinical response to
the combination of vancomycin, cefepime, and levofloxacin.
Pulmonary was consulted and felt that COP was a possible
underlying diagnosis but did not recommend treatment with
steroids or further work up at this time as pt seemed to having
consistent clinical response to the above antibiotic regimen.
Pt remained afebrile for >72hrs before discharge. The patient
should continue antibiotic coverage with vancomycin, cefepime &
Levaquin for 14 days for HCAP (final day [**2108-4-29**]). He may
continue albuterol and ipratriopium nebs with IS as needed. Pt
was given referral to see [**Location (un) 2274**] pulmonary after discharge to
ensure resolution of PNA.
.
#. HIV: Most recent CD4 was 350 in [**Month (only) 404**] though he was noted
to have a low CD4 now in the setting of acute illness. Unclear
why, but patient listed as taking an NNRTI (etravirine) +
boosted PI (lopinavir/ritonavir) which would not be a typical
outpatient MD, "he has had stable virologic suppression on this
two drug regimen. Initially he was on raltegravir in addition
but did not tolerate it - felt general malaise - and better off
of it. While a 2 drug HIV regimen is not standard of care for
initial therapy - there are a lot of studies confirming what he
has - which is prolonged stable virologic suppression and CD4
improvements on just 2 antivirals after suppression has been
achieved." Continued on home regimen.
.
# Leukocytosis: Etiology unknown. Pt denied any new localizing
symptoms but has loose stools at baseline and wanted to use
immodium. Cdiff toxin was negative x2 and UA was not
suggestive of infection. White count was resolving by the time
of discharge
.
# Acute-on-chronic renal failure: Recent baseline 1.3-1.6,
increased to 1.8 here with FENA consistent with prerenal
azotemia. He received IV support and creatinine improved to
1.5. The patient's creatinine remained stable once po intake
improved.
.
# Hypertension: Enalapril and HCTZ restarted once patient's
creatinine had stabilized.
.
# Hyperlipidemia: Continued home statin/ASA.
Medications on Admission:
- Aspirin 81 mg PO Daily
- One Daily Multivitamin PO daily
- Calcium PO daily
- Pravastatin 40 mg QHS
- Lopinavir-ritonavir 200 mg-50 mg 3 tablets [**Hospital1 **]
- Enalapril-hydrochlorothiazide 10 mg-25 mg PO Daily
- Acyclovir 400 mg PO Twice Daily
- Fish oil-fat acid comb8-herb comb137 1,200 mg (400
mg-400mg-400mg) PO daily
- Etravirine 100 mg 2 tablets PO daily
- Lorazepam 1 mg PO QHS
- desonide 0.05 % Topical Cream Topical [**Hospital1 **] to rash in ears
[- Bicalutamide 50 mg PO daily] stopped recently; PSA
nonresponsive
[- finasteride 5 mg PO daily] stopped recently; PSA
nonresponsive
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lopinavir-ritonavir 200-50 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for to rash in ears.
6. enalapril maleate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO DAILY (Daily).
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2
hours) as needed for SOB.
14. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
15. cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q12H
(every 12 hours) for 6 days: Continue through [**2108-4-29**].
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 6 days: Continue through
[**2108-4-29**].
17. levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous Q48H (every 48 hours) for 6
days: Continue through [**2108-4-29**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center [**Location 1268**]
Discharge Diagnosis:
Primary diagnosis: Pneumonia, bacterial
Secondary diagnoses:
HIV
Hypertension
Chronic kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 26233**],
It was a pleasure participating in your care at [**Hospital1 771**].
You were admitted because you had a pneumonia. After a brief
stay in the Intensive Care Unit, you remained stable with a
combination of antibiotics. You will go to a rehabilitation
facility that will continue these antibiotics for a total course
of 14 days.
During your stay, your home medications did not change. At the
rehabilitation facility, you will continue the antibiotics:
vancomycin, cefepime, levofloxacin. You will also have available
albuterol and ipratropium nebulizers if you feel short of
breath.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge. Also
please contact your provider to schedule an appointment within
2-4 weeks with Pulmonary**
|
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icd9cm
|
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[
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,434
| 129,483
|
32305
|
Discharge summary
|
report
|
Admission Date: [**2120-12-19**] Discharge Date: [**2121-1-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
s/p MVA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 85 y/o F w/h/o CAD txfed here from OSH s/p MVA.
Restrained, hit tree. She was on her way home from visiting her
very ill husband in the hospital. She remembers driving, then
remembers hitting the tree. She blacked out at some point before
the collision. She denies CP/palps/dizzyness/headache prior.
Denies feeling anxious before the event. Does state she was
eating normally but had not been sleeping much since her husband
was admitted to the hospital. She was seen at OSH where CT
c-spine showed C2 fx with mild displacement, pelvic plain film
was negative for fx. She had a set of cardiac enzymes negative
there. She received a tetanus vaccination and was pan scanned at
OSH found to have C2 fx and sternal fx. She was transferred here
for further management. On exam is neurovascularly intact.
.
ROS is positive for occassional CP on exertion last 1 mo ago
controlled w/Nitro SL; able to climb [**7-4**] steps before SOB, able
to walk 1 block w/o SOB. Denies fever/N/V, has been eating and
drinking OK; notes h/o of BRBPR, none recently. negative for
palps/visual changes/headache/dizzyness.
Past Medical History:
DM2- '[**04**]
HTN
CAD s/p MI [**2079**] and again in [**9-2**]
h/o multiple hospitalizations for unstable angina '[**79**] and '[**94**]
CHF per pt but not listed. States LE edema worse in day resolves
o/n
h/o rectal polyps
h/o early leukoplakia, h/o gastric ulcers
Grieving, but no depression
chronic diarrhea
arthritis- right hip and right shoulder
LBP
h/o ovarian cysts s/p XRT in the 40s
.
Past surgical history:
s/p thyroidectomy '[**09**]
s/p appy '[**55**]
ovarian cyst removal in [**2053**]'s
s/p hysterectomy '[**64**]
ccy '[**80**]
cataract implants BL
Laminectomy [**11/2111**]
arthroscopic surgery knees BL '[**14**]
Social History:
Pt is a married woman lives in [**Hospital1 **] w/ her husband in
daughter in law's home. Previously lived in FL for 28 yrs but
has been up herer x 1 year. Son passed away of cancer one year
ago and husband is very ill. Nonsmoker, nondrinker.
Family History:
Unremarkable per pt
Physical Exam:
PE: 97.2-98.8, 130-160/60-70, 14-16, 98-99% ?RA, 93% on 2LNC,
recheck this AM 96% on 2LNC
Gen: NAD, in [**Location (un) 2848**] J collar, lying at about 30 degrees
HEENT: PERRL, EOMI, OP clear
Neck: supple, No LAD, unable to assess JVP given collar
Chest: CTAB anteriorly no wheezes/rhonchi
Cardiac: PMI non-displaced, s1, s2, no m/r/g
ABD: +BS, NTND, no HSM,
Ext: no cyanosis or clubbing, no edema
Neuro: A&Ox3, moves all 4, 5/5 strength, sensation intact to
light touch
Pertinent Results:
Admission labs:
[**2120-12-19**] 09:21PM WBC-12.2* RBC-4.21 HGB-12.8 HCT-37.2 MCV-88
MCH-30.4 MCHC-34.4 RDW-13.9
[**2120-12-19**] 09:21PM NEUTS-87.7* BANDS-0 LYMPHS-7.2* MONOS-4.7
EOS-0.3 BASOS-0.2
[**2120-12-19**] 09:21PM PLT SMR-NORMAL PLT COUNT-194
[**2120-12-19**] 09:21PM GLUCOSE-158* UREA N-15 CREAT-0.8 SODIUM-134
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-29 ANION GAP-15
[**2120-12-19**] 09:21PM CALCIUM-9.5 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2120-12-19**] 09:21PM CK(CPK)-189*
[**2120-12-19**] 09:21PM CK-MB-7
[**2120-12-19**] 09:21PM cTropnT-<0.01
[**2120-12-20**] 10:50AM BLOOD CK(CPK)-251*
[**2120-12-20**] 10:50AM BLOOD CK-MB-6 cTropnT-<0.01
.
Imaging:
CT C-SPINE W/O CONTRAST [**2120-12-19**]
IMPRESSION:
1. Extensively comminuted fractures of the base of the C2 (type
3 C2 fracture), with 4-mm destruction and retropulsion fragment
indenting the thecal sac. No gross hematoma is noted, however,
the assessment of the spinal cord is somewhat limited, and MRI
will further delineate this abnormality in the spinal canal and
thecal sac. Fracture line extends to the right transverse
foramen, however, the right vertebral artery itself is somewhat
away from the fracture line separated by the fat plane. If
clinically indicated, dedicated vascular study such as CTA or
MRA could be obtained. Degenerative changes.
.
CTA NECK W&W/OC & RECONS [**2120-12-21**]
IMPRESSION:
1. Bilateral pars interarticularis and posterior body of C2
fractures with minimal epidural hematoma not compressing the
cord.
2. The left vertebral artery is largely thrombosed shortly after
the origin with retrograde filling via the basilar artery at the
more distal portion. Given only mild stenosis of the origin of
the left vertebral artery, this occlusion may be an acute event.
3. Calcified atherosclerotic plaques involving the aortic arch
and the common carotid artery and internal carotid artery bulbs
without significant stenosis.
.
CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial hemorrhage or major vascular
territorial infarct. Left maxillary sinus disease.
.
TTE (Complete) Done [**2120-12-24**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Transmitral Doppler and tissue velocity imaging are
consistent with Grade I (mild) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall is hypertrophied. 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. The left ventricular inflow
pattern suggests impaired relaxation. There is moderate
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
.
EEG Study Date of [**2120-12-24**]
IMPRESSION: Abnormal EEG in the waking and drowsy states due to
the
frequent bursts of generalized slowing. This finding is not
specific
with regard to etiology but implies a dysfunction in midline
structures.
Vascular disease is one possible cause. Nevertheless, there were
no
areas of persistent focal slowing, and there were no
epileptiform
features.
.
CT CHEST W/CONTRAST [**2121-1-1**]
IMPRESSION:
1. Mild congestive heart failure.
2. No evidence of pneumonia or lung mass. Secretions or
aspirated material, left lower lobe segmental bronchi.
3. Atherosclerosis, including coronary arteries.
.
CTA HEAD W&W/O C & RECONS [**2121-1-1**]
IMPRESSION:
1. Unchanged Hangman's fracture: Bilateral pars interarticularis
and posterior body of C2 fractures.
2. No radiologic evidence for a mass or CVA.
Brief Hospital Course:
85 yo woman with PMHx sig. for CAD who presents after MVA from
syncope with C2 and sternal fx and found to have L vertebral
artery thrombosis.
.
# C2, sternal fx: She was evaluated and treated by [**Month/Day/Year 1957**] Spine.
She was found to have a bilateral fracture of the C2 pars
"Hangmans" fracture, Type 1 or Type 2, and has elected to have
treatment in cervical collar as opposed to halo or surgery due
to several factors including her medical co-morbidities and a
unilateral vertebral artery injury with occlusion. [**Month/Day/Year 1957**] Spine
has discussed with her that if her fracture does not heal
satisfactorily in the future, surgery may need to be
reconsidered. She is to wear the neck collar for 8 weeks.
Physical therapy worked with her. She has elected to follow up
with a local orthopedist in [**Hospital1 **]. An appointment has been
made for her. Pt was discharged to rehab.
.
# Syncope: Pt was ruled out for MI upon admission by CEs and
EKGs. She had no sig. events recorded on telemetry. She had an
ECHO that showed no outlet obstruction. She was not
orthostatic. An EEG showed no epileptiform features. Neurology
felt that a dissection of the L vertebral artery could have
resulted in thrombosis, resulting in syncope.
.
# L vertebral artery thrombosis: Pt's neurological exam
remained nonfocal throughout her hospitalization. Vascular
Surgery and Neurology (stroke) were consulted. Initially,
anticoagulation with heparin was contraindicated as pt had a
small cervical epidural hematoma as well. [**Hospital1 1957**] Spine felt this
was not a contraindication as the pt was 1 week out from her
trauma. Neurology recommended a MRI/MRA to assess for
dissection. Unfortunately, we were unable to obtain the pt's
records of a stapedectomy performed in the early [**2073**] to
determine safety of obtaining a MRI. A CT head without contrast
was performed instead to rule out intracranial bleed. Given the
pt's lack of focal neurological symptoms and concern for fall
risk, it was decided against therapeutic anticoagulation. She
was started on ASA 325 mg. She will follow up with vascular
surgery.
.
# SIADH: This was resistant to fluid restriction and Nephrology
was consulted. Pt required hypertonic saline and spent a night
in the intensive care unit for closer monitoring. Her serum
sodium increased appropriately with 1 liter fluid restriction
and hypertonic saline. She was successfully transitioned to
salt tabs. She is discharged on NaCl 1 gm TID and furosemide 20
mg for maintenance of serum sodium. She will need a serum
sodium checked in 1 week, and if low, will need to follow up
with Dr. [**First Name (STitle) 805**] of Nephrology (([**Telephone/Fax (1) 817**]).
.
# OSA: Pt was started on CPAP 6 cm H2O with 4 lpm O2. She will
need an outpatient sleep study.
.
# Delirium: Pt became delirious after taking increased pain
medications, ambien, and trazodone. This resolved the following
day. Her narcotic pain meds were limited to oxycodone 2.5 mg po
q 4 hrs prn and standing acetaminophen, and she did well with
that. She was continued on trazodone 25 mg qhs prn insomnia.
BZDs were avoided for the rest of the hospitalization.
.
# UTI: Pt was treated with ciprofloxacin x 3 days.
.
# Hyponatremia: Pt remained asymptomatic. Initially, she was
thought to be volume depleted and her Na improved with NS IVFs.
However, her Na then declined further on fluids and she was
placed on fluid restriction for SIADH. Her HCTZ was also held.
.
# CAD: Pt was continued on statin, ACEI, BB, and ASA.
.
# HTN: Pt BP was elevated. Her metoprolol was increased to 50
mg [**Hospital1 **] and she was continued on her ACEI. Her HCTZ was
discontinued due to hyponatremia. Furosemide was started
instead.
.
# Hypothyroidism: TSH was WNL. She was continued on her
levothyroxine.
.
# Chronic Diarrhea: Stool cultures inc. O&P were negative. C.
diff was negative x2. Per pt, this has been worked up by GI as
outpatient and she is treated with loperamide.
.
# DNR/DNI
Medications on Admission:
Simvastatin 40mg daily
Quinipril 10mg once daily
levothyroxine 150mcg one daily
HCTZ 12.5mg once daily
Toprol XL 50mg once daily
Protonix 40mg once daily
Actos 30mg once daily
Propoxyphene-N w/APAP 100/650mg
ASA 81mg once daily
Nitro SL prn
Omega 3 once daily
Calcium 600mg once daily
loperamide 2mg once daily
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Quinapril 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
7. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
10. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day) as needed for back rash.
11. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
Blueberry [**Doctor Last Name **] Healthcare - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnoses:
Syncope
C2 and sternal fractures
Syndrome of inappropriate anti-diuretic hormone
Obstructive sleep apnea
.
Secondary Diagnoses:
Diabetes mellitus II
Hypertension
Coronary artery disease
Congestive heart failure
Chronic diarrhea
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after you blacked out resulting in a motor
vehicle accident. You had broken a neck bone and your
breastbone. Orthopedic surgeons have evaulated you and
recommended that you wear your neck collar for 8 weeks. You
will need to follow up with Dr. [**First Name (STitle) **], the orthopedic surgeon
by your home, as you requested.
.
You were also found to have a blood clot in one of your arteries
leading to your head. You will need to be on aspirin 325 mg
daily for this until otherwise directed. You will follow up
with vascular surgery.
.
Your sodium has been low. This has improved with salt tabs and
restricting your fluid intake to 1 liter. You need to continue
the salt tabs for now and you were started on furosemide. You
may now drink when you are thirsty. If you sodium is still low,
you will need to follow up with Nephrology (Kidney doctors).
.
Please take your medications as directed. Your Toprol XL has
been increased to 100 mg daily to help lower your blood
pressure. Your hydrochlorothiazide has been decreased because
of your low serum sodium. You have been started on furosemide.
.
If you develop lightheadedness, confusion, sudden weakness,
numbness/tingling, slurred speech, blurry vision, dizziness,
chest discomfort, shortness of breath, or any other worrisome
symptoms, please call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 10508**] or go to the Emergency Department.
Followup Instructions:
You have requested to see an orthopedic surgeon closer to home.
You have been scheduled for an appointment with an orthopedic
surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Monday, [**1-8**] at 10:45 AM.
Please call [**Telephone/Fax (1) 75503**] with any questions, concerns, or to
change your appointment.
.
If you decide to stay within the [**Hospital1 1170**], you can follow up with Dr. [**Last Name (STitle) 1007**]. Appointments have
been made for:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2121-1-29**] 11:40
Provider: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2121-1-29**] 12:00
.
You also have a follow up appointment with Vascular surgery, Dr.
[**Last Name (STitle) 3407**] on [**2121-2-11**] at 1:00PM. The phone number is [**Telephone/Fax (1) 1237**].
.
Please also follow up with your primary care doctor, Dr. [**Last Name (STitle) **].
An appointment has been made for you on [**2121-1-22**] at
10:30AM. The clinic number is [**Telephone/Fax (1) 10508**].
.
If your sodium is still low after 1 week, please follow up with
Dr. [**First Name (STitle) 805**] of Nephrology. The clinic number is ([**Telephone/Fax (1) 817**].
|
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,322
| 118,607
|
12982
|
Discharge summary
|
report
|
Admission Date: [**2169-8-25**] Discharge Date: [**2169-8-31**]
Date of Birth: [**2090-7-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Nifedipine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Speech Arrest
Major Surgical or Invasive Procedure:
R frontal craniotomy for resection of mass [**2169-8-28**]
History of Present Illness:
The pt is a 79 year-old right-handed male with past medical
history of HTN, HLD, CAD s/p MI and stenting
procedures,peripheral [**Month/Day/Year 1106**] disease with multiple stents
placed (most recently [**8-18**]) and recurrent oral cancer who
presents with and episode of staring and speech arrest, and now
dysarthria.
The patient was in his usual state of health this afternoon at
6pm when he was at a football game for his grandson. [**Name (NI) **] was
sitting in the stands when his wife and daughter-in-law noted
that he was staring straight ahead and was not responsive. They
noted that he was drooling or foaming at the mouth. They did
not note a facial droop, he appeared to be able to hold his
upright
posture. He was not responsive to commands, and at one point
appeared to be gagging. They noted his eyes were forward and
there was no particular deviation to any side. The family is
not sure how long he was unable to speak, the think at least a
few minutes passed before he was taken to a local hospital. The
patient is not clear if he remembers the entire event. He does
indicate that he remembers some time were he was unable to get
words out, but he has no recollection of his family trying to
communicate with him.
His family called EMS and the ambulance arrived. He has some
recollection of getting into the ambulance. They noted that he
was able to stand and walk to the ambulance with some
assistance.
The patient believes he was able to speak with some difficulty
when he arrived at the OSH. There he had a head CT which showed
a possible mass in the right frontal lobe with surrounding
edema.
By report it was stated that he was "aphasic" at the OSH, but no
further information was given. He was transferred to [**Hospital1 18**] for
further evaluation.
Past Medical History:
Coronary aterry disease, s/p MI and LCx stenting [**2155**]
Peripheral [**Year (4 digits) 1106**] disease.
Hypertension.
Hyperlipidemia.
GERD.
Social History:
The patient is retired, and married with adult children. Was a
shipyard manager until early 40's. Smoked extensively (3-4PPD)
until [**2148**]'s. No ETOH
Family History:
His father had a MI at age 69. Sister had a MI at age 70,
his brother died of a MI at age 47 and another sister had CABG
at
age 62.
Physical Exam:
Physical Exam: On Admission
Vitals: T: P: R: 16 BP: SaO2:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, tongue appears half
size
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: no hair on LE bilaterally, right leg cooler to
touch
then left, hard to palpate pulse in legs.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to name
[**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact
repetition and comprehension. There were no paraphasic errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was severely dysarthric
although improved over the hour. Able to follow both midline
and
appendicular commands. Pt. was able to register 3 objects and
recall [**1-11**] at 3 minutes. There was no evidence of apraxia or
neglect. Poor Luria sequencing.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: Initially slightly L NLF, now no facial droop, facial
musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue in midline
-Motor: Normal bulk, increased tone at legs bilaterally.
Bilateral slight pronator drift. Mild postural tremor
bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
left delt with some giveway.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
Had
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 2 3 2
R 2 2 2 2 1
Plantar response was extensor bilaterally.
-Coordination: Mild intention tremor bilaterally. Normal HKS
bilaterally.
-Gait: Good initiation. Narrow-based, could not tandem. negative
Romberg:
On Discharge:neurologically intact.
Pertinent Results:
ADMISSION LABS:
[**2169-8-24**] 10:15PM PT-11.7 PTT-21.6* INR(PT)-1.0
[**2169-8-24**] 10:15PM WBC-7.1 RBC-4.25* HGB-14.4 HCT-42.8 MCV-101*
MCH-33.8* MCHC-33.6 RDW-14.4
[**2169-8-24**] 10:15PM GLUCOSE-107* UREA N-30* CREAT-1.7* SODIUM-133
POTASSIUM-7.6* CHLORIDE-95* TOTAL CO2-25 ANION GAP-21*
[**2169-8-25**] 12:10AM K+-4.3
DISCHARGE LABS:
CT Head [**8-25**]:
IMPRESSION: 1.6 cm mass centered in the right frontal lobe with
associated
vasogenic edema. Metastasis highly suspect, possibly from
adenocarcinoma. No significant associated midline shift. MRI is
recommended for further
evaluation.
CT Torso [**8-25**]:
1. Large heterogeneous right paratracheal lymph node described
above. Given its location at the junction of the distal trachea
and right mainst em bronchus, this would likely be amenable to
endotracheal biopsy.
2. Heterogenous enhancement of the prostate with scattered
calcifications
that are nonspecific. Recommend PSA as well as clinical exam to
further
evaluate for potential prostate carcinoma.
3. Small spiculated focus at the right lung apex. This might
represent
scarring, but neoplasia cannot be excluded; recommend 3 month
chest CT
followup.
MRI Brain [**2169-8-27**]
WAND study again demonstrates a right frontal lobe irregular
rim-enhancing lesion as described previousl.
CT head [**2169-8-29**]:
1. Status post right frontal mass resection with trace
hyperdense material in the post-surgical bed may be surgical
packing material or trace blood. Several locules of air may also
be packing material.
2. Small amount of bifrontal pneumocephalus.
3. Vasogenic edema surrounding the resection bed.
4. Status post right frontal craniotomy.
MRI Brain [**2169-8-29**]
1. Status post resection of a right frontal lobe lesion with
expected
sequelae. No evidence of nodular enhancement at the resection
margin to
suggest residual disease. Continued followup is recommended.
2. No new enhancing lesion seen with stable cortical areas of
slow diffusion in the left frontal, parietal and temporal lobes.
These remain concerning for acute/subacute infarcts and less
likely metastatic lesions that do not enhance.
Brief Hospital Course:
The patient was admitted to the NSurg service for further work
up and management. He was loaded with 10mg of Decadron and kept
at 4mg Q6. He was given Keppra for further seizure prevention.
An MRI of his head was obtained, which revealed 1.8cm R frontal
mass. Patient's exam remains nonfocal and he was taken to the OR
on [**8-28**] for R frontal craniotomy for resection of mass. Post
operatively, patient was nonfocal with a head CT that showed
some small amount of hemorrhage in the resection cavity, but was
otherwise stable. He was transferred to the floor on [**8-29**] with
an MRI pending. The MRI was performed and reviewed by Dr. [**Last Name (STitle) **]
who found it to have satisfactory post-op changes.
On [**8-30**] he had an episode of speech arrest and visual
disturbance thought to be a seizure and his Keppra was increased
to 1000mg [**Hospital1 **]. Cardiology suggested that he start ASA ASAP and
Dr. [**Last Name (STitle) **] approved this for [**9-2**]. Plavix is no longer needed.
He was cleared medically and by PT on [**8-31**] and was discharged.
Medications on Admission:
- Lipitor 20 mg qd
- Plavix 75 mg qd
- Fish Oil 1,000 mg Cap qd
- CIPRODEX 0.3 %-0.1 % Ear Drops, Susp 2 DROPS in the right ear
[**Hospital1 **]
- Buffered Aspirin 325 mg qd
- Hydrochlorothiazide 25 mg Tab qd
- Felodipine SR 10 mg 24 hr qd
- Losartan 100 mg qd
- Pepcid AC 20 mg qd
- Nitrostat 0.4 mg Sublingual Tab qd
- Metoprolol Tartrate 25 mg [**Hospital1 **]
- Multivitamin qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Four
(4) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for acid
reflux.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Hydrochlorothiazide 12.5 mg Capsule Sig: 0.5mg Capsule PO
DAILY (Daily).
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) for 0 months: 2mg Every 6 hours on [**8-31**], then 2mg Every
12 hours [**9-1**] forward.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Frontal Mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge 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.
?????? You may start taking Aspirin on [**9-2**]. You are not required to
take Plavix anymore by cardiology.
?????? You have been prescribed Keppra (Levetiracetam)for seizure
prophylaxis, you will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-17**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in [**3-14**] weeks.
??????You will need a CT scan of the brain without contrast.
You have an appointment with the Brain [**Hospital 341**] Clinic, [**Name6 (MD) 640**] [**Name8 (MD) 15756**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2169-9-11**] 9:30
The following appointments are listed for your conveinince.
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2169-10-4**] 10:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2169-10-4**] 11:15
Completed by:[**2169-8-31**]
|
[
"198.3",
"V45.82",
"530.81",
"412",
"272.4",
"584.9",
"401.9",
"348.5",
"V10.02",
"414.01",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
10084, 10090
|
7250, 8327
|
289, 350
|
10153, 10153
|
5085, 5085
|
11939, 13164
|
2526, 2660
|
8760, 10061
|
10111, 10132
|
8353, 8737
|
10304, 11916
|
5436, 7227
|
3781, 5029
|
2690, 3194
|
5042, 5066
|
236, 251
|
378, 2173
|
5102, 5419
|
10168, 10280
|
2195, 2339
|
2355, 2510
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,987
| 132,913
|
54996
|
Discharge summary
|
report
|
Admission Date: [**2116-8-10**] Discharge Date: [**2116-8-14**]
Date of Birth: [**2082-11-22**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:33 y/o F with history of anxiety presents s/p being hit with
car door and falling to the ground. Patient reports +LOC and
headache. She states that the last thing she remembers is the
gear in the car changing and the car rolling back. She attempted
to stop it from going into the street and was hit. She reports
headache, nausea, and dizziness. She also reports generalized
weakness. She denies any numbness or tingling, difficulty with
speech, or change in vision.
PMHx:anxiety and depression
All:NKDA
Medications prior to admission:Lexapro 20 mg QD, klonipin 0.5 mg
[**Hospital1 **] prn
Social Hx:Lives at home with her two daughters, is a stay at
home
mom. Reports social ETOH, denies any tobacco or illicit drugs
Family Hx:NC
ROS:as above
Past Medical History:
Depression and anxiety
Social History:
Social Hx:Lives at home with her two daughters, is a stay at
home
mom. Reports social ETOH, denies any tobacco or illicit drugs
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T:97.4 BP:117/66 HR:70 R: 20 O2Sats:98%
Gen: WD/WN, comfortable, NAD.
HEENT: R posterior hematoma
Pupils: 3-2 mm bilaterally EOMs: intact
Neck: in trauma collar
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-21**] 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,3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact 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 [**5-23**] throughout. No pronator drift
Sensation: Intact to light touch
Discharge:
gen: c/o headache, but pleasant and cooperative
neuro: + photophobia, AAOx3, PERRL, CNII-XII intact, motor and
sensory intact, no drift, no clonus, coordination intact
Pertinent Results:
NCHCT [**2116-8-10**]
1. Bilateral frontal subdural hematomas, left greater than
right, measuring Preliminary Reportup to 5 mm. Small blood
product in the left sylvian fissure, compatible with Preliminary
Reportsubarachnoid hemorrhage. Small hemorrhagic contusion of
the left inferior
Preliminary Reportfrontal lobe. Mild associated left lateral
ventricle effacement.
2. Right occipital bone fracture extends along the skull base to
the foramen Preliminary Reportmagnum just posterior to occipital
condyle.
Preliminary Report3. Right posterior scalp subgaleal hematoma.
CT C-SPINE [**2116-8-10**]
1. Nondisplaced fracture of the right aspect of occipital bone
extends along Skull base to the foramen magnum immediately
posterior to occipital condyle.
2. No cervical spine fracture. No acute alignment abnormality or
Preliminary Reportprevertebral soft tissue abnormality.
3. Multinodular thyroid gland. Non-emergent thyroid US may be
obtained for
Preliminary Reportfurther evaluation, if not recently performed.
CT head [**2116-8-11**]
1. Stable intracranial hemorrhage, allowing for expected
decreased density of subarachnoid hemorrhage. No new hemorrhage.
2. Apparent slightly decreased size of the left ambient
cistern, most likely related to head tilt. Recommend close
attention on follow-up imaging. No source of increased mass
effect or edema is seen to suggest that this is a true finding.
3. Right occipital bone fracture disrupting the right jugular
foramen and
extending into the foramen magnum, as seen previously.
Brief Hospital Course:
Ms. [**Known lastname 112297**] was evaluated in the emergency room and admitted to
the neurosurgery service. She was sent to the ICU for close
monitoring and neuro checks. She developed nausea and vomiting
at 3 am and was given some mannitol along with IV dilaudid.
On HD #2 repeat head CT was stable without increased hemorrhage
or edema. Patient remained nauseous and photophobic, but
improving since admission.
On HD #3 patient's headache and photophobia were stable; her
nausea continued to improve. Her mannitol was weaned to 12.5mg
q6 hrs. Her diet was advanced. Her C-spine was cleared (has
occipital condyle fracture which is not weight-bearing, stable)
and she was advanced to soft collar. Her neuro checks were
liberalized to q2 hours and she was transferred to the step-down
unit.
On [**8-13**] her headache was improving and she was neurologically
intact. Her mannitol was further tapered to 12.5 Q12 hrs. OT was
consulted as she had LOC. They recommend TBI followup for
cognitive therapy.
Now DOD, patient is afebrile VSS. She is set for discharge home
in stable condition and will follow-up.
Medications on Admission:
Lexapro 20 mg QD,
klonipin 0.5 mg [**Hospital1 **] prn
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, t>38.5
2. Acetaminophen-Caff-Butalbital [**1-20**] TAB PO Q4H:PRN h/a
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s)
by mouth every four (4) hours Disp #*120 Tablet Refills:*0
3. Clonazepam 0.5 mg PO BID:PRN anxiety/depression
4. Docusate Sodium 100 mg PO BID
RX *Col-Rite 100 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
5. Escitalopram Oxalate 20 mg PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) [**1-20**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every four (4) hours Disp #*60 Tablet Refills:*0
7. Phenytoin Sodium Extended 100 mg PO TID
RX *Dilantin Extended 100 mg 1 capsule(s) by mouth three times a
day Disp #*90 Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Left frontal contusion
Cerebral edema
Headaches
Traumatic brain injury
Nausea/vomiting
R occipital condyle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Nonsurgical Brain Hemorrhage
?????? 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 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**].
?????? **Please continue dilantin until follow-up with neurosurgery
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) **], 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.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
Completed by:[**2116-8-14**]
|
[
"348.5",
"852.26",
"E817.0",
"300.00",
"311",
"801.06"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6234, 6240
|
4221, 5337
|
318, 325
|
6400, 6400
|
2660, 4198
|
7735, 8394
|
1315, 1319
|
5443, 6211
|
6261, 6379
|
5363, 5420
|
6551, 7712
|
1349, 1541
|
894, 1107
|
270, 280
|
353, 863
|
1834, 2641
|
6415, 6527
|
1129, 1153
|
1169, 1299
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,047
| 113,108
|
38331
|
Discharge summary
|
report
|
Admission Date: [**2114-10-9**] Discharge Date: [**2114-11-24**]
Date of Birth: [**2044-6-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
cough and fevers x 1 month
Major Surgical or Invasive Procedure:
endotracheal intubation
bone marrow biopsy
History of Present Illness:
70 yo female with complicated hx of lung disease, thought likely
to be Rheumatoid lung, previously evaluated/treated at [**Hospital1 **] in MN, now presents with symptoms similar to previous
presentations with cough and fevers x 4-5 weeks.
.
Pt notes that her sx previously began approx [**7-9**], with onset of
rhinorrhea with post-nasal drip, development of a cough, and
subsequent persistent fevers. During the initial episode, she
was treated with levofloxacin and her symptoms appeared to
improve for a few months. Her symptoms later recurred. She was
evaluated at [**Hospital3 14659**] in MN, where her nephew is a
pulmonary-critical physician. [**Name10 (NameIs) **] the diagnosis is not
entirely clear, she is presumed to have rheumatoid lung disease
without evidence of articular involvement. She had a repeat CT
chest at [**Hospital1 **] approx 6 weeks ago; pt not aware of results. Pt
states that she has had extensive testing, but is unclear about
details.
She notes that she has a hx of hematologic involvement with her
prior episodes, and has required blood transfusion previously.
Her HCT has dropped from 30 to 24.
.
More recently, she was provided a course of Levofloxacin, which
she completed [**9-30**], which did not provide benefit.
.
For futher details of prior admission at [**Hospital1 **], see PMH below.
.
.
ROS:
+: as per HPI, plus: night sweats - last 1 month ago, decreased
appetite, LE edema, cough, hematochezia. Hemorrhoids. Fatigue.
.
Denies:
weight changes, chills/rigors, photophobia, loss of vision, sore
throat,
chest pain, palpitations, LE edema, orthopnea/PND, DOE, SOB,
hemoptysis, nausea, vomiting, abdominal pain, abdominal
swelling, diarrhea, constipation, hematemesis, melena, easy
bleeding/bruising, LAD, dysuria, rashes, myalgias, arthralgias,
headache, confusion, dizziness, vertigo, paresthesias, weakness,
depression, orthostasis.
Past Medical History:
1. Significant for a diagnosis of rheumatoid lung disease. She
was hospitalized after complaints of cough and fever at the [**Hospital3 85404**] in 08/[**2112**]. She was found to have interstitial pulmonary
infiltrates, had a hematologic involvement, elevated CCP, and
mild splenomegaly. Her lung disease was consistent with
organizing pneumonitis and small airways inflammatory process.
She had a lung biopsy, which was not diagnostic, but consistent
with potential rheumatoid lung disease. Has been treated with
prednisone and azathioprine as well as hydroxychloroquine.
There
was some question of whether there was a component of
hypersensitivity pneumonitis as well given that she lived in a
house in [**State 760**] with significant mold. She has subsequently
moved from that house. She has no joint manifestations of
rheumatoid arthritis. The patient spent much of the winter of
[**2112**], hospitalized in the [**Hospital3 14659**]. She had a prolonged
hospitalization in [**7-/2113**], and then again was readmitted in
12/[**2112**]. See below. Was subsequently in a rehabilitation
facility until [**2114-3-15**], and recently moved to [**Location (un) 86**].
2. Proximal lower extremity myopathy.
3. Distal fibular fracture in [**1-/2114**], after a fall, underwent
nonoperative treatment.
4. Deep venous thrombophlebitis, diagnosed also in [**10/2113**], had
a repeat ultrasound revealing some residual clot after three
months; therefore, I had an extension of her course to a
six-month total period of treatment, finished this at the end of
06/[**2113**].
5. Urge incontinence.
6. Osteoporosis.
7. Osteoarthritis. She is soon to undergo a right total hip
replacement at the [**Hospital3 14659**].
8. C. diff colitis x2.
9. Recurrent urinary tract infections. Had an admission for
urosepsis at the [**Hospital3 14659**] from [**2113-11-2**], to [**2113-11-22**].
10. Anemia of chronic disease.
11. GERD.
12. Thyroid nodule with a negative biopsy and evaluation in the
past.
13. Fibrocystic changes in breast.
14. Cardiovascular. The patient had an extensive lower
extremity edema during her hospitalization, had a normal
echocardiogram in [**3-/2114**], revealing an ejection fraction of 60%
with no valvular heart disease.
15. Diverticulosis. Had a colonoscopy in [**12/2113**], that was
otherwise unrevealing.
16. History of hypertension, taken off medications during [**Hospital1 **]
hospitalization.
PAST SURGICAL HISTORY: Status post appendectomy, status post
tonsillectomy, and thumb surgery on the left eight years ago.
Social History:
(Per record review. Was confirmed with patient.)
The patient was born in [**State 760**]. She has never married and
has never had any children. Lives with a cat at home and as
above has recently moved to [**Location (un) 86**] to be closer to her family.
Her brother and [**Name2 (NI) 802**] live in [**Name (NI) 1439**]. Drinks occasional alcohol.
No history of tobacco. No history of IVDU. Did have a blood
transfusion when she was hospitalized at the [**Hospital1 **]. She is able
to drive and is fairly independent at this point, limited mostly
by the pain in her
right knee. Denies any falls at home. No history of abuse.
Has two brothers.
Family History:
(Per record review. Was confirmed with patient.)
Mother died secondary to complications from what
sounds like colon cancer, also had a history of diabetes.
Father
was a longtime smoker, had COPD. Both brothers have a history
of
CAD and valvular heart disease, but no early CAD in the family.
No breast or ovarian cancer.
Physical Exam:
VS: 99.2 106/50 91 20 93RA
GEN: AAOx3. Pleasant, non-toxic.
HEENT: eomi, perrl, MMM.
Neck: No LAD. JVP WNL.
RESP: CTA B. No WRR.
CV: RRR. No mrg.
ABD: +BS. Soft, NT/ND. Obese.
Ext: 2+ LE edema B to knee. No clubbing.
Neuro: CN 2-12 grossly intact.
Pertinent Results:
[**2114-10-9**] 10:36AM BLOOD WBC-3.7* RBC-2.70* Hgb-7.9* Hct-24.7*
MCV-91 MCH-29.1 MCHC-31.9 RDW-20.5* Plt Ct-155
[**2114-10-9**] 10:36AM BLOOD Neuts-81* Bands-0 Lymphs-12* Monos-4
Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2114-10-11**] 07:05AM BLOOD WBC-3.7* RBC-2.46* Hgb-7.3* Hct-23.1*
MCV-94 MCH-29.6 MCHC-31.5 RDW-21.0* Plt Ct-150
[**2114-10-9**] 10:36AM BLOOD Glucose-108* UreaN-18 Creat-0.7 Na-139
K-3.9 Cl-108 HCO3-23 AnGap-12
[**2114-10-9**] 10:36AM BLOOD ALT-13 AST-32 LD(LDH)-1134* AlkPhos-61
TotBili-0.8
[**2114-10-11**] 07:05AM BLOOD LD(LDH)-1273*
[**2114-10-9**] 10:36AM BLOOD proBNP-652*
[**2114-10-9**] 10:36AM BLOOD TotProt-6.3* Mg-2.1 Iron-45
[**2114-10-9**] 10:36AM BLOOD calTIBC-209* VitB12-353 Hapto-88
Ferritn-790* TRF-161*
[**2114-10-11**] 07:05AM BLOOD RheuFac-3
[**2114-10-10**] 07:00AM BLOOD B-GLUCAN- Negative
[**2114-10-15**] 01:15PM BLOOD HIV Ab-NEGATIVE
[**2114-10-14**] 08:45AM BLOOD PEP-ABNORMAL B IgG-1745* IgA-250 IgM-473*
IFE-MONOCLONAL
[**2114-10-20**] 09:26AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 [**Last Name (un) **]
[**2114-10-20**] 09:26AM BLOOD ANCA-NEGATIVE B
[**2114-10-18**] 07:00AM BLOOD Cortsol-12.8
[**2114-10-14**] 08:45AM BLOOD CRP-39.8*
Anti-CCP: >250 (Strong Positive: >59)
Aspergillus and B-glucan: negative
BCR/ABL [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 85405**]
BCR-ABL T(9;22) FUSION 0.000
VITAMIN D, 1,25 (OH)2, TOTAL 26
Induced sputums: negative for PCP
QUANTIFERON-TB GOLD Results Pending
BRUCELLA ANTIBODY, AGGLUTINATION Results Pending
CMV IgM: negative
Lyme Serology: negative
Toxoplasma: IgG positive, IgM negative
Blood and urine cultures negative.
CT CHEST W/O CONTRAST IMPRESSION:
1. No evidence of PCP infection or rheumatoid lung interstitial
disease.
2. Mixed solid/ground-glass 1.8 cm LUL nodule concerning for
neoplasm such as bronchoalveolar cell carcinoma; 3-month
followup CT is recommended to evaluate for resolution.
3. A left lower lobe crescentic soft tissue irregulartiy,
smaller lingular
ground glass opacity and 3 mm LLL nodule should all be
reevaluated at that
time.
4. Splenomegaly; given rheumatoid arthritis and decreased WBC,
this suggests Felty syndrome.
5. Right thyroid nodules, for which ultrasound would be more
appropriate for evaluation.
6. Severe tracheomalacia; severe bronchomalacia of right
mainstem
bronchus/bronchus intermedius.
CT ABD/PELVIS IMPRESSION:
1. Splenomegaly with spleen measuring 18 cm in the axial
dimension and 16 cm in the craniocaudal dimension and multiple
splenules. No CT evidence of portalhypertension. Splenomegaly is
nonspecific, and lymphomatous/leukemic
etiologies are differential considerations. No other adenopathy
in the
abdomen or pelvis.
2. Compression fracture of the T12 vertebral body with mild
retrolisthesis of T12 on L1.
3. The left adrenal is mildly thickened which may represent
adrenal
hyperplasia.
Peripheral blood FLOW CYTOMETRY IMMUNOPHENOTYPING INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin lymphoma
are not seen in specimen. Correlation with clinical findings is
recommended. Flow cytometry immunophenotyping may not detect all
lymphomas as due to topography, sampling or artifacts of sample
preparation.
SPECIMEN: BONE MARROW ASPIRATE ONLY. DIAGNOSIS:
CELLULAR MARROW WITH MARKED ERYTHROID HYPERPLASIA AND NUMEROUS
HEMOPHAGOCYTIC HISTIOCYTES. THERE IS NO EVIDENCE OF
MYELODYSPLASIA. SEE NOTE.
Note: There is no morphologic evidence of lymphoma or a classic
chronic myeloproliferative syndrome. The presence of numerous
hemophagocytic histiocytes raises the possibility of a
macrophage activation syndrome which may be related to her
previously diagnosed rheumatoid disease. Although her diagnosis
of rheumatic lung disease has been put in doubt by recent
imaging of the lungs, her inflammatory markers remain elevated
and may be due to an ongoing rheumatological or other autoimmune
disorder.
CHROMOSOME ANALYSIS-BONE MARROW
KARYOTYPE: 46,XX[14]
INTERPRETATION:
No clonal cytogenetic aberrations were identified
in metaphases analyzed from this unstimulated
specimen. This normal result does not exclude a
neoplastic proliferation.
Mosaicism and small chromosome anomalies may not be
detectable using the standard methods employed.
Cardiac Echo: IMPRESSION: Normal biventricular systolic
function. Normal estimated left ventricular filling pressure.
Moderate estimated pulmonary artery systolic hypertension.
PET IMPRESSION: 1. Splenomegaly without associated increased
FDG-avidity to suggest lymphomatous involvement. No FDG-avid
adenopathy.
2. Mild diffusely increased FDG-avidity involving the bone
marrow that is non-specific and could be related to drug
reaction, though leukemic involvement cannot be excluded, for
which clinical correlation and interval follow-up can be
obtained as indicated.
3. Lower lobe predominant subpleural reticulation demonstrating
increased
FDG-avidity most compatible with a component of rheumatoid lung
involvement and associated active inflammation. 4. Grossly
stable ground-glass nodule in the left upper lobe; though does
not demonstrate FDG-avidity, BAC is not excluded, and continued
follow-up is recommended. 5. Stable heterogeneously enlarged
right thyroid lobe with multiple non-FDG avid nodules that can
be correlated with ultrasound.
Brief Hospital Course:
Ms. [**Known lastname **] was a 70 year old female with a PMH significant for
possible RA (on prednisone, azathioprine, and
hydroxychloroquine), possible RA associated ILD, and DVT (not
currently anticoagulated) admitted on [**2114-10-9**] for 4 months of
productive cough and several weeks of fever to 102. She was
transferred to the [**Hospital Unit Name 153**] for hypoxic respiratory distress. During
her prolonged hospital stay, she has been evaluated by rheum,
ID, hematology-oncology and pulmonary for her fever, CTD,
pancytopenia, splenomegaly, and possible ILD. She underwent bone
marrow biopsy demonstrating hemophagocytic histiocytes,
therefore the diagnosis of HLH was strongly considered. She was
restarted on cyclosporine, dexamethasone, and infliximab. As
patient was mentating/performing well on SBP's >80, that was set
as the limit for pressor use. After starting treatment for HLH
with cyclosporine, dexamethasone, IVIg, and infliximab, the
patient was eventually weaned off pressors with BP's staying in
the 80-90 /40-50 range. In addition, she has a LUL ~2 cm nodule
concerning for BAC.
.
Her hospital course has been complicated by episodes of
transient hypoxia and intermittent hypotension. She was never
intubated or required non-invasive ventilation and she was
eventually weaned to RA. In terms of her hypotension, she was
started on pressors on admission to MICU. Infectious, endocrine
& cardiac work up were unrevealing and she was eventually
started on midodrine for pressure support. She was started on
epogen for anemia. Lastly she had evidence of a missed STEMI and
was started on aspirin.
.
On the floor she continued to deteriorate clinically and her
code status was changed to comfort measures only.
Medications on Admission:
ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth q week
AZATHIOPRINE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - one teaspoon by
mouth [**Hospital1 **] prn cough may cause sedation
HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) by mouth once a
day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
OXYBUTYNIN CHLORIDE - 5 mg Tablet - 0.5 (One half) Tablet(s) by
mouth three times a day
Medications - OTC
ASCORBIC ACID - 1,000 mg Tablet - 2 Tablet(s) by mouth once a
day
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a
day
CALCIUM [CALCIO [**Doctor First Name 15**] [**Month (only) 16**]] - 500 mg Tablet - 1 Tablet(s) by mouth
(1250) [**Hospital1 **]
CHOLECALCIFEROL (VITAMIN D3) - 2,000 unit Tablet - 1 Tablet(s)
by
mouth once a day
DOCUSATE SODIUM - 100 mg Capsule - 2 Capsule(s) by mouth once a
day
FOLIC ACID - 0.4 mg Tablet - 1 Tablet(s) by mouth once a day
GLUCOSAMINE HCL-MSM - 750 mg-750 mg Tablet - 2 Tablet(s) by
mouth
once a day
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
OMEGA-3 FATTY ACIDS [FISH OIL] - 1,000 mg Capsule - 1 Capsule(s)
by mouth twice a day
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2115-1-13**]
|
[
"562.10",
"788.31",
"273.1",
"287.5",
"284.1",
"782.4",
"715.90",
"359.89",
"733.00",
"416.8",
"610.1",
"V49.86",
"518.82",
"415.19",
"276.1",
"273.8",
"V12.51",
"401.9",
"300.4",
"288.4",
"458.8",
"790.7",
"599.0",
"782.3",
"288.50",
"789.2",
"V66.7",
"309.9",
"285.29",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
14602, 14611
|
11591, 13326
|
332, 376
|
14662, 14671
|
6184, 11568
|
14727, 14857
|
5571, 5895
|
14570, 14579
|
14632, 14641
|
13352, 14547
|
14695, 14704
|
4784, 4885
|
5910, 6165
|
266, 294
|
404, 2292
|
2314, 4760
|
4901, 5555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,228
| 127,021
|
54410
|
Discharge summary
|
report
|
Admission Date: [**2186-5-8**] Discharge Date: [**2186-5-9**]
Date of Birth: [**2124-6-6**] Sex: M
Service: MEDICINE
Allergies:
Motrin
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Chief Complaint: Unresponsiveness
Reason for MICU transfer: Unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61M w/ hx alchol abuse and multiple ED visits for alcohol abuse,
who was found unresponsive today by the EMS. They found him in
seated position on the street with minimal respirations
(reportedly 2x/min). They bagged him on the way in, noted to be
unresponsive. BS at that time was 148 and he was 84% on RA.
In the ED, initial VS were BP 110s, HR 80s. He had "barely a
gag" reflex in the ED but did give him etomidate and
succinylcholine for intubation. He was then intubated due to the
minimal respirations. He was given 2L NS, and ETOH level 429,
with a positive serum and urine benzos. CT scan of head and neck
performed and showed no acute bleed or fracture per wet read.
On arrival to the MICU, patient's VS are 98.5 66 109/76 16 99%
on ventilator. Pt is intubated and sedated, not following
commands.
Review of systems: Unable to obtain a review of systems as the
pt is currently intubated.
Past Medical History:
ETOH abuse w/ reported history of seizures and DTs
Polysubstance abuse (heroin remotely, and cocaine more recently)
Chronic HCV infection
Remote history of vertebral osteomyelitis
Low Back Pain / Degenerative disease / Vertebral compression
fractures
Pseudo-seizures
Hypertension
Depression
Left parietal bone lesion NOS - ?atypical hemangioma
Calf injury [**2175**] with left gluteal transplant to left calf
Social History:
(per OMR)
Reports at least 1 [**12-26**] pints of vodka plus wine per day. He
drinks because he is "depressed." Smokes 1 cigar per day. Used
heroin >3 years ago and cocaine >1 year ago. Emigrated from
[**Male First Name (un) 1056**] in [**2132**].
Family History:
(per OMR)
DM in mother, brother. Father died of throat cancer. No FH of
drug or alcohol abuse.
Physical Exam:
Admission Physical Exam:
Vitals: 98.5 66 109/76 16 99% on
General: Intubated, sedated, not following commands
HEENT: ET tube in place, pupils equal and minimally reactive.
2cm laceration over the left eye that is not currently bleeding
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally when auscultated
anteriorly, with no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
involuntary guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Deferred given sedation
Pertinent Results:
ADMISSION LABS:
[**2186-5-8**] 10:30AM BLOOD WBC-8.4 RBC-4.45* Hgb-12.7* Hct-40.3
MCV-91 MCH-28.4 MCHC-31.4 RDW-16.5* Plt Ct-258
[**2186-5-9**] 06:55PM BLOOD Neuts-62.1 Lymphs-32.3 Monos-3.5 Eos-1.4
Baso-0.7
[**2186-5-8**] 10:30AM BLOOD PT-10.4 PTT-31.6 INR(PT)-1.0
[**2186-5-8**] 10:30AM BLOOD Fibrino-267
[**2186-5-8**] 10:30AM BLOOD Glucose-124* UreaN-8 Creat-0.8 Na-142
K-3.7 Cl-101 HCO3-23 AnGap-22*
[**2186-5-8**] 10:30AM BLOOD Lipase-67*
[**2186-5-10**] 06:30AM BLOOD cTropnT-<0.01
[**2186-5-8**] 10:30AM BLOOD Albumin-4.7 Calcium-8.8 Phos-2.9 Mg-1.7
[**2186-5-8**] 10:30AM BLOOD Osmolal-404*
[**2186-5-8**] 10:30AM BLOOD ASA-NEG Ethanol-492* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2186-5-8**] 11:25AM URINE Color-[**Location (un) **] Appear-Cloudy Sp [**Last Name (un) **]-1.022
[**2186-5-8**] 11:25AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
[**2186-5-8**] 11:25AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2186-5-8**] 11:25AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
IMAGING:
-[**5-8**] CT Head:
IMPRESSION: No acute intracranial process.
.
-[**5-8**] CT C-spine:
IMPRESSION:
1. No fracture.
2. Moderate degenerative changes of the cervical spine with
resultant
moderate neural foraminal narrowing.
Brief Hospital Course:
61M w/ hx alchol abuse and HCV who was found unresponsive by EMS
on the street who was then intubated given low respirations for
inability to protect his airway and found to have polysubstance
intoxication with ethanol and benzos. By morning after
admission, pt had awoken, was extubated without event, and
insisted on leaving the hospital; was ambulating without
difficulty and speaking coherently. He left the ICU before
further w/u or care could be provided.
.
# Airway protection - Pt was found down and unresponsive. He was
subsequently intubated due to minimal respirations at 2x/min for
airway protection given his intoxication as evidenced by his
highly positive ethanol level. His vent settings were weaned
quickly o/n, and he was extubated without event by the morning
after admission.
.
# Unresponsiveness - Most likely due to polysubstance abuse with
ethanol and benzodiazepines. He has had multiple presentations
in the ED for alcohol abuse and was seen in the ED on the day
prior to this admission, because he was found altered v.
intoxicated. A CT scan of his head and neck was done at that
time because he had a laceration above his left eyebrow, that
was repaired with glue and were negative for bleed or fracture.
Pt had no stigmata of active infection. CT head and C-spine were
unremarkable; he was maintained on CIWA w/ ativan, and was given
a Banana bag x1 L, MVI, thiamine, and folate. Pt left the
hospital before consult social work and the addiction team could
be consulted.
.
# Anion-gap acidosis - Most likely due to elevated ethanol and
lactate levels.
.
# Hypernatremia - Pt w/ mild hypernatremia of 147 that was
likely due to lack of free water as it is unclear what his diet
may truly be like.
.
# Hx mild transaminitis - Likely due to combination of chronic
alcohol abuse and HCV.
.
# Hx Hypertension - initially held home Amlodipine (unclear if
was really taking this at home) given SBP in the low 100s upon
admission.
.
TRANSITIONS OF CARE:
-Pt left before f/u could be established. Pt likely needs
assistance in cessation of alcohol and related social issues, as
he has had recurrent admissions for intoxication or being found
down.
Medications on Admission:
Amlodipine 10mg PO daily
Discharge Medications:
None, pt left prior to being set up for d/c home
Discharge Disposition:
Home
Discharge Diagnosis:
Altered mental status secondary to alcohol intoxication
Discharge Condition:
Ambulatory, conversant
Discharge Instructions:
Pt left before f/u could be established
Followup Instructions:
Pt left before f/u could be established
Completed by:[**2186-5-10**]
|
[
"535.30",
"291.81",
"786.59",
"401.9",
"303.01",
"305.60",
"070.54",
"V60.0",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6398, 6404
|
4079, 6033
|
344, 350
|
6503, 6527
|
2721, 2721
|
6615, 6685
|
1995, 2092
|
6325, 6375
|
6425, 6482
|
6275, 6302
|
6551, 6592
|
2132, 2702
|
1208, 1281
|
242, 306
|
378, 1188
|
3848, 4056
|
2737, 3839
|
6054, 6249
|
1303, 1714
|
1730, 1979
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,486
| 156,490
|
51059+51060
|
Discharge summary
|
report+report
|
Admission Date: [**2140-11-13**] Discharge Date: [**2140-11-27**]
Date of Birth: [**2082-11-2**] Sex: F
Service: GENERAL SURGERY/GREEN TEAM
HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old
female who had a history of partial gastrectomy in [**2131**] for
what was diagnosed as gastric outlet obstruction secondary to
pyloric stenosis. She also has a history of hypertension,
asthma, gastroesophageal reflux disease, depression, anxiety,
migraines, history of osteoarthritis involving the left knee,
status post total knee replacement in [**2135**], and status post
multiple knee replacements with infections treated with
courses of antibiotics.
ALLERGIES: Kefzol and Keflex which lead to anaphylaxis.
MEDICATIONS ON ADMISSION:
1. Estradiol.
2. Fentanyl patch.
3. Amitriptyline.
4. Vicodin p.r.n.
5. Scopolamine patch.
6. Pantoprazole.
7. Clonazepam.
8. Verapamil SR.
9. Reglan.
10. Tylenol.
11. Pilocarpine.
The patient presented and was initially admitted to the
Medical Service with a six to eight week history of nausea,
vomiting, anorexia, and a 10 pound weight loss. The nausea
was continuous and occasionally bile-tinged but there was
never any blood. She is now currently only tolerating
liquids. She has been seeing her GI doctor for these
treatments and was basically admitted on [**2140-11-13**] for
further evaluation of this problem.
She was admitted and hydrated. She underwent an EGD on
[**2140-11-15**]. The EGD was notable for a normal
esophagus and evidence of a previous Billroth II with both
limbs of the Billroth II strictured and did not allow passage
of the scope. These findings were consistent with stricture
at the prior anastomotic site and General Surgery was
consulted for this reason.
PHYSICAL EXAMINATION ON ADMISSION: On initial examination,
her temperature was 99.2, down to 98.1, blood pressure
126/72, heart rate in the 90s, breathing at 20, saturating at
99% on room air. General: She was well appearing in no
acute distress. Lungs: Clear bilaterally. Heart: Regular.
Abdomen: She had a midline surgical scar without any
evidence of hernia. It was soft, nontender, nondistended,
without guarding or rebound tenderness. Extremities: She
had a left knee with an incisional scar and some swelling.
No lower extremity edema.
LABORATORY DATA: White count 8.4, hematocrit 32.7, platelets
302,000. K 4.3, BUN and creatinine 6 and 0.5. Her LFTs were
relatively unremarkable.
HOSPITAL COURSE: The patient was scheduled for an upper GI,
small bowel follow through and this was consistent with
stenoses of the afferent limb of the Billroth II. For this
reason, she was scheduled for surgical correction of this
stricture at the prior anastomotic site. She was continued
n.p.o. Her preoperative evaluation was unremarkable.
On [**2140-11-18**], she underwent a gastrojejunostomy revision,
creation with a Roux-en-Y limb. This was done on [**2140-11-18**].
The procedure went well without any complications.
Postoperatively, she did well. She was stable. She was
receiving adequate pain control and had adequate urine output
as well. She was out of bed to chair by postoperative day
number one. Her NG tube was continued and on suction.
By postoperative day number three, she continued to do well.
She was ambulating. Her lungs sounded clear. The heart was
regular. Her belly was slightly distended but her wound was
clean, dry, and intact with no erythema. She continued on a
morphine PCA for pain. Her NG tube was removed and she was
advanced to sips on postoperative day number four which she
tolerated. She was advanced to clears on postoperative day
number five. Her morphine PCA was removed and changed to
p.o. pain medications by postoperative day number six. She
was otherwise doing well, ambulating, tolerating the clears,
and was advanced to a regular diet on postoperative day
number seven. She was passing gas.
She was discharged to home on postoperative day number nine
after having a bowel movement.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Stricture at the previous
gastrojejunostomy, underwent a revision gastrojejunostomy
with Roux-en-Y.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 3214**]
MEDQUIST36
D: [**2141-2-24**] 09:19
T: [**2141-2-24**] 23:08
JOB#: [**Job Number 106054**]
Admission Date: [**2140-11-13**] Discharge Date: [**2140-11-27**]
Date of Birth: [**2082-11-2**] Sex: F
Service: GENERAL SURGERY
ADMITTING DIAGNOSIS: Stenosed gastrojejunostomy, nausea, and
vomiting.
POSTOPERATIVE DIAGNOSIS: Status post gastrojejunostomy
anastomosis revision, creation of Roux-en-Y.
HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old
female with a history of pyloric stenosis, status post
antrectomy and Billroth II in [**2131**]. The patient presented
with a six to eight week history of nausea and vomiting as
well as a 10 pound weight loss. The patient's nausea is
continuous and emesis follows meals. There is occasional
bile but no blood. She now tolerates only liquids and she
vomits solid foods. There was no early satiety, dysphagia,
or odynophagia. There were low-grade temperatures to 100
degrees Fahrenheit and occasional chills. The patient failed
to improve her symptoms with scopolamine and Fentanyl
patches.
The patient presented on [**2140-11-13**] secondary to
walking up a flight of stairs and experiencing fatigue.
There is no recent travel history or change in diet. Stools
were light brown. Rare cough. No associated diarrhea,
dysuria, chest pain, shortness of breath, sore throat, or
rhinorrhea.
PAST MEDICAL HISTORY:
1. Pyloric stenosis, status post partial gastrectomy in
[**2131**].
2. Osteoarthritis involving the left knee, underwent a total
knee replacement in approximately [**2135**].
3. Status post revision of left knee total knee arthroplasty
in [**2138**] and [**2139**].
4. Asthma.
5. GERD.
6. History of UTIs.
7. Status post [**Location (un) 931**] rod secondary to kyphosis surgery
at five years of age.
8. Migraines.
9. Hypertension.
10. Chronic pain.
PAST SURGICAL HISTORY: As above.
FAMILY HISTORY: Mother had tuberculosis, now deceased. The
patient's father is deceased. The patient's brother is
living and well. The patient is not known to have
tuberculosis.
SOCIAL HISTORY: The patient is married. The patient's
husband is health care proxy.
ALLERGIES: Cephazolin, cephalexin lead to anaphylaxis.
ADMISSION MEDICATIONS:
1. Estradiol 0.5 mg p.o.
2. Progesterone 100 mg q.d.
3. DHEA.
4. Fentanyl patch 25 micrograms q. 72 hours.
5. Amitriptyline 75 mg p.o. h.s.
6. Vicodin p.r.n.
7. Scopolamine patch.
8. Pantoprazole 40 mg p.o.
9. Clonazepam 1 mg p.o. t.i.d.
10. Verapamil 120 mg p.o. q. 24.
11. Metoclopramide 10 mg IV q. six hours.
12. Acetaminophen p.r.n.
13. Pilocarpine 5 mg t.i.d.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
100.1, pulse 93, 108/68, 20, 97% on room air. HEENT:
Anicteric. EOMI. Neck: No bruits, supple. Pulmonary:
Clear to auscultation. Coronary: S1, S2, no murmurs, rubs,
or gallops. Abdomen: Well-healed midline scar, nondistended.
Bowel sounds positive, soft, nontender. Extremities: No
clubbing, cyanosis or edema. There were 2+ DP pulses
bilaterally. Knee with surgical scar, notable for warmth,
swelling. Neurological: The patient was alert and oriented.
Cranial nerves II through XII were grossly intact. Strength
in the upper and lower extremities [**4-10**]. Sensation intact.
LABORATORY DATA: CBC 8.4, hematocrit 32.7, platelets
302,000. LFTs within normal limits. Panel 7 within normal
limits.
Chest x-ray: Minimal scarring versus atelectasis at the left
lung base.
KUB: No radiographic evidence for obstruction or free air.
EGD report: Previous Billroth II of the stomach, both limbs
of the Billroth II were strictured, not allowing passage of
the scope.
HOSPITAL COURSE: The patient was admitted on [**2140-11-13**] for possible partial gastric outlet obstruction. She
received metoclopramide 10 mg IV q. six as well as Zofran.
The patient was started on IV fluids and was scheduled for an
endoscopy.
An EGD showed evidence of a previous Billroth II. Both limbs
of the Billroth II were strictured, did not allow passage of
the scope. Surgery was subsequently consulted on [**2140-11-16**]. The General Surgery attending determined that the
patient had a partially obstructed afferent limb. There was
no clear evidence of diathesis. Therefore, the stricture was
presumed to be benign.
On [**2140-11-18**], the patient underwent gastrojejunostomy
and revision, creation of Roux-en-Y for stenosed
gastrojejunostomy. The procedure was performed by Dr. [**Last Name (STitle) 519**]
and assisted by Dr. [**Last Name (STitle) 7820**]. Intravenous fluids were 3 liters.
The estimated blood loss was 150 cc. The patient put out 750
cc of urine during the case. The patient underwent general
anesthesia and was extubated and transferred to the Recovery
Room in stable condition.
Postoperatively, the patient denied nausea and had pain which
was controlled by morphine. The abdomen was moderately
distended and diffusely tender to palpation. On
postoperative day number one, the patient received
clindamycin and gentamycin times one dose. LR was running at
80 cc per hour. The patient was out of bed to chair. The
nasogastric tube was continued on a strict basis.
On postoperative day number two, antibiotics were
discontinued. The abdomen was soft and minimally distended.
There was diffuse tenderness.
On postoperative day number three, the patient's Foley was
discontinued. The patient's nasogastric tube was
subsequently discontinued as well. On postoperative day
number four, the patient's diet was advanced to sips. On
postoperative day number five, the patient's diet was
advanced to clears. The patient remained afebrile throughout
the postoperative course.
On postoperative day number six, the patient was switched to
p.o. medications. On postoperative day number seven, the
patient was given a regular diet.
On postoperative day number nine, the patient was discharged
to home after having passed stool.
FOLLOW-UP INSTRUCTIONS: The patient was instructed to
follow-up with Dr. [**Last Name (STitle) 519**] in two weeks. She was told to return
to the hospital for wound erythema or discharge as well as
nausea or vomiting. She was instructed to continue with her
outpatient medications as well as Percocet and Colace for her
pain and constipation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 4348**]
MEDQUIST36
D: [**2141-3-5**] 11:36
T: [**2141-3-5**] 11:59
JOB#: [**Job Number 106055**]
|
[
"401.9",
"530.81",
"537.0",
"E878.8",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"44.5",
"45.91",
"44.39"
] |
icd9pcs
|
[
[
[]
]
] |
6308, 6474
|
4112, 4641
|
761, 1787
|
8081, 10342
|
6640, 7037
|
6280, 6291
|
7052, 8063
|
4663, 5774
|
10367, 10965
|
5796, 6256
|
6491, 6617
|
4052, 4090
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,561
| 192,697
|
17131
|
Discharge summary
|
report
|
Admission Date: [**2163-6-22**] Discharge Date: [**2163-7-13**]
Date of Birth: [**2106-12-8**] Sex: M
Service: BMT
REASON FOR ADMISSION: The patient was admitted for high-dose
methotrexate therapy.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
gentleman who was recently diagnosed with [**Year (4 digits) **] lymphoma.
He underwent a laparotomy for acute abdominal pain secondary
to presumed appendicitis. A preoperative computed tomography
scan showed a 5-cm X 8-cm mass. Biopsy revealed high-grade
lymphoma consistent with [**Year (4 digits) **] lymphoma.
The patient had a negative positron emission tomography scan,
and bone marrow results were negative. The patient was felt
to have a low volume resected [**Year (4 digits) **] lymphoma and was
treated with the McGraft protocol. He tolerated his first
cycle of chemotherapy well; including intrathecal therapy and
is now being admitted for high-dose methotrexate therapy.
Currently, the patient feels weak. He has mild nausea. He
complaints of cervical pain but denies fevers or chills.
PAST MEDICAL HISTORY: Past medical history is notable only
for cervical disc disease.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: The patient was on no medications
at this time.
FAMILY HISTORY: The patient's family history was notable
for diabetes. Sister had also been diagnosed with [**Name (NI) **]
lymphoma.
SOCIAL HISTORY: The patient's social history is notable for
him being a pharmacist.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
patient's temperature was 99.1 degrees Fahrenheit, his blood
pressure was 138/100, his heart rate was 100, and his oxygen
saturation was 96% on room air. In general, the patient was
a pleasant male. In no apparent distress. The oropharynx
was clear. His sclerae were anicteric. There was no
palpable lymphadenopathy. Cardiovascular examination was
notable for tachycardia; otherwise no murmurs. The lungs
were clear to auscultation bilaterally. The abdomen was
soft, nontender, and nondistended. There was a well-healed
midline surgical scar. There was no edema. There were no
skin rashes. Neurologic examination was nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission were notable for a white blood cell count of 1.1,
with an absolute neutrophil count of 560, his hematocrit was
38.6, and his platelets were 104. Sodium was 136, potassium
was 2.9, chloride was 97, bicarbonate was 28, blood urea
nitrogen was 13, and his creatinine was 09. The patient's
liver function tests were notable for an AST of 40, ALT was
23, alkaline phosphatase was 106, and total bilirubin was
0.8. The rest of the patient's laboratories were within
normal limits.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: In
short, the patient is a 56-year-old gentleman with [**Name (NI) **]
lymphoma here for high-dose methotrexate therapy.
1. [**Name (NI) **] LYMPHOMA ISSUES: The patient underwent high-dose
methotrexate therapy with leucovorin rescue. Despite
leucovorin rescue, the patient's methotrexate levels remained
markedly elevated. Thus, the patient underwent urine
alkalinization to attempt to clear methotrexate. The
patient's methotrexate levels eventually became close to
undetectable, and his white blood cell count returned to
within normal limits by the time of discharge.
2. INFECTIOUS DISEASE ISSUES: The patient was neutropenic
upon admission and within a few days began to spike
temperatures. He was covered empirically with cefepime and
gentamicin. He was later also covered empirically with
vancomycin and Flagyl secondary to his recent abdominal
surgery.
The patient continued to spike temperatures on this regimen
and was started on AmBisome. He was also started on
acyclovir for a rash on his chest that was consistent with
zoster.
There was concern that cefepime was interacting with his
methotrexate clearance. Thus, this was changed to
ciprofloxacin.
The patient's white blood cell count began to rise, and he
was no longer neutropenic. Thus, antibiotics were killed
off; however, the patient continued to have low-grade
temperatures throughout the course of his hospitalization.
No definitive source for these fevers were ever localized.
3. SUBDURAL HEMATOMA ISSUES: The patient fell while using
the rest room on the evening of [**2163-6-30**]. On
examination, he was noted to have a frontal hematoma as well
as nose and cheek abrasions. At this time, the patient had
platelets of 39. A head computed tomography revealed that
the patient had a subdural hematoma.
The patient was transferred to the Medical Intensive Care
Unit for closer monitoring, neurologic checks, and
Neurosurgery was consulted. Neurosurgery felt watchful
waiting was more appropriate for this patient. The patient
had a follow-up head computed tomography which showed that
his hematoma was stable. The patient's platelets were
aggressively repleted during this time to keep his platelet
count above 100. The patient had no neurological deficits
during this period.
4. GASTROINTESTINAL ISSUES: The patient complained of
low-grade abdominal pain and nausea during the course of his
hospitalization. The patient was started on a proton pump
inhibitor with little relief.
The patient underwent an esophagogastroduodenoscopy which
showed evidence of gastritis. The patient was continued on a
proton pump inhibitor and symptomatic control of his nausea.
5. ACCESS ISSUES: General Surgery was consulted and placed
a quad-lumen subclavian in this patient. This line was used
for total parenteral nutrition temporarily during the
patient's stay. The line was discontinued prior to
discharge.
6. PSYCHIATRIC ISSUES: The patient was seen by the
Psychiatry Service for a sleep disorder and a depressed mood.
He was started on Remeron prior to discharge.
CONDITION AT DISCHARGE: The patient was discharged in good
condition on [**2163-7-13**].
DISCHARGE DIAGNOSES:
1. [**Year (4 digits) **] lymphoma.
2. Subdural hematoma.
3. Gastritis.
MEDICATIONS ON DISCHARGE: (The patient's medications on
discharge were as follows)
1. Lansoprazole 30 mg by mouth twice per day.
2. Leucovorin 25 mg by mouth q.6h.
3. Remeron 7.5 mg by mouth q.h.s.
4. Potassium chloride 20 mEq by mouth once per day.
5. Sucralfate 10 mg by mouth four times per day.
6. Compazine 25 mg by mouth q.6h. as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], M.D. [**MD Number(1) 7775**]
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2163-10-18**] 10:38
T: [**2163-10-20**] 12:52
JOB#: [**Job Number 48107**]
|
[
"287.5",
"250.20",
"288.0",
"E884.6",
"V58.1",
"852.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.92",
"99.25",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
1319, 1439
|
6008, 6084
|
6111, 6704
|
1252, 1301
|
2827, 5906
|
5921, 5987
|
246, 1083
|
1106, 1225
|
1456, 2793
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,515
| 129,364
|
11942+56306
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-11-25**] Discharge Date: [**2184-12-10**]
Date of Birth: [**2130-3-15**] Sex: M
Service: .
HISTORY OF PRESENT ILLNESS: Patient is a 54-year-old
gentleman who presented with dysphagia last year with
endoscopic diagnosis of poorly differentiated adenocarcinoma
of the esophagus with a lesion seen 30 to 33 cm with partial
esophageal obstruction and two similar masses more distal.
Endoscopic ultrasound at the time showed tumor through the
muscularis and one enlarged lymph node clinically stated at
T3. There was no evidence of distal metastasis at the time
of staging. He next underwent adjunctive chemotherapy and
radiotherapy followed by esophageal gastrectomy in [**2184-3-12**]. Approximately three weeks later, the patient developed
severe lower back pain with further work up. He was found to
have metastatic lesions at the L2, L3 level. Needle biopsy
was positive for mets for poorly differentiated
adenocarcinoma.
The patient underwent a vertebroplasty at [**Hospital3 **] per Dr.
[**Last Name (STitle) **] in [**2184-6-12**] and subsequently completed XRT. He was
admitted most recently to [**Hospital **] [**Hospital3 2063**] with
recurrent respiratory distress and hypotension, stabilized in
the ICU. It was noted that his lower back pain was
increasing in the past two to three days. He complained of
mild onset of paresthesias to the left lower extremity and he
was diagnosed with a right middle lobe and right lower lobe
pneumonia by chest x-ray. CT Scan of the chest was positive
for infiltrates. He was transferred to [**Hospital1 190**] for further management of his L2-L3
metastasis. MRI showed significant compression of the thecal
sac.
Patient also has a past medical history of diabetes type 2
and past surgical history of distal esophagectomy and partial
gastrectomy.
PHYSICAL EXAMINATION: Patient was afebrile. Vital signs
were stable with saturations of 94% on room air. He was
awake, alert and oriented times three, conversant. Speech
was fluent. Affect was appropriate. Pupils were equal,
round and reactive to light. EOM full. Smile and tongue
were midline. Face was symmetric. Neck was supple with full
range of motion. Lungs: Decreased breath sounds with faint
rales and rhonchi to the right lower base posterior,
otherwise clear. Heart: Normal sinus rhythm at 94, normal
S1, S2 without murmurs, rubs, or gallops. Abdomen: Has a
midline incision which is clean and dry. Positive bowel
sounds in all four quadrants. Rectal tone is within normal
limits. Guaiac negative. Extremities: No cyanosis,
clubbing or edema. Neurologically: His motor strength is
[**5-16**] in both upper extremities. Lower extremities: His IPs
were 4+ bilaterally, otherwise he was [**5-16**]. Sensation was
intact to light touch without saddle anesthesia. His deep
tendon reflexes are 2+ throughout with the exception of the
ankles which were 1+. His toes were downgoing.
LABORATORY DATA ON ADMISSION: White count 9.5, hematocrit
31.6, platelets 334. Sodium 140, potassium 4.2, chloride
105, CO2 24, BUN 14, creatinine 0.5 and glucose is 396. The
patient was started on sliding scale insulin.
MRI from [**Hospital1 **] shows compression fracture of the L2-L3
level with retropulsion and compression of the thecal sac.
Patient underwent anterior vertebroplasty from the L2-L4
levels by Dr. [**Last Name (STitle) **] on [**2184-11-26**] without inter-procedure
complication. The patient was stable neurologically. He was
taken to the OR on [**2184-11-29**] for L2-L3 vertebrectomy.
During the removal of the methacrylate from the L2-L3 disc
space, a large amount of anterior bleeding was encountered
emanating from the region of the aorta. This was quickly
packed off with large sponges and manual pressure. This was
maintained until Vascular Cardiac surgeons arrived. They
achieved vascular control and repaired the laceration of the
aorta. Due to ongoing pressure requirements and metabolic
derangements following vascular repair, the decision was made
to not proceed with the vertebrectomy and spinal
stabilization.
During closure of the skin, the patient developed a wide
complex heart rhythm, V-tach, V-fib and requiring CPR.
Normal sinus rhythm was achieved and patient was transferred
to the CSRU for close monitoring. He had four liters of
blood loss at the time and also had a clot in the distal
aorta on cross clamping which caused loss of pulses in the
lower extremities below the femoral arteries.
On [**2184-11-30**], the patient was awake, alert, following
commands and moving all extremities spontaneously and to
command. He had positive pulses in his lower extremities
with the exception of the right DP. His temperature was
100.3 F, blood pressure was 98/54 and he was Amiodarone drip
as well as Fentanyl for pain, Levophed and an insulin drip.
He had [**Name (NI) **] PT pulses bilaterally. DP was present on
the left, but not on the right and his right foot was cool to
touch.
On [**12-2**] the patient was awake and alert. His dressing was
clean, dry and intact. His motor strength was [**5-16**]. He had a
right PT pulse and left DP and PT pulses. He was transferred
with two units of packed cells for a hematocrit of 27.8 and
given platelets for a platelet count of 62. He was
transferred to the regular floor on [**2184-12-2**].
On [**2184-12-3**], the patient underwent an L3 retroperitoneal
vertebrectomy with L2-L4 stabilization with caging. The
patient tolerated the procedure well. He was monitored in
the Surgical Intensive Care Unit postoperatively. Had chest
tubes and two wall suction. He was seen by the Acute Pain
Service and started on Methadone 10 mg p.o. b.i.d. and
Dilaudid PCA.
On [**2184-12-6**], the patient's PCA was discontinued. He was
started on p.o. Hydromorphone, continued on 10 mg of
Methadone and his Fentanyl patch was weaned to 200 mics q.
three days. He tolerated p.o. pain medication well. His
motor strength was [**5-16**] in all muscle groups. His incision
was clean, dry and intact. He was seen by Physical Therapy
and Occupational Therapy and found to require rehab prior to
discharge to home.
DISCHARGE MEDICATIONS:
1. Ancef 1 gram IV q. eight hours until [**2184-12-11**].
2. Fentanyl patch 200 mics topically q. 72 hours.
3. Miconazole powder 2% one application topically t.i.d.
p.r.n.
4. Hydromorphone 8 to 12 mg p.o. q. four hours p.r.n. for
breakthrough pain. Methadone 10 mg p.o. b.i.d. for pain.
5. Heparin 5000 units subcu q. 12 hours.
6. Colace 100 mg p.o. b.i.d.
7. Tylenol 650 p.o. q. four hours p.r.n.
8. Lorazepam 1 mg p.o. q. eight hours p.r.n.
9. Insulin per sliding scale.
10. Albuterol neb one neb inhaler q. six hours p.r.n.
11. Neurontin 300 mg p.o. t.i.d.
12. Hydrocortisone 100 IV q. eight hours.
13. Protonix 40 mg IV q. 24 hours.
14. Kefzol 1 gram IV q. eight hours until [**2184-12-9**].
CONDITION ON DISCHARGE: The patient was in stable condition
at the time of discharge and will follow up with Dr. [**Last Name (STitle) 1327**]
next week for staple removal.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2184-12-8**] 10:54
T: [**2184-12-8**] 10:58
JOB#: [**Job Number 37594**]
Name: [**Known lastname 6779**], [**Known firstname 63**] Unit No: [**Numeric Identifier 6780**]
Admission Date: [**2184-11-25**] Discharge Date: [**2184-12-10**]
Date of Birth: [**2130-3-15**] Sex: M
Service:
In addition to the previously dictated discharge summary,
this is to update patient's discharge medications.
DISCHARGE MEDICATIONS:
1. Cephazolin 1 gram IV q8h until [**2184-12-14**].
2. Decadron taper for one week as indicated in the discharge
page one summary to begin with three days of 4 mg tid, and
then 2 mg tid for three days, and then 2 mg [**Hospital1 **] for three
days, and then stop.
DR.[**Last Name (STitle) 562**],[**First Name3 (LF) 863**] 14-127
Dictated By:[**Last Name (STitle) 6781**]
MEDQUIST36
D: [**2184-12-10**] 10:42
T: [**2184-12-14**] 03:59
JOB#: [**Job Number 6782**]
|
[
"427.41",
"198.5",
"998.11",
"V10.03",
"250.00",
"998.2",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.49",
"39.31",
"77.99",
"81.06",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
7728, 8223
|
1873, 2980
|
165, 1850
|
2995, 6177
|
6932, 7705
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,082
| 171,174
|
35706
|
Discharge summary
|
report
|
Admission Date: [**2176-4-8**] Discharge Date: [**2176-4-11**]
Date of Birth: [**2115-11-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Distal and proximal tracheal stent granulation tissue and
tracheomalacia
Major Surgical or Invasive Procedure:
Rigid bronchoscopy, Y stent removal.
History of Present Illness:
60 yo M w/TBM s/p Y-stent placement in [**12-25**] found to have
persistent, moderate stenosis w/granulation tissue around stent
in [**1-22**] admitted from Federal Prison on [**4-1**] to [**Hospital 16843**]
Hospital with MRSA pneumonia and hypoxic, hypercapnic
respiratory
failure complicated by acute congestive heart failure.
The patient was doing okay at prison, with his trach, but using
pessy-muir valve, speaking, eating, breathing okay, until
recently when he developed increased mucus plugging and
shortness
of breath, and so was transferred to [**Hospital 16843**] Hospital (as
above). There, he was placed on mechanical ventilation for
presumed PNA with LLL collapse (per report) and sputum that grew
out MRSA, and leukocytosis of 12.1. He was started on
antibiotics (vancomycin), was initially weaned off the
ventilator
but then restarted after mucus plugged. He underwent
bronchoscopy that revealed granulation tissue distal to the
airway stent in RMS and LMS, along with "dynamic obstruction" of
airway due to TBM distal to the stent.
He also had an NGT placed and was started on tube feeds
(osmolite
1.5), and had a Foley placed to monitor UOP, and a rectal tube
for the development of diarrhea (C dif neg thus far). The
patient
was alos treated for congestive heart failure, as was diuresed
with lasix [**Hospital1 **] (per records not a home med), though his
creatinine did rise from 0.9 to 1.74.
Past Medical History:
COPD, chronic respiratory failure, s/p tracheostomy, obesity
hypoventilation syndrome, congestive heart failure, b/l knee
arthritis, gout, psoriasis.
Social History:
Patient is incarcerated. Former smoker
Family History:
non-contributory
Physical Exam:
Anicteric, EOMi, no JVD, no LAD
CN grossly intact
Edentulous, NGT in place (R nare)
regular rate but premature beats frequently, + systolic murmur
at
URSB, no radiation
BS decreased b/l, but no rales, no ronchi
abd soft NT
Foley in place, foreskin able to be pulled back, slight mucus
around foreskin
Rectum b/l raw skin, red, at gluteal folds, rectal tube in
place,
breakdown st I b/l
no c/c/e, venous stasis pigmentation left medial malleolus,
Skin psoriasis at knees b/l, wrists b/l, stomach
2+ DP b/l
A line in place in R wrist
Neuro: strength grossly intact
Pertinent Results:
[**2176-4-10**] 04:57AM BLOOD WBC-8.3 RBC-3.56* Hgb-10.5* Hct-31.2*
MCV-88 MCH-29.4 MCHC-33.6 RDW-16.0* Plt Ct-147*
[**2176-4-9**] 02:04AM BLOOD Neuts-75.5* Lymphs-16.8* Monos-4.3
Eos-2.9 Baso-0.5
[**2176-4-10**] 04:57AM BLOOD PT-13.5* PTT-33.1 INR(PT)-1.2*
[**2176-4-10**] 04:57AM BLOOD Glucose-95 UreaN-23* Creat-1.5* Na-141
K-3.6 Cl-96 HCO3-36* AnGap-13
[**2176-4-10**] 04:57AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.1
Brief Hospital Course:
[**4-8**]: Pt. admitted to ICU with vent.
[**4-9**]: Pt. underwent bronch and stent removal. Please see
operative note for more details. Pt. returned to ICU
postoperatively without incident. Stable for transfer.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-17**]
Puffs Inhalation Q6H (every 6 hours).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for mucus plugging.
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for dry skin.
10. Insulin
Please continue insulin sliding scale as attached. Adjust as
facility physician desires to achieve optimal glucose control.
11. Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs
Miscellaneous Q2H (every 2 hours) as needed for secretions.
14. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
15. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane ONCE
(Once) as needed for brochoscopy for 1 doses.
16. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1
doses.
18. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q6H (every 6
hours) as needed for anxiety.
19. Morphine 2 mg/mL Syringe Sig: 2-4 mg Injection Q4H (every 4
hours) as needed for pain.
20. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 81231**]
Discharge Diagnosis:
Acute on chronic hypercapnic respiratory failure w/granulation
tissue at distal end of tracheal stent
Discharge Condition:
Stable.
Discharge Instructions:
Resume all home medications. Seek immediate medical attention
for fever >101.5, chills, increased redness, swelling, bleeding
or discharge from incision, chest pain, shortness of breath,
difficulty breathing, severe headache, increasing neurological
deficit, or anything else that is troubling you. No strenuous
exercise or heavy lifting until follow up appointment, at least.
Do not drive or drink alcohol while taking narcotic pain
medications. Call your surgeon to make follow up appointment.
Followup Instructions:
Followup with Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **] in 3 weeks for preoperative
planning. Call ([**Telephone/Fax (1) 1504**] to make an appointment.
Please obtain preoperative cardiac clearance with outpatient
cardiologist before any operative planning is scheduled. Thank
you.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2176-4-10**]
|
[
"274.9",
"519.19",
"V46.11",
"496",
"428.21",
"482.42",
"518.84",
"278.00",
"428.0",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.78",
"97.23",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
5334, 5386
|
3185, 3398
|
393, 432
|
5532, 5542
|
2746, 3162
|
6086, 6526
|
2129, 2147
|
3421, 5311
|
5407, 5511
|
5566, 6063
|
2162, 2727
|
281, 355
|
460, 1882
|
1904, 2056
|
2072, 2113
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,754
| 165,130
|
51941
|
Discharge summary
|
report
|
Admission Date: [**2128-5-23**] Discharge Date: [**2128-5-31**]
Service: MEDICINE
Allergies:
Codeine / Darvon / Levofloxacin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CC:[**CC Contact Info 107528**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F with PmHx significant for CAD s/p MI x 2 s/p PCI/stent x2
([**2123**], [**2125**]),DMII, hypertension, diabetes, GERD, asthma,
arthritis, DVT, CRI, and cholangitis/pancreatitis, recently
admitted [**Date range (1) 82134**] with diverticulitis and perforation managed
medically, who now presents with hypoglycemia and rectal
bleeding.
.
Ms. [**Known lastname 74762**] presented [**5-15**] with 1 wk h/o LLQ pain and was found
by CT scan to have sigmoid diverticulitis with associated
perforation. She was managed conservatively without operation,
with a combination of bowel rest and antibiotics (Zosyn ->
augmentin). Course also notable for diarrhea, and although 3 C
dif toxin assays were negative, flagyl was added empirically for
presumed c dif colitis. Patient was also noted to have labile
blood sugars.
.
Ms. [**Known lastname 74762**] was found by her grandson this afternoon to be
somnolent and difficult to arrouse, diaphoretic,and called EMS.
UPon arrival, herFSG was noted to be 34. Ms. [**Known lastname **] has not
been eating much since the recent discharge, stating that she
had a poor appetite. She states that she has not had a similar
episode of hypoglycemia for approximately two years.
.
Ms. [**Known lastname 74762**] also reports an episode of rectal bleeding this am,
with blood on the bowel movement and turning the toilet water
red. She denies having BRBPR prior to this episode, and did not
notice bleeding with a subsequent bowel movement. SHe has
continued to have loose bowel movements since recent discharge,
with approx [**1-15**] bm/day. No fevers, no NS. No abdominal pain.
.
In the ED, she was noted to have guaiac + brown stool. HCT noted
to be 26.4 on ED admission (was 29.8 on recent discharge).
Past Medical History:
-CAD: s/p MI x 2: anterolateral MI [**2123**] s/p PTCA/stenting of a
large diagonal branch of a "twin" LAD. s/p NSTEMI [**2125**] with cath
demonstrating 30% prox and mid RCA, 70% diag, 100% intermedius,
95% OM1 s/p OM1 Velocity Hepacoat stent. EF 51%.
-Hypertension
-hyperlipidemia
-DMII
-asthma
-gerd
-arthritis
-DVT ([**2118**])
-CRI baseline cr ~1.5
-cholangitis/pancreatitis/cholecystitis ([**2125**]), s/p ERCP with
stent
placement and sphincterotomy for a common bile duct stone.
-s/p cesarean section.
Social History:
The patient does not use tobacco or alcohol.
She lives alone, but her gradson lives above her and looks in on
her frequently.
Family History:
N/C
Physical [**Year (4 digits) **]:
(at admission)
T98.8 P 73 BP 162/50 RR 20 100% RA
Gen: patient appears stated age, found lying flat in bed, in NAD
HEENT: Sclera anicteric, conjunctiva uninjected, PERL, EOMI,
MMM, no sores in OP
Neck: no JVD, no LAD, nl ROM
Cor: RRR nl S1 S2 no M/R/G
Chest: diffuse expiratory wheeze
Abd: soft, dystended with tympany though nontender and with +BS
x 4. No HSM appreciated.
EXT: no calf tenderness. 2+ pitting edema to just below the knee
Neuro: MS [**First Name (Titles) **] [**Last Name (Titles) **], CN II-XII in tact, UE/LE strength 5+
bilaterally, 2+
DTRs (biceps, triceps, patellar), nl cerebellar [**Last Name (Titles) **]
Pertinent Results:
Abd CT:
IMPRESSION:
1. No significant interval change in sigmoid diverticulitis with
associated contained perforation. No drainable collection is
identified.
2. Cholelithiasis without evidence of cholecystitis.
3. No short change in cystic right adnexal lesion, as discussed
on the recent CT.
4. Trace amount of air within the bladder, which could be
consistent with prior instrumentation. Clinical correlation
recommended.
5. New small right pleural effusion.
-----
CXR [**5-23**]:IMPRESSION: No acute cardiopulmonary process.
-----
CXR [**5-25**]:IMPRESSION: Small left effusion without evidence of
overt CHF.
-----
CXR [**5-28**]:IMPRESSION: No definite evidence of congestive heart
failure or pneumonia.
-----
Echo:
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
probably normal
though the views are limited and the study technically
difficult. Overall left
ventricular systolic function is probably normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4. The aortic valve leaflets are mildly thickened. No aortic
regurgitation is
seen.
5.The mitral valve leaflets are mildly thickened. Though
difficult to assess
given the limited views, probably moderate (2+) mitral
regurgitation present.
6.There is moderate pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
-----
CXR PA/Lat:
Subsegmental atelectasis.
Incidental anterior compression fracture of thoracic vertebral
body, as seen on the preoperative film.
-------------
[**2128-5-23**] 05:55PM BLOOD WBC-6.5 RBC-2.83* Hgb-8.7* Hct-26.4*
MCV-94 MCH-30.6 MCHC-32.8 RDW-13.9 Plt Ct-604*
[**2128-5-23**] 05:55PM BLOOD WBC-6.5 RBC-2.83* Hgb-8.7* Hct-26.4*
MCV-94 MCH-30.6 MCHC-32.8 RDW-13.9 Plt Ct-604*
[**2128-5-23**] 05:55PM BLOOD Neuts-71* Bands-5 Lymphs-12* Monos-10
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2128-5-24**] 04:52AM BLOOD PT-13.5* PTT-29.0 INR(PT)-1.2
[**2128-5-23**] 05:55PM BLOOD Glucose-82 UreaN-21* Creat-1.5* Na-137
K-4.5 Cl-107 HCO3-19* AnGap-16
[**2128-5-24**] 04:52AM BLOOD ALT-12 AST-22 LD(LDH)-158 AlkPhos-74
TotBili-0.6
[**2128-5-26**] 07:05AM BLOOD proBNP-5302*
[**2128-5-24**] 04:52AM BLOOD Albumin-2.1* Calcium-7.3* Phos-2.7 Mg-1.6
[**2128-5-30**] 07:00AM BLOOD Calcium-7.6* Phos-1.8* Mg-1.5* Iron-33
[**2128-5-30**] 07:00AM BLOOD VitB12-729 Folate-10.1 Ferritn-495*
[**2128-5-23**] 08:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2128-5-23**] 08:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
[**2128-5-28**] 09:35AM URINE RBC-6* WBC-2 Bacteri-NONE Yeast-NONE
Epi-1
------
UCx neg x2
BCx neg x3
C Diff neg
Brief Hospital Course:
1. GI bleed: In the ED, she had guaiac + stool and Hct=26.4(down
from 29.8 on D/C several days earlier). Went to floor for a
short time, but there was noted to have BRBPR and passed
multiple clots. Her BP also dropped from systolic of 130s to
100s. She wasn't symptomatic from this BP. She was transferred
to the ICU and given IVfs which brought her BP up quickly. She
was also given 3 units PRBCs. In ICU, she had no bloody BMs,
and her Hct was stable since transfusions. Surgery also saw her
in the ED and believed that surgery not indicated at this time.
Her ASA/Plavix was held during admission given bleed, but
restarted on discharge. She did have traces of blood in her
stools several more times during admission, but her Hct remained
stable. She had nL BMs for 3-4 days before D/C without blood.
Believe bleed was secondary to her diverticulae. Does not
appear to be result of her known perforation. Her diet was
advanced slowly and she did well, without nausea/vomiting or abd
pain. Discussed with GI, and no possibility of colonoscopy for
at least 6 weeks after her perforation. She will see her PCP as
[**Name9 (PRE) 3782**] and can have GI colonoscopy set up for 6-8 weeks from now.
.
2. Diverticulitis - She was started on Augmentin and Flagyl with
plans to finish 7 day course on last D/C. On readmission, she
was switched to flagyl and Unasyn given known perf and
possibility of diverticulitis. She also had bandemia, but nL
WBC ct. Cxs and CXR were neg, and no other obvious [**Last Name (un) 68421**] of
infection. Abd was benign throughout. She was febrile for much
of her stay here (low grade), but this had resolved by
discharge. We stopped her Flagyl several days before D/C, and
sent her out on Augmentin(had switched from Unasyn when she came
to floor) to finish 14 day course of abx.
.
3. Wheezing - She began to have wheezing on [**Last Name (un) **] and has
albuterol at home. CXRs were clear multiple times, but she did
not respond to nebs very well. Also continued her Advair. She
was put on PO prednisone in ICU, but this was stopped when she
reached floor. We were concerned this may be pulm edema and not
only reactive airways (likely combination of both). Decided to
try diuresis based on high BNP and LE edema despite clear CXR.
She had a good diuresis for several days and this resulted in
improvement in her O2 sats, LE edema, and comfort. She was then
sent out on Lasix 10 mg qday. Had previously been on HCTZ and
this was stopped given new Lasix.
.
4. CAD - Held ASA/Plavix given bleed. Also, her BB and ACE-I was
held due to hypotension initially. As she stabilized, these
were added back and resulted in excellent BP control. She was
sent out on these and Lasix as above.
.
5. DM - Held glyburide as she was hypoglycemic on admission.
Continued her on HISS. Initially with high glucose sec to
steroids. After D/C of these, she continued to run high in
200s. Decided to start rosiglitazone as this is not affected in
renal failure and should not cause hypoglycemia. Started at
dose of 2 mg qday and discharged on dose of 4 mg qday. She was
also given a glucometer and strips and told to check her BS at
least daily. She should bring readings to PCP f/u and have
medds adjusted as needed.
.
6. Diarrhea - Continued empiric flagyl when pt admitted. Repeat
C Diff again neg. Believe her diarrhea was possibly sec to abx.
Stopped her Flagyl several days into stay. Don't believe there
was an infectious source or malabsorption. By discharge, her
stools had become more formed and less frequent. Can have this
followed as outpt if it continues.
.
7. CRI: Her baseline recently was Cr=1.5-1.7. She was actually
better than this for several days and then started to rise with
diuresis. This then stabilized and her Cr was 1.4 on D/C.
Again, can be followed by PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) **] throughout.
.
8.Seen by PT multiple times and was walking well with her
walker. They felt she was safe to go home. She was set up with
very close support, including: home VNA, home PT, bedside
commode, Lifeline, home glucometer.
.
9.She had a compression fracture noted on CXR that was felt to
be old. SHe was started on Ca and Vit D here. In addition,
believe she should be started on Alendronate as an outpt,
possibly after a bone scan if PCP feels this is indicated. Also,
a 6 cm adnexal cyst was seen on abd CT. No obvious sxs from
this. Will defer this to outpt work-up.
Medications on Admission:
Albuterol 1-2 puffs Q6H
Advair 250/50
plavix
glyburide 2.5
Asa 81
atenolol 100
vicodin PRN
Augmentin 250-125 through [**5-28**] daily
Flagyl 500 [**Hospital1 **] through [**5-28**] [**Hospital1 **]
protonix
HCTZ 3x/wk 25
lisinopril 10
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. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
13. Lancets
Please supply pt with Lancets to use for blood glucose
monitoring.
14. Glucometer Strips
Please supply pt with 1 month supply of glucometer strips for
testing. Refills:3
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Principal:
1. Diverticulitis.
2. Lower GI Bleed.
3. Diastolic Heart Failure.
4. Hypoglycemia.
5. Anemia - Blood Loss, ESRD.
6. Incidental note of L5 and T10 compression fractures.
Secondary:
1. Diabetes Mellitus Type II.
2. Hyperlipidemia.
3. Hypertension.
4. Chronic Renal Failure.
5. COPD.
5. Anterolateral STEMI [**2123**] s/p PTCA-Stent of Diag (Twin LAD).
6. Lateral NSTEMI [**2125**] s/p PTCA-Stent of proximal OM1.
Discharge Condition:
Stable. Ambulating well with walker. No pain. LE edema much
improved. Eating normally. No blood in stools. Afebrile. Vitals
stable.
Discharge Instructions:
Please call Dr [**Last Name (STitle) 24253**] or return to the ED(by ambulance) if you
have any more blood in your stools, dizziness, lightheadedness,
chest pain, shortness of breath, or fevers.
-Take your medications as directed.
-We stopped the following medications:
1.HCTZ
2.Glyburide
-We started the following medications, please take them as
directed:
1.Calcium
2.Vitamin D
3.Rosiglitazone
4.Lasix(furosemide)
Followup Instructions:
1. 6.0 cm right cystic adnexal lesion. Interval follow-up
recommended.
----
Please see Dr [**Last Name (STitle) 24253**] on [**2128-6-8**] at 10:45 am for a follow-up
appointment.
|
[
"428.30",
"493.90",
"428.0",
"412",
"424.0",
"250.80",
"584.9",
"401.9",
"530.81",
"787.91",
"V45.82",
"276.2",
"593.9",
"562.12",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12530, 12588
|
6286, 10752
|
269, 276
|
13055, 13188
|
3444, 6263
|
13653, 13836
|
2753, 3425
|
11038, 12507
|
12609, 13034
|
10778, 11015
|
13212, 13630
|
198, 231
|
304, 2059
|
2081, 2593
|
2609, 2737
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,823
| 167,634
|
45530
|
Discharge summary
|
report
|
Admission Date: [**2160-12-27**] Discharge Date: [**2160-12-31**]
Date of Birth: [**2081-12-20**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Cough, Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 year old Male w/ h.o. metastatic bronchoalveolar Carcinoma w/
multiple recent PNAs p/w fever to 104.3, cough on 2L-6L. O2sats
93% max.
Unfortunately pt is a poor historian. He states that over the
past few weeks he has noted intermittent low grade fevers,
however yesterday his fevers were notably higher with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**]
of 104. It is unclear if his cough also started yesterday or
whether it has been several weeks, he is able to state that it
is mostly non-productive and the only expectorant he sees is
white. He also endorses chronic rhinorrhea but denies any recent
change. 2 days ago he noted some pleuritic chest pain over his
rt lower thoracic side which resolved within 24 hours. He did
receive the H1N1 and Influenzae vaccine last year. He wanted to
manage this at home but spiked to 104 again so went to the ED.
Of note pt was recently diagnosed with bronchoalveolar carcinoma
in the Spring and started his first round of pemetrexed
chemotherapy on [**2160-12-9**]. His next cycle is this Tuesday. He has
noted a left foot drop which started several weeks ago and is
being followed by Dr. [**Last Name (STitle) 724**].
In the ED, initial vitals were noted to be T97.5, HR 73, BP
132/88, RR 20, Sat 91%. Pt's lab data was notable for a
leukocytosis with a left shift. Bld cultures were drawn and the
pt was given Cefepime 2gm IV per heme-onc recs. A CXR was
notable for new RLL infiltrate versus effusion. U/A was
unremarkable He was noted to be saturating low 80s on 2L of
oxygen and was thus increased to 6L and then 50% Facemask where
his sat was noted to improve to mid 90s.
Last set of vital signs prior to transfer were HR 72, BP 120/83,
99% on FM. On arrival to the floor pt was switched to shovel
mask with hydration saturating 98-100% with no signs of
accessory muscle use.
On transfer, O2sats higg 90s on 3L. Looks fine per report.
Crackles RLL with egophony. R strabismus longstanding, L foot
drop thought [**1-27**] to decreased fat pad over peroneal nerve per
Dr. [**Last Name (STitle) 724**]. Gait ataxic, PT consulted. Otherwise neuro exam ok.
BAC can proceed to PNA-like carcinona. Has been afebrile. D/c'd
cefepime; on vanc, ctx, and levofloxacin because ICU admit and
recent hospitalizations. Metformin held for ?imaging; had been
hypoglycemic on arrival (?Po intake) but FSG fine since. C- and
L/S-spine MRI to evaluate for spondylosis.
Past Medical History:
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2, on glipizide and metformin.
2. Coronary artery disease. Status post inferior myocardial
infarction in [**2139**]. Inferior posterior mild hypokinesis,
persists on echocardiogram. He also has mild MR. [**First Name (Titles) **] [**Last Name (Titles) 1834**]
angioplasty and then stenting of ramus intermedius in 06/[**2149**].
He was re-stented in the same spot in 08/[**2149**].
3. Bladder cancer. He is on an alpha interferon three times
yearly. He is being followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
4. Obstructive sleep apnea. He uses CPAP.
5. Hypertension.
6. Hyperlipidemia.
7. Allergic rhinitis.
8. Status post right total knee replacement.
9. Chronic back pain / spinal stenosis. He is status post L4/L5
laminectomy in [**2113**].
10. Status post right ulnar impingement release.
11. Erectile dysfunction.
12. History of erysipelas with chronic right lower extremity
skin changes.
13. GERD.
14. Depression.
15. Bronchoalveolar carcinoma, Dx [**2160-3-26**]
Social History:
He lives with his wife. They are independent for all of their
activities of daily living. He was a three-pack-per-day smoker
until his early 20's (15-20 pack-year hx). He does not drink or
use drugs.
Family History:
His dad had lymphoma, and mom has a history of rectal cancer.
Both parents had heart disease. Other relatives had diabetes
mellitus. He has adopted children.
Physical Exam:
GENERAL: Elderly, thin Caucasian Male lying down in bed in NARD.
HEENT: PERRL, rt sided strabismus, normocephalic, atraumatic.
MMM.
CARDIAC: S1, S2, no m/g/r, RRR
LUNGS: Crackles noted over RLL with + egophany. Otherwise CTA
b/l.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema noted.
NEURO: A&Ox3. CN II-[**Last Name (LF) **], [**First Name3 (LF) 81**], XII intact on examination.
Preserved sensation throughout. Left sided foot drop noted. Gait
not assessed but he requires
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs
[**2160-12-27**] 12:30PM WBC-12.2* RBC-4.17* HGB-11.9* HCT-35.6*
MCV-85 MCH-28.5 MCHC-33.3 RDW-14.7
[**2160-12-27**] 12:30PM PLT COUNT-435
[**2160-12-27**] 12:30PM NEUTS-76.8* LYMPHS-14.6* MONOS-5.5 EOS-2.7
BASOS-0.5
[**2160-12-27**] 12:30PM PT-13.7* PTT-25.5 INR(PT)-1.2*
[**2160-12-27**] 12:30PM GLUCOSE-122* UREA N-15 CREAT-1.0 SODIUM-137
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
[**2160-12-27**] 12:37PM LACTATE-1.7
[**2160-12-27**] 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
Discharge Labs
[**2160-12-31**] 06:45AM BLOOD WBC-9.2 RBC-4.42* Hgb-12.8* Hct-38.2*
MCV-86 MCH-28.9 MCHC-33.5 RDW-14.5 Plt Ct-559*
[**2160-12-31**] 06:45AM BLOOD Glucose-118* UreaN-12 Creat-0.9 Na-142
K-4.7 Cl-108 HCO3-25 AnGap-14
[**2160-12-31**] 06:45AM BLOOD Calcium-10.7* Phos-3.0 Mg-1.5*
Urine Studies
[**2160-12-27**] 02:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2160-12-27**] 02:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
Blood and Urine Cultures - NEGATIVE
Radiology
CXR - Again noted is the right lower lobe consolidation which
has been seen on multiple prior examinations and consistent with
known bronchoalveolar cell carcinoma. There may be a slight
increase in the density of the consolidation. There may have
been interval development of a right pleural effusion. As such,
a superimposed infection cannot be entirely excluded, but
is felt unlikely. Correlate clinically. If indicated, chest CT
may be of benefit to provide further details.
Brief Hospital Course:
79 y/o male with recent diagnosis of BAC, fever, multiple
episodes of PNA p/w hypoxia likely recurrent PNA.
# Pneumonia - Pt was notably hypoxic in the ED with a
requirement of 50% on facemask. He was initially admitted to
the ICU, where he was treated with vanco, cefepime and
levofloxacin. He improved with this treatment and ultimately was
transferred to the OMED floor service. On the floor, he was
continued on levofloxacin alone and continued to improve. He
was discharged home to complete a 14 day course of levofloxacin.
# Bronchoalveolar Carcinoma - On admission, the patient's next
cycle of chemotherapy was due in 4 days. His chemotherapy was
held considering his current illness. He was instructed to
follow-up with his oncologist as an outpatient.
# Foot Drop - The patient has a known foot drop and is followed
by Dr. [**Last Name (STitle) 724**]. He was seen by PT was fitted with a boot for his
foot drop.
# DM II - The patient's oral diabetic medications were initially
held in the case that he would need a CT scan. They were
resumed at discharge.
# HL - Continued on statin.
# GERD - Continued on home regimen of Ranitidine.
Medications on Admission:
Bupropion HCl 300 mg daily
Diltiazem HCl 180 mg daily
Folic Acid 1 mg daily
Glipizide 10 mg [**Hospital1 **]
Ibuprofen 400 mg [**Hospital1 **]
ISMN S.R. 120 mg daily
Metformin 850 mg [**Hospital1 **]
Metoprolol XL 50 mg daily
Ranitidine 300 mg qHS
Rosuvastatin 20 mg daily
Acetaminophen 1,000 mg [**Hospital1 **] PRN
ASA 81 mg daily
Loratadine 10 mg daily
Docusate Sodium 100 mg [**Hospital1 **] PRN
Senna 8.6 mg [**Hospital1 **] PRN
Multi-Vitamins W/Iron 1 Tab daily
Discharge Medications:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
2. Diltiazem HCl 180 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
7. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a
day as needed for pain.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Multivitamins with Iron Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days: To complete a 14-day course, ending on [**2161-1-9**].
Disp:*10 Tablet(s)* Refills:*0*
18. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Pneumonia
Secondary:
Bronchoalveolar carcinoma
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 presented to the ER for evaluation of fevers and found to
have a pneumonia. You were initially admitted to the ICU but
were transferred to the oncology service when stable. You have
continued to have clinical improvement on antibiotics and no
longer require supplemental oxygen. You were evaluated by the
physical therapist, who thought you were safe for discharge to
home with services. You were also fitted for a boot given your
foot drop.
Please be aware that your blood sugars may vary in the setting
of your infection as well as with decreased appetite. Please
continue to check your blood sugars and call your [**Last Name (un) **]
physician
Your chemotherapy was delayed in the setting of infection.
Please discuss your treatment plan at your follow-up visit with
your Oncology team. Also, please reschedule the MRI and EEG
studies that Dr. [**Last Name (STitle) 724**] recommended.
The following changes were made to your medications:
STARTED on levofloxacin, to take for 9 more days (last dose
[**1-9**])
STARTED on ondansetron, to take as needed for nausea
You can use an over-the-counter cough medication like
guaifenesin as needed for your cough
Please take all medications as directed
Followup Instructions:
You are scheduled to follow up with your Oncology team on
[**2161-1-6**]. Your appointment with Dr. [**Last Name (STitle) 10351**] and Dr. [**Last Name (STitle) **] at
9:30am. Your appointment with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 5556**] is at 10:30am.
Please call their office at [**Telephone/Fax (1) 22**] with any questions.
|
[
"V10.46",
"530.81",
"412",
"401.9",
"736.79",
"496",
"162.5",
"275.2",
"414.01",
"781.3",
"V10.51",
"198.3",
"272.0",
"250.00",
"V45.82",
"486",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9914, 9972
|
6480, 7638
|
289, 295
|
10073, 10073
|
4811, 6457
|
11480, 11841
|
4063, 4222
|
8157, 9891
|
9993, 10052
|
7664, 8134
|
10250, 11457
|
4237, 4792
|
237, 251
|
323, 2755
|
10087, 10226
|
2799, 3830
|
3846, 4047
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,182
| 136,054
|
5143
|
Discharge summary
|
report
|
Admission Date: [**2102-12-22**] Discharge Date: [**2102-12-26**]
Date of Birth: [**2032-10-10**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
femoral line placement
History of Present Illness:
70y/o F with DM2, HTN, ESRD on HD, dCHF, Dementia, was noted to
have mental status changes (verbally unresponsive) after HD
today. Nurse at the HD center states that she usually is AxOx4
but today was noted to have altered level of consciousness. BG
was noted to be 70. Given food, BG increased to 100. Patient
received 4 hours of HD, patient altered throughout. After HD,
called 911 for unresponsiveness. Pt responds to pain but does
not follow commands. She had 3 hours and 15min of dialysis, her
pre HD weight was 54kg, post was 50.7kg.
In field patients vital signs were: HR: 98, BP: 116/40, RR: 14,
sats 100%, gluc 105.
In ED noted to have fever to 101.0, HR: 101, BP: 80/42, RR: 14,
Sats 99%. Code sepsis called, patient was had central access
placed in right femoral vein, given 1l NS, CTX 1gm and
vancomycin 1gm. She was also given 1gm tylenol, haldol 2.5mg x1.
Past Medical History:
HTN
DM
ESRD on HD
CHF (diastolic)
CVA x 2
Dementia
Social History:
Lives in Nursing Home. Daughter, [**Name (NI) 21085**], lives nearby.
Family History:
Non-contributory
Physical Exam:
PE:
T: 96.8 HR: 81 BP:123/38 RR:14 Sats: 100%
GEN: elderly AAF, NAD, opens eyes, does not follow commands,
does not reply to questions, resists you on examination.
HEENT: EOMI, PERRL, unable to visualize mouth
NECK: no bruits, no JVD
CV: RRR, 3/6 SEM
PULM: CTA b/l, no w/r/r
ABD: soft, flat, BS present, NT/ND
EXT: no c/c/e, DP/PT 1+ b/l
NEURO: unable to assess, patient not compliant with exam, will
resist with my movements.
Pertinent Results:
CEREBROSPINAL FLUID (CSF) PROTEIN-54* GLUCOSE-59
CEREBROSPINAL FLUID (CSF) WBC-1 RBC-6*
[**2102-12-22**] 08:54PM LACTATE-6.4*
[**2102-12-22**] 07:42PM LACTATE-6.3*
[**2102-12-22**] 07:30PM POTASSIUM-3.6
WBC-5.9 RBC-4.39 HGB-13.1 HCT-40.4 MCV-92 MCH-29.9 MCHC-32.5
RDW-20.9*
NEUTS-74.3* LYMPHS-19.7 MONOS-5.7 EOS-0.2 BASOS-0.1
PLT COUNT-311
[**2102-12-22**] 05:20PM LACTATE-7.6* K+-3.6
GLUCOSE-73 UREA N-30* CREAT-4.3* SODIUM-141 POTASSIUM-3.4
CHLORIDE-90* TOTAL CO2-23 ANION GAP-31*
cTropnT-0.15*
ALBUMIN-4.4 CALCIUM-10.6* PHOSPHATE-2.4*# MAGNESIUM-1.6
PT-13.2 PTT-30.7 INR(PT)-1.2
CXR: no infiltrates, prelim read
CT: no ICH, multiple chronic small vessel infarcts
Brief Hospital Course:
This is a 70 yo F with HTN, DM2, Dementia, and ESRD on HD who
presented with altered mental status. In the ED she was noted
to be febrile, hypotensive, tachycardic and with a lactate in
7's, so code sepsis was initiated; the patient had R femoral
central access obtained and received 1L NS, CTX 1gm, and
vancomycin 1gm. She was also given 1gm tylenol and haldol 2.5mg
x1 and was subsequently admitted to the MICU. Given her initial
presentation, there was concern for sepsis; yet she had no
leukocytosis or bandemia. Overdialysis was a possibility, since
it was reported that the patient was dialyzed down 4 kg. Her
hypotension, elevated lactate, and tachycardia could be
attributed to hypoperfusion. She responded to 1L of IVF and had
a normal heart rate and stable BP. There was no evidence of
seizure activity. Her CXR was without infiltrate. She underwent
LP, and showed no evidence of meningitis. Her antibiotics were
stopped by the MICU team and she was transferred to the floor.
On the floor her blood cultures came back with 1/2 bottles of
coag neg staph, likely a skin contaminant. Vancomycin levels
were checked and she received vancomycin at hemodialysis. CSF
cultures remained negative. The patient is being discharged on
a 10 day course of vancomycin, to be dosed at hemodialysis for
vanco levels less than 15.
.
The patient's altered mental status was of unclear etiology.
Upon review of OMR notes, patient has presented similarly in
past. Prior work-up has been unrevealing (EEG: normal, CT: old
infacts). Her behavior has been noted to have a diurnal
pattern, with the patient being more conversive in the evenings
and mute/not interactive in the mornings. Previously, neurology
had been following the patient and thought her MS changes were
[**1-11**] toxic/metabolic insults. Head CT showed no acute changes.
CSF was without infection. Her hypercalcemia may be
contributing to her mental status. Per her family, the patient
was close to baseline.
.
The patient's hypercalcemia was thought to be due to tertiary
hyperparathyroidism. Her cinacalcet was continued. PTH, TSH,
and Vit D studies were sent as well.
.
The renal team was made aware of patient. Her metabolic
acidosis was thought to be related to uremia and dehydration.
She was dialyzed on Monday. Her anti-hypertensives were held
pre-HD. She was given a dose of vancomycin at HD and cultures
were drawn. Nephrocaps and sevelamer were continued.
.
The patient was continued on her outpatient medications. She is
not recommended to go home on two nitrates for her hypertension.
The Bblocker and ACE may be titrated up to reduce the need for
two nitrates (isordil and NG paste).
Medications on Admission:
1. senna qhs
2. colace 100mg [**Hospital1 **]
3. cinacalcet 30mg daily
4. ducolax 10mg prn
5. MOM 30cc prn
6. Isordil 20mg tid
7. compazine 5mg [**Hospital1 **]
8. nepro supplement
9. celexa 20mg daily
10. ferrous sulfate 325mg tid
11. risperidone 1mg qhs
12. HISS
13. NTG paste q6 prn
14. Reglan 5mg daily
15. tylenol 650mg [**Hospital1 **]
16. aricept 5mg daily
17. labetolol 500mg [**Hospital1 **]
18. protonix 40mg daily
19. asa 325mg daily
20. nifedipine xl 90mg dialy
21. lisinopril 40mg daily
22. nephrocaps 1 daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prochlorperazine 10 mg Tablet Sig: 0.5 Tablet PO Q12 () as
needed.
9. Labetalol 200 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day): Please hold pre-HD.
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Please hold pre-HD.
11. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous At
hemodialysis for 10 days: Please dose for vanco levels <15.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8221**] - [**Location (un) 583**]
Discharge Diagnosis:
altered mental status
hypotension
..
ESRD on HD
dementia
Discharge Condition:
stable, mentating at baseline. normotensive and afebrile.
Discharge Instructions:
Please return if you experience low blood pressure (<90/60),
fever > 101.5, shortness of breath, chest pain, or any other
worrisome symptoms.
.
Please take all medications as directed. You have been started
on an antibiotic, vancomycin, for possible blood infection.
Your isordil has been stopped. You also should not take your
other blood pressure medicines on the morning before
hemodialysis.
Followup Instructions:
Please follow-up with your Primary Care Doctor within 1-2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"294.8",
"428.0",
"458.9",
"275.42",
"428.30",
"585.6",
"250.40",
"403.91",
"276.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6755, 6828
|
2579, 5261
|
289, 313
|
6928, 6988
|
1878, 2556
|
7433, 7592
|
1397, 1415
|
5835, 6732
|
6849, 6907
|
5287, 5812
|
7012, 7410
|
1430, 1859
|
233, 251
|
341, 1216
|
1238, 1291
|
1307, 1381
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,041
| 168,024
|
53941
|
Discharge summary
|
report
|
Admission Date: [**2171-5-18**] Discharge Date: [**2171-5-21**]
Date of Birth: [**2120-6-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Chief Complaint: Dizziness
Reason for MICU transfer: Hypotension
Major Surgical or Invasive Procedure:
transued 1 unit pRBC
History of Present Illness:
50 year old male with DM, ETOH cirrhosis complicated by
encephalopathy and varaceal bleed, s/p TIPS listed on trasnplant
list. Was seen by his hepatologist Dr. [**Last Name (STitle) **] who had noted
hyponatremia to 125 and referred him to the ED out of concern
for hepatic decompensation.
He reports that he has had a cough productive of green sputum
and sharp chest pain x 3 days which is located in the mid
sternum, the pain is made worse by stair climb and improves with
rest. He has not noted the pain at rest. He has had associated
dsypnea and light headedness. Of note, as part of his liver
transplant workup he had a cardiac catheterization [**2171-4-16**]
which showed non obstructive coronary artery disease LVEF
He states that he has been 100% compliant with his medications
and is taking lactulose to maintain 3 BM daily. He had been
treated with furosemide 40mg PO BID he states lower extremity
swelling had improved and furosemide changed to furosemie 20mg
daily yesterday.
In the ED, initial vitals T96.8 P62 BP89/48 RR20 SaO2100% RA.
Ultrasound at bedside showed no ascites with patent TIPS. UA
negative, CXR negative, Given Vancomycin. Discussed with
hepatlogy who recommended admission. Given 3L IVF with pressures
in the mid 80's. 18g and 20g. Labs were remarkable for K: 5.6 Na
125 HCT 28 (down from HCT 32) GUIAC negative
EKG with no peaked T waves. Vitals on transfer P78 BP86/52 RR18
Sa O296% RA
On arrival to the MICU, vitals were t: 98.5 P58 BP 90/49 RR13
SaO2 96%RA. He stated that his breathing was comfortable, and
was without complaints.
Review of systems:
(+) Per HPI, also positive for bifrontal headaches,
(-) Denies neck stiffness, fever, night sweats, recent weight
loss or gain. Denies cough, or wheezing. Denies palpitations.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency.
Past Medical History:
Past Medical History:
1. Alcoholic cirrhosis Listed on transplant
2. Esophageal varices s/p TIPS [**2165**]
3. Portal HTN
4. Hepatic encephalopathy
5. Mild, non-obstructive CAD
6. IDDM
7. OSA on CPAP
Social History:
- Born in Equador lives at home with wife, recently married in
[**2171-3-26**].
- Retired firefighter
- Tobacco: Denies
- Alcohol: Former heavy drinker >10 drinks/ day last drink new
years eve [**2170**]
- Illicits: Denies
Family History:
Father: CABG at Age 65, Diabetes
Mother: Diabetes
Physical Exam:
Vitals: t: 98.5 P58 BP 90/49 RR13 SaO2 96%RA
General: Middle aged male appearing alert, oriented, no acute
distress
HEENT: Sclera icteric, mucous membs dry
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
liver border not palpated
SKIN: hyperpigmented macules over left abdomen with a smaller
patch over right abdomen
GU: no foley
Ext: Bilateral ankle edema
Neuro: CNII-XII intact, positive asterixis
Pertinent Results:
[**2171-5-18**] 12:05PM BLOOD WBC-11.8* RBC-2.75* Hgb-10.4* Hct-28.1*
MCV-102*# MCH-37.9* MCHC-37.1* RDW-14.8 Plt Ct-85*#
[**2171-5-19**] 02:50AM BLOOD WBC-6.7 RBC-2.24* Hgb-8.4* Hct-23.2*
MCV-104* MCH-37.7* MCHC-36.3* RDW-15.1 Plt Ct-54*
[**2171-5-19**] 08:26AM BLOOD WBC-8.4 RBC-2.82*# Hgb-10.4* Hct-28.9*
MCV-103* MCH-36.9* MCHC-36.0* RDW-15.9* Plt Ct-69*
[**2171-5-19**] 11:07PM BLOOD WBC-6.7 RBC-2.39* Hgb-8.7* Hct-23.9*
MCV-100* MCH-36.6* MCHC-36.5* RDW-16.0* Plt Ct-50*
[**2171-5-20**] 03:48AM BLOOD WBC-8.3 RBC-2.47* Hgb-9.0* Hct-24.8*
MCV-100* MCH-36.3* MCHC-36.1* RDW-16.1* Plt Ct-45*
[**2171-5-20**] 03:48AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Burr-OCCASIONAL
[**2171-5-18**] 12:05PM BLOOD PT-27.4* PTT-49.7* INR(PT)-2.6*
[**2171-5-18**] 12:05PM BLOOD Plt Ct-85*#
[**2171-5-19**] 02:41PM BLOOD PT-25.4* PTT-60.7* INR(PT)-2.4*
[**2171-5-19**] 08:26AM BLOOD Plt Ct-69*
[**2171-5-20**] 03:48AM BLOOD PT-26.1* PTT-150* INR(PT)-2.5*
[**2171-5-20**] 03:48AM BLOOD Plt Ct-45*
[**2171-5-19**] 02:41PM BLOOD Thrombn-29.0*
[**2171-5-19**] 02:41PM BLOOD Fibrino-126*
[**2171-5-19**] 02:41PM BLOOD FDP-40-80*
[**2171-5-18**] 12:05PM BLOOD Glucose-225* UreaN-35* Creat-1.0 Na-125*
K-5.6* Cl-89* HCO3-31 AnGap-11
[**2171-5-20**] 03:48AM BLOOD Glucose-162* UreaN-15 Creat-0.6 Na-131*
K-4.6 Cl-101 HCO3-26 AnGap-9
[**2171-5-18**] 02:56PM URINE Hours-RANDOM UreaN-429 Creat-44 Na-81
K-25 Cl-68
[**2171-5-18**] 02:56PM URINE Osmolal-375
[**2171-5-18**] 12:05PM BLOOD ALT-40 AST-62* CK(CPK)-29* AlkPhos-151*
TotBili-16.7* DirBili-7.3* IndBili-9.4
[**2171-5-20**] 03:48AM BLOOD ALT-37 AST-58* AlkPhos-168* TotBili-10.5*
[**2171-5-18**] 12:05PM BLOOD Albumin-2.9* Calcium-8.8 Phos-4.1 Mg-1.8
[**2171-5-20**] 03:48AM BLOOD Albumin-2.2* Calcium-8.2* Phos-2.2*
Mg-2.1
ECHO [**2171-3-22**]
IMPRESSION: mild focal LV hypokinesis with preserved ejection
fraction. Mildly dilated right ventricle with borderline
function and mild to moderate pulmonary hypertension. No
evidence of intrapulmonary shunting or PFO/ASD. Mild mitral
regurgitation, trace aortic regurgitation.
Cardiac cath [**2171-4-16**]
1. Non-obstructive coronary artery disease.
2. Severely elevated LVEDP suggestive of severe diastolic
dysfunction.
3. Minimally elevated PASP.
4. Preserved Cardiac Index.
5. Normal systemic arterial blood pressure.
EKG NSR at 77, normal intervals, low voltage in the limb leads,
no STE, no peaked Twaves.
Brief Hospital Course:
50 year old male with ETOH cirrhosis complicated by
encephalopathy and varaceal bleed s/p TIPS is admitted with
hypotension. Hospital course complicated by declining Hct and
coagluopathy.
ACUTE
# Hypotension: Vitals in ED T96.8 P62 BP89/48 RR20 SaO2100% RA.
BP runs low at baseline per clinic records: [**2171-5-8**] 88/56.
Patient was given multiple NS boluses and tranfused 1 unit pRBC.
Atenolol was held. He was mentating and without without signs of
cerebral or myocardial hypoperfusion. BP, HR and UOP remained
stable throughout MICU course.
# Anemia of acute blood loss: Hct 28->23 at which point given 1
unit pRBC. Responded with Hct to 28.9->25.9->23.9->24.8. Hct now
stable around 25. Guiac negative stool. Concerned for GIB and
other causes of anemaia but no apparent source of active
bleeding.
# Coagluopathy: PT 28.1, PTT 150, INR 2.7. Platelt 85. INR 3.
Throbmin 29. Fibrinogen 126. FDP 40-80. Likely [**12-27**] underlying
liver disease.
# Acute kidney injury: Resolved. Creatinine up from baseline of
0.6 to 1.0 on admission. He has been treated with furosemide and
reported that he had the dose had been increased in the past
weeks. Creatinine returned to baseline of 0.6 day after
admission after NS boluses and Lasix and Metolazone were held
uring the MICU course.
# Chest pain: Resolved. Patient reported chest pain with
atypical features x3 days prior to admission. Ruled out ACS.
Pain resolved.
# Cough: patient with cough productive of green sputum, CXR x 2
did not show infiltrates. Given that he is afebrile and
hypotension is believed to be near baseline, held antibiotics in
the MICU.
# Hypovolemic Hyponatremia: patient reported increased
furosemide dose recently and appeared hypovolemic on admission.
started on 1200cc volume restriction and sodium stablized.
# Hyperkalemia: K 5.6 on admission, EKG does not show any peaked
twaves. Hyperkalemia resolved as acute renal failure resolved.
- Lastest K 4.6.
# Leukocytosis: 11.8 on admission. Resolved.
- f/u blood and urine cultures
Chronic
# ETOH Cirrhosis: patient is not currently drinking and is
listed on the transplant list. MELD score is 27 up from 26. He
has asterixis on exam and no sign of ascites.
- continued home meds except for furosemide and spironolactone
# Diabetes:
- Insulin sliding scale
# Obstructive sleep apnea
- CAP overnight
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Lactulose 15 mL PO QID
titrate to 3BMs daily
2. Clotrimazole 1 TROC PO 5X/DAY
3. Atenolol 25 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Spironolactone 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Vitamin D 50,000 UNIT PO DAILY
9. Glargine 55 Units Bedtime
10. Rifaximin 550 mg PO BID
Discharge Medications:
1. Clotrimazole 1 TROC PO 5X/DAY
2. Furosemide 20 mg PO DAILY
pls hold for sbp<95
RX *furosemide 20 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Glargine 55 Units Bedtime
4. Lactulose 15 mL PO QID
titrate to 3BMs daily
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Rifaximin 550 mg PO BID
8. Spironolactone 50 mg PO DAILY
pls hold for sbp<95
RX *spironolactone 50 mg 1 Tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Outpatient Lab Work
Chem-7, Coags, CBC, LFTs
Please fax lab results to [**Hospital1 18**] Hepatology [**Telephone/Fax (1) 697**]
Dx: cirrhosis, hyponatremia, hypovolemia
10. Vitamin D 50,000 UNIT PO 1X/WEEK (TU)
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Hypotension
etOH Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 110630**],
You were admitted to the hospital because you were not feeling
well, and you were found to be very dehydrated. You were
initially admitted to the intensive care unit because your blood
pressures were low. Your blood sodium levels were also found to
be low. We stopped giving you diuretics for a few days and gave
you plenty of fluids by IV. At the time of discharge, we
restarted your diuretics (Lasix and spironolactone) at a
different (lower) dose.
Upon discharge, please:
CHANGE your dose of Lasix (furosemide) to 20mg daily
CHANGE your dose of Aldactone (spironolactone) to 50mg daily
STOP your atenolol, please discuss with your hepatologist at
next visit.
Please have your blood drawn on Thursday [**2171-5-23**]. The lab can
fax the results to [**Telephone/Fax (1) 697**]. This is to make sure your new
dose of diuretics is correct.
An appointment for Dr. [**Last Name (STitle) **] is below. Please keep these
appointments and call the office if you're unable to make them.
It was a pleasure taking care of you, thank you for choosing
[**Hospital1 18**]!
Followup Instructions:
Department: TRANSPLANT
When: THURSDAY [**2171-6-6**] at 8:50 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"414.01",
"786.2",
"287.5",
"303.93",
"327.23",
"456.21",
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"286.9",
"458.9",
"288.60",
"285.1",
"572.3",
"276.7",
"571.2",
"786.59",
"V49.83",
"584.9"
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icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9467, 9473
|
5941, 8281
|
369, 391
|
9557, 9557
|
3459, 5918
|
10838, 11158
|
2794, 2846
|
8769, 9444
|
9494, 9536
|
8307, 8746
|
9708, 10815
|
2861, 3440
|
2006, 2315
|
281, 331
|
419, 1987
|
9572, 9684
|
2359, 2538
|
2554, 2778
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,925
| 162,022
|
38665
|
Discharge summary
|
report
|
Admission Date: [**2114-1-28**] Discharge Date: [**2114-2-9**]
Date of Birth: [**2066-1-18**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Headache/Facial Pain
Major Surgical or Invasive Procedure:
Suboccipital burr holes for evacuation of abscess.
Re-do craniotomy for evaculation of re-accumulated abcess
PICC line placement
Teeth Extraction
History of Present Illness:
This is a 48 year old male with a [**4-12**] history of R facial
pain and headache, as well as progressively worsening LUE/LLE
weakness. He was seen at his PCPs office for the pain on
Wednesday of last week, was diagnosed with sinusitis/bronchitis,
and was placed on PCN 500 TID. Has developed progressive L-sided
weakness since then, to the point where he is now unable to use
his L arm, or walk without holding on to something. He fell at
home this morning, and was sent by ambulance to [**Hospital6 50929**]. A head CT was performed, which demonstrated a large, R
posterior parietal/occipital mass with significant vasogenic
edema, sulci effacement, and 6mm of midline shift. He was given
10mg of Decadron, Dilantin load, and transferred to [**Hospital1 18**] for
continued care. A chest XR was also concerning for a R lung lobe
opacification/possible underlying nodule.
He continues to complain of significant facial pain and
headache,
as well as LUE and LLE weakness. He is also significantly
dizzy.
He denies visual changes, Nausea, vomiting, or R-sided weakness.
Past Medical History:
1. Recently diagnosed Bronchitis
2. Psoriasis
Social History:
Divorced. 3 children. Works as custodian. 10pk/yr smoking
history, quit 1 year ago. Denies EtOH
Family History:
Noncontributory
Physical Exam:
On Admission:
O: T:99.5 BP: 130/78 HR:60 R:18 O2Sats:96%
Gen: WD/WN, comfortable, NAD. Extensive psoriasis rash to entire
body.
HEENT: normocephalic, atraumatic. Pupils: [**4-10**] sluggish,
EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-7**] 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, 5 to 4
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 3/5 to L hand grasp, bicep, tricep, deltoid.
4-/5 to left lower IP, Ham, Quad. Gastroc, AT, [**Last Name (un) 938**] 0/5. RUE/RLU
[**4-11**]. Unable to check pronator drift with LUE flaccidity.
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
On Discharge: His right sided strength is full. His Left sided
strangth varies daily but has improved where each group is [**3-12**]
strength or above. Sensation is intact to light touch. His
incision is clean and dry without erythema or drainage. His
taples are in place. His is AA OR x 3, PERLLA, EOMI, Face
symmetrical, tongue midline.
Pertinent Results:
MR HEAD W & W/O CONTRAST [**2114-1-28**]
Large ring-enhancing lesion identified at the right parietal and
occipital region, more likely consistent with the large abscess
formation with irregular enhancement capsule, the remote
possibility of a neoplasm cannot be completely ruled out.
Significant mass effect and effacement of the sulci with
anterior displacement of the right ventricular atrium is
identified, there is also shifting of the normally midline
structures towards the left with approximately 6.1 mm of
deviation. No frank evidence of uncal herniation is identified,
however, there is mild effacement of the perimesencephalic
cisterns on the right. A small focus of high signal intensity is
noted on the FLAIR at the left frontal subcortical white matter,
possibly reflecting a gliotic foci. No other areas with abnormal
enhancement are identified. Inspissated secretions are noted at
the right maxillary sinus with restricted diffusion, raising the
possibility of sinusitis, there is also mucosal thickening at
the left maxillary sinus.
CT HEAD W/O CONTRAST [**2114-1-29**]
1. Post-surgical changes with decreased leftward shift now
measuring 2 mm. Persistent hypodensity in the right parietal
lobe with surrounding edema and pneumocephalus is identified.
Small punctate hyperdensity consistent with hemorrhagic foci is
consistent with post-surgical changes.
2. Sinus disease.
MRI brain [**2114-2-1**]:
In comparison with the post-surgical head CT dated [**1-29**],
[**2113**], there is evidence of increase fluid with new ring
enhancement in the
area of the previously drained right parietal abscess,
concerning for abscess reaccumulation. Increasing mass effect
and worsening midline shifting towards the left as described
above. Apparently, there is new satellite lesion identified in
the medial aspect of the right occipital lobe measuring
approximately 9.8 x 5 mm in size. Stable post-surgical changes
noted on the right parietal convexity.
CT head [**2114-2-1**]
No evidence of postoperative intracranial hemorrhage or new
collection. Persistent vasogenic edema within the right parietal
lobe with
interval decrease of mass effect and left shift.
Brief Hospital Course:
48 y/o male presented with a 5 day history of facial pain and L
sided weakness. He was seen by his PCP for his facial pain and
treated with PCN for sinusitis. He then began to develop L sided
weakness which lead him to fall. He went to an OSH where a head
CT showed a large R posterior parietal /occipital mass with
significant edema. Patient was transferred to [**Hospital1 18**] and admitted
to the ICU. Patient was taken to the OR emergently on [**1-28**] for
suboccipital burr holes for evacuation of abscess. He remained
intubated post operatively. In the post operative period,
patient presented with L sided weakness that over the night and
into [**1-29**] has improved to a [**3-12**]. Exam on [**1-30**] off propofol
follows commands, moves all extremities, L [**3-12**] and full strength
with R side. Corrected dilantin level was 7.3.
ENT and dental were consulted to determine cause of infection.
ENT does not believe that his sinuses are the cause of his
abscess and dental will re-examine the patient when extubated
and able to have a better exam. The patient has multiple dental
carries and loose teeth. Infectious disease recommends
vanc/ancef/flagyl.
On the morning of [**2-1**], the patient was found to be markedly
weaker on the left upper and lower extremity, and he was
increasingly lethargic. A stat head CT was performed, which
demonstrated significant increase in mass effect/edema in the R
hemisphere, and a possible re accumulation of his brain abscess.
He was taken emergent to the OR for an evacuation of this
abscess. Approximately 15cc of pus was drained. He went back
to the SICU intubated, due to his PNA, thick bronchial
secretions, and his pre op Na of 124.
On [**2-2**] he was extubated and Mannitol was being weaned. His
3%NSS was stopped [**Male First Name (un) **] [**2-3**] and he was transferred to the step
down unit. and then the floor on [**2114-2-5**]. His Left sided
weakness continued to gradually improve. Mannitol and Decadron
were tapered. He was being followed by infectious disease and
they made final recommendations for IV ceftriaxone and po Flagyl
for a minimum of 6 weeks.
He had teeth extraction with oral surgery on [**2114-2-8**], as this may
have been a cause for the abscess. PICC line was placed on
[**2114-2-9**] and he was medically cleared for transfer to rehab.
Medications on Admission:
1. Pen VK 500mg QID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Headache.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Insulin Regular Human 100 unit/mL Solution Sig: Two (2) units
Injection ASDIR (AS DIRECTED).
9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-9**]
Tablets PO Q4H (every 4 hours) as needed for pain.
12. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for itching.
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for prn itch.
16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
17. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q12H (every 12 hours) as needed for
cerebral abscess.
18. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed for anxiety/CIWA scale.
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right Posterior Parietal Abcess
Dental Cares
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:
?????? 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. You should have your staples removed at rehab on
[**2114-2-14**].
?????? 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain with contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2114-2-9**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
[]
]
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10006, 10078
|
5788, 8124
|
339, 487
|
10167, 10167
|
3589, 5765
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11860, 12214
|
1789, 1807
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1822, 1822
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279, 301
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515, 1589
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2383, 3230
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1836, 2091
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10182, 10323
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1611, 1659
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1675, 1773
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,517
| 133,824
|
5854
|
Discharge summary
|
report
|
Admission Date: [**2151-7-20**] Discharge Date: [**2151-8-4**]
Date of Birth: [**2075-7-24**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tetracycline Analogues /
Erythromycin Base / Atenolol / Lidoderm
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
75 yo F with h/o CAD, afib, PE's on anticoagulation and chronic
back pain presents after a fall. The pt reports that she recalls
being in bed last night, and noticing that the night light that
she wears around her neck had gotten intertwined with the
lifeline button she wears, and she thinks she may have thought
that she dropped it on the floor and went looking for it. The
next part that she remembers she is on the floor of the bedroom,
trying to get up multiple times and hitting various parts of her
body on the brass bed frame. She has never experienced weakness
like this and denies any difficulty with ambulation or balance
usually. She had gone on a trip to NH and [**State 1727**] on Saturday and
did extensive walking. On Sunday she slept most of the day
(which was unusual for her) and she noted a new cough and chest
congestion, but did not produce anything with the cough. She
denies fever, chills, nausea, vomiting, or urinary symptoms. She
did recently have a facet block/epidural injection of the lumbar
back for pain on [**7-16**], and has felt well since then.
.
This morning the pt's dtr found the patient on the floor at
home. The pt reports she had had a normal BM during the time she
was on the floor, and was unable to get up to go to the
bathroom. Pt was then brought to the ED.
.
In the ED, initial vs were: 97.5 95 88/39 16 98%. Due to
hypotension, blood cx and urine cx were sent and the patient was
given 500cc NS, vancomycin and zosyn. CT abd/pelvis and CThead
were unremarkable for any acute changes. Chest xray showed right
upper >lower lobe consolidation concerning for pna v ca. FAST
scan in ED was negative. Labs were notable for elevated troponin
to 0.15, and leukocytosis of 14. Pt was admitted to the ICU for
further monitoring of hypotension.
.
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:
Coronary Artery Disease s/p MI in [**2141**]
Atrial Fibrillation
S/P thoracoscopic left upper lobectomy [**2149-2-13**] for two
distinct adenocarcinomas, S/P adjuvant chemotherapy [**2149-6-13**] -
[**2149-9-13**] with carboplatin and pemetrexed
Postoperative right vocal cord paralysis.
Postoperative pulmonary embolism [**2149-2-13**] and again [**Month (only) 216**]
[**2149**], on long-standing Coumadin
Aortic stenosis
History of breast cancer and radiation.
History of melanoma, resected.
S/P right and, most recently, left total knee replacements.
Back pain.
squamous cell carcinoma
multiple SBOs, status
post sigmoid colectomy
hypertension
arthritis with significant sciatica
subclinical carotid disease
osteopenia
early emphysema
Hearing Loss
Hyperthyroidism
Macular Degeneration
s/p Bilateral Cataract Surgeries
Diverticulitis
Chronic renal insufficiency
Social History:
Worked as a manager for her husband auto supply office. Husband
passed away 2 years ago. Lives in a single-family home, does all
driving, shopping, cooking by herself. Two dtrs. Quit tobacco 20
years ago. No alcohol or drug use.
Family History:
Not relevant to fall.
Physical Exam:
Physical Exam on Admission to [**Hospital Unit Name 153**]
Tmax: 36.7 ??????C (98 ??????F)
Tcurrent: 36.7 ??????C (98 ??????F)
HR: 85 (70 - 85) bpm
BP: 133/49(72) {112/45(63) - 133/51(72)} mmHg
RR: 20 (13 - 23) insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Height: 65 Inch
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, ? rales
and rhonchi at R base
CV: Regular rate and rhythm, holosystolic crescendo descrescendo
murmur heard throughout the precordium, radiating to bilateral
carotids and loudest at LUSB, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley, no CVA ttp
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox3, speech fluent, pleasant. CN II-XII intact and
symm. LE strength symm, [**6-17**]
Skin: Multiple ecchymoses- L shoulder, bilat hips, abd, LE
Pertinent Results:
Labs at Admission: [**2151-7-20**] 02:30PM
WBC-14.1*# RBC-4.34 Hgb-12.1 Hct-36.2 MCV-83 Plt Ct-249
Neuts-87.4* Lymphs-8.6* Monos-3.4 Eos-0.4 Baso-0.2
PT-22.2* PTT-41.7* INR(PT)-2.1*
Glucose-113* UreaN-16 Creat-0.8 Na-138 K-3.4 Cl-101 HCO3-25
AnGap-15
ALT-47* AST-105* CK(CPK)-4606* AlkPhos-59 TotBili-0.6
Lipase-16
CK-MB-13* MB Indx-0.3 cTropnT-0.15*
Lactate-1.8 K-3.4*
CK(CPK)-3945*
CK-MB-12* MB Indx-0.3 cTropnT-0.08*
CK(CPK)-2748*
CK-MB-7 cTropnT-0.07*
Imaging:
[**2151-7-20**]
- CT head: There is no evidence of intracranial hemorrhage,
edema, shift of normally midline structures, hydrocephalus, or
acute large vascular territorial infarction. Periventricular and
subcortical white matter
hypodensities are consistent with chronic small vessel ischemic
disease. Mild prominence of ventricles and sulci are consistent
with age-related
involutional change. Calcifications are seen in the bilateral
carotid
siphons. There are aerosolized secretions within the left
sphenoid sinus.
Scattered ethmoidal air cell mucosal thickening is seen
bilaterally. The
remainder of the visualized portions of the paranasal sinuses
and mastoid air cells are well aerated. No fractures are
identified.
IMPRESSION: No acute intracranial process.
- CT C-spine: There is no evidence of fracture or change in
alignment compared to [**2150-8-10**]. There is no prevertebral
edema or hematoma. Multilevel degenerative changes are noted
including marked disc space narrowing at C3-4 and C4-5. Grade 1
anterolisthesis of C2 on C3 is unchanged. Minimal
anterolisthesis of C6 on C7 is also unchanged. There is
multilevel uncovertebral and facet joint hypertrophy causing
varying degrees of neural foraminal narrowing. Please refer to
the MR report from [**2150-8-10**] for complete review of
level-by-level degenerative changes. There are no
pathologically enlarged lymph nodes within the cervical region.
Bilateral carotid artery calcifications are noted. Prominence of
the thyroid isthmus does not appear significantly changed
compared to CT from [**2150-1-13**]. Aside from mild
pleuro-parenchymal scarring at the lung apices, the visualized
portions of the lungs are unremarkable.
IMPRESSION:
1. No evidence of fracture or change in alignment.
2. Multilevel degenerative changes of the cervical spine, as
described above.
3. Prominence of the thyroid isthmus, not significantly changed
compared to CT from [**2150-1-13**].
- CT abd/pelvis: ABDOMEN CT: A 5-mm nodule in the right middle
lobe (2:5) is not significantly changed in appearance compared
to the prior study from [**2151-5-31**]. Aside from minimal right
basilar dependent atelectasis, the remainder of the visualized
portions of the lungs is unremarkable. Coronary artery
calcifications are seen. The liver is normal appearing. The
portal vein is patent. There is mild intrahepatic biliary duct
dilatation, not significantly changed. The gallbladder is
distended and there are stones seen within dependent portion of
its body and neck, not significantly changed compared to the
prior exam. The pancreatic duct is mildly prominent, measuring 5
mm, unchanged in size. The pancreas is otherwise unremarkable.
The spleen is normal appearing. The adrenal glands are
unremarkable. Tiny hypodensities within the right kidney are too
small to characterize but are likely simple cysts. The left
kidney is unremarkable. The stomach is normal appearing. The
patient is status post prior small bowel surgery and there is an
unremarkable anastomosis between two loops of small bowel. The
remainder of the small bowel and colon are normal appearing.
Calcifications of the aorta and iliac arteries are noted.
PELVIS CT: The bladder is unremarkable. The patient appears
status post hysterectomy. The adnexa are not well visualized.
There is no free fluid in the pelvis. No pathologically enlarged
lymph nodes are seen. BONE WINDOW: No fractures are identified.
Grade 1 retrolisthesis of L4 on L5 is not significantly changed.
IMPRESSION:
1. No acute abdominal or pelvic process.
2. Distention of the gallbladder, cholelithiasis, and mild
intrahepatic
biliary duct dilatation are not significantly changed. Mild
dilation of the main pancreatic duct is also not significantly
changed.
- CXR: New interstitial opacities much more predominant in the
right upper lung versus the right lower lung. The left lung is
relatively spared. While a superimposed acute process such as
multifocal pneumonia may be considered, the overall appearance,
in the setting of a prior known cancer, is suggestive of
possible lymphangitic spread. Consider followup chest CT for
more detailed evaluation.
[**2151-7-21**]
- Trans-thoracic Echocardiogram: The left atrium is elongated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. 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.
The aortic valve leaflets (3) are mildly thickened. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic stenosis. Mild aortic and mitral regurgitation.
Borderline pulmonary hypertension.
[**2151-7-22**]
- MRI head: 1. No hemorrhage, infarction or enhancing mass.
2. Chronic small vessel white matter ischemic change appears
similar to [**2149**].
[**2151-7-22**]
- CT w/o contrast:
1. Moderately severe emphysema with superimposed new right upper
lobe
pneumonia. No evidence of necrosis or cavitation. New small
bilateral
pleural effusions are noted.
2. Multiple pulmonary nodules, unchanged from [**2151-6-21**].
Continued
followup as recommended on that study is appropriate.
3. Status post left upper lobectomy. No evidence of local
recurrence at the suture margin.
4. Small lucent lesions in the C7 left lamina are unchanged from
most recent comparisons, though new from more remote studies,
and could represent
metastases.
Note Date: [**2151-7-28**]
The LUL apical segments were surgically absent and the stump
appeared NL without lesions. The remainder of the
tracheobronchial tree was NORMAL without blood, secretions, or
masses, lesions. Even the RUL bronchi were patent and without
bloody secretions. A BAL was performed in the Apico post seg of
the RUL -> 100cc NS were instilled with a return of 40 cc cloudy
- NON-BLOODY fluid. There was minor mucosal oozing of blood with
suction and scope trauma.
IMPRESSION: RUL pneumonia c/b hemorrhage from inflammation and
friable airway mucosa - no proximal lesion / mass. No evidence
of
active hemorrhage. Radiographic and clinical follow-up needed.
Bronchial washings-Bronchioalviolar lavage: NEGATIVE FOR
MALIGNANT CELLS.
KUB [**7-31**]- No evidence of obstruction or ileus. No evidence of
megacolon
Micro: C.difficile negative x 3; PCR also negative. Respiratory
viral and bacterial cultures negative; blood cultures negative.
Labs at Discharge:
[**2151-8-4**] 06:00AM WBC-4.7 RBC-3.45* Hgb-9.5* Hct-29.1* MCV-84 Plt
Ct-469*
[**2151-8-4**] 06:00AM PT-31.2* PTT-150* INR(PT)-3.1*
[**2151-8-1**] 06:20AM Glc-107* UreaN-5* Creat-0.5 Na-134 K-3.3 Cl-100
HCO3-25
[**2151-8-1**] 06:20AM CK(CPK)-53
Brief Hospital Course:
76F w/PMH of lung CA s/p resection, chronic pain (spinal
stenosis), and multiple PE's on lifelong anticoagulation
presenting with fall at home, found to have pneumonia.
Community Acquired Pneumonia: Patient completed a course of
Ceftriaxone and Azithromycin. While in the ICU she developed
hematemesis, which was felt to be due to anticoagulation and her
underlying pneumonia. Anticoagulation was held, and she
underwent bronchoscopy which did not find any evidence of cancer
recurrence. Anticoagulation was re-started, and patient had no
further episodes of hematemesis. Her respiratory status remained
stable on room air, her WBC remained normal, and she remained
afebrile.
Diarrhea: Throughout hospitalization, pt. complained of profuse
watery diarrhea and abdominal cramping. C difficile toxin was
negative times three, and stool PCR was also negative. While
awaiting these results patient was started empirically on Flagyl
with no change in her stool output. This was stopped when her
PCR returned negative. Her diarrhea slowed but did not resolve
during her hospitalization, and was thought to be secondary to
antibiotic associated diarrhea as well as cessation of narcotic
pain medications (see below). She maintained good oral intake
and her electrolytes remained stable despite ongoing diarrhea.
Spinal Stenosis/Chronic Pain: There was some concern raised by
family during this hospitalization that the patient may have
been misusing narcotics. Her daughters claimed she had several
bottles of pain medications at home from different providers,
but did not volunteer the names of those providers. In
discussion with the patient's PCP further collaboration of
medication misuse was unable to be confirmed, but given these
concerns and the patient's initial presentation of being found
down for several hours, her long-acting pain medications were
stopped and Oxycodone was begun. The patient became very upset
when told by her daughters that she was addicted to drugs and
needed to attend Rehab, and that her pain medication use was
contributing to the dissolution of one daughter's marriage; she
then insisted on stopping her narcotic medications entirely.
Ultram was started. Analgesic benefit was unclear as patient
would no longer rate her pain, stating simply that it "was
something she would have to deal with." Ongoing discussion
regarding pain management will need to be continued in the
outpatient setting.
History of Multiple PE's: Coumadin managed by [**Hospital1 18**]
anticoagulation services. Patient was bridged back to Coumadin
with Heparin, and was discharged on a dose of 5mg (last five
doses prior to discharge: 5, 5, 5, 7.5, 7.5; INR at discharge
3.1). The [**Hospital3 **] was updated and will follow-up
her next INR on [**Last Name (LF) 2974**], [**8-6**] and adjust her Coumadin
accordingly.
Hypertension: Patient's home anti-hypertensives were held
initially in the setting of hypotension on admission. They were
slowly re-started, and her lisinopril was increased from 10mg to
20mg.
Patient will be seen in follow-up at the [**Hospital 1944**] clinic.
Pertinent issues to be addressed at this visit include pain
control, diarrhea, and blood pressure control.
Medications on Admission:
enoxaparin 60 mg/0.6 mL -inject sc q 12 hrs *for bridging,
recently INR subtherapeutic, so has been using lovenox*
Citalopram 40 mg once a day
Celebrex 200 mg once a day
Calcitrate-Vitamin D 315 mg-200 unit Tab-2 Tablet(s) by mouth
once a day
morphine ER 15 mg twice a day do not fill until [**2151-7-10**]
aspirin 81 mg once a day
Ativan 0.5 mg qam, and two tabs qhs
ProAir HFA 90 mcg/Actuation -1-2 puffs(s) by mouth every four
(4) to six (6) hours prn
Lisinopril 10 mg once a day
Alendronate 70 mg once weekly
Simvastatin 20 mg once a day
omeprazole 20 mg once a day
Zolpidem 5 mg -[**2-14**] Tablet(s) by mouth at night as needed for
insomnia
Adalat CC 90 mg once a day
Pentasa 500 mg -2 Capsule(s) by mouth twice a day
Warfarin 2 mg Tab-take up to 3 Tablet(s) by mouth daily
warfarin 5 mg --take up to 2 Tablet(s) by mouth daily
Warfarin 3 mg -Take up to 3 Tablet(s) by mouth once a day
gabapentin 300 mg Cap--3 Capsule(s) by mouth at bedtime and 1
qam
oxybutynin chloride ER 5 mg 24 hr once a day for bladder
Multivitamin Cap
Lidoderm 5 % (700 mg/patch) Adhesive Patch
apply to affected area 12 hours on 12 hours off once a day
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. mesalamine 250 mg Capsule, Extended Release Sig: Four (4)
Capsule, Extended Release PO BID (2 times a day).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a day:
In the morning.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
11. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day.
12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day: In
the morning.
13. Ativan 0.5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
14. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
15. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. Adalat CC 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*1*
18. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
19. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at
4 PM.
20. Outpatient Lab Work
Please have your INR checked on [**Last Name (LF) 2974**], [**8-6**], with the
results faxed to the [**Hospital3 **].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 16449**] Homecare
Discharge Diagnosis:
hypotension
fall
community acquired pneumonia
emphysema
lung and breast cancers
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 had hypotension (low blood pressure) after a fall at home.
Your hypotension resolved. It was thought that hypotension was
from dehydration and community-acquired pneumonia. You also
developed cough with blood in your sputum. We stopped your blood
thinners for some time and we discussed bronchoscopy to reveal
the source of bleeding and rule out the possibility of lung
cancer coming back. The bronchoscopy showed no evidence of
cancer. We resumed your blood thinners (coumadin) and you are
being sent home on 5mg. This dose will be adjusted by the
[**Hospital3 **] as needed. You experienced severe
diarrhea and cramping in the hospital felt to be due to the
antibiotics you were receiving; infectious causes of the
diarrhea were ruled out.
Medication changes: Given the concern of falls at home and the
fact that your pain medications were contributing, your Morphine
was stopped and you were started on Ultram. Your current
Coumadin dose is 5mg. No other changes were made to your home
medications.
Followup Instructions:
Please follow-up with Dr.[**Last Name (STitle) **] on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building at 9:40 on [**Last Name (LF) 2974**], [**8-6**]. Dr.[**Last Name (STitle) **] works with
Dr.[**Last Name (STitle) **] and will be following up on the issues addressed during
your hospitalization.
Please also keep the following previously scheduled
appointments:
Department: [**Location (un) **] SPINE (NHB)
When: TUESDAY [**2151-8-17**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20031**], MD [**Telephone/Fax (1) 3736**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: [**Hospital3 249**]
When: [**2151-9-14**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
18435, 18495
|
12377, 15580
|
363, 378
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2611, 3478
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3494, 3725
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,045
| 195,707
|
11274
|
Discharge summary
|
report
|
Admission Date: [**2150-8-3**] Discharge Date: [**2150-8-5**]
Date of Birth: [**2119-9-1**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Carvedilol
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Hypertension urgency, Diabetic Ketoacidosis, Acute Diastolic CHF
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30 year old Female who presents to the ED with worst headache of
her life, found to be having malignant hypertension with a [**First Name3 (LF) **]
pressure approximately 210/110. She was also noted with severe
hyperglycemia 383, rose 445 on arrival to the floor. She is also
noted in diastolic CHF with a markedly elevated BNP. She was
hypoxemic as well at 88% on room air.
.
The patient notes she has felt terrible for over a week, with
vomitting on the day of arrival and may have skipped 1-2 doses
of her insulin sliding scale as a result. She denies fever or
chills. She reports that her hypertension has been very
difficult to manage, recently seen by Dr. [**Last Name (STitle) **] over at [**Last Name (un) **]
on [**7-8**], and her medications were adjusted. On morning of
admission her BP this AM was 211/110. She was driven to the ED
by her mother for her pounding frontal and left sided headache.
Pt was hospitalized [**Date range (1) 36190**]/[**2150**] for viral meningitis but
reports resolution of her symptoms prior to this episode. She
notes a R hallux toenail fell off a few weeks ago but denies any
pain, redness or swelling. She she denies any other infectious
symptoms including fever, congestion, cough, SOB, dysuria, or
diarrhea.
In the ED initial vital signs were 97.3 99 196/106 20 100%.
She was transiently triggered for hypoxia s/p receiving zofran
4mg, morphine 4mg, her sats was 88% on RA, which improved with
O2 to 98% on 2L. EKG showed nsr, no ST changes. Patient declined
LP, Ha resolved. Labs were notable Cr of 2.7 (baseline 1.3 in
[**3-/2150**]), proBNP: 8244, Hct: 28.3 (baseline), Trop-T: 0.07, Gluc
of 383, AGap=22. CT Head W/O Contrast negative for acute
intracranial process. CXR notable for fluid overload. Pt was
given zofran 8mg IV, reglan 10mg IV, Morphine Sulfate x1,
labetolol 20mg IV x2, hydral 10mg IV x 1, Lorazepam, Furosemide,
Aspirin 325mg, 10U SQ x1. Patient was admitted for HTN
urgency/emergency with hyperglycemia and transferred to the MICU
for insulin drip, HTN, and fluid management. Vital signs prior
to transfer 161/79 86 19 100%2L.
In the ICU she was placed on insulin drip with normalization
of ion gap and was transitioned to her home glargine and ISS,
diabetic diet and D5 1/2NS+20K. She was seen by [**Last Name (un) **] this
morning who recommended q2-4h FSBG, home glargine 20U QAM and an
increased humalog sliding scale.
Her [**Last Name (un) **] pressure was controlled on her home regimen with
goal BP in 140-150. Her lisinopril and furosemide were held in
the context of [**Last Name (un) **]. Her renal injury was treated with gentle
hydration and Cr remained stable. Her mild hypoxia in the ED
resolved in the MICU, patient was transferred to the floor on
room air. She was continued on all of her other home
medications.
Past Medical History:
- T1DM since age 3, c/b peripheral neuropathy and gastroparesis,
followed by [**Last Name (un) **]
- frequent DKAs, last at [**Hospital3 3583**] [**2-21**]
- HTN
- Anemia of chronic disease
- Hypothyroidism
- Diastolic heart failure, followed by Dr. [**First Name (STitle) 437**]
- CKD, unknown etiology, baseline 1.3-1.8 since [**1-/2150**]
- Depression
- Anxiety
- H/o perirectal abscess
- Eating disorder, bulimia
- Bacterial overgrowth
- osteopenia
- back fracture s/p a fall
- h/o stress fracture in right 4th metatarsal
- h/o bacteremia from PIV [**3-/2150**]
- menometrorrhagia
- ovarian cyst, followed by Dr. [**First Name (STitle) **]
- Recent Cataract Surgery
Social History:
- lives with parents in [**Location (un) 8072**], MA
- worked as CNA at [**Hospital3 **] facility but has not worked
for several months
- Ex-smoking 0.5 ppd x 4-5 years, quit [**9-/2149**]
- Denies EtOH
- Denies IVDU
- Not sexually active x 3 years. Had 2 partners in the past. No
history of STI.
- Recently started PT for strengthening after a back fracture
and deconditioning
Family History:
- PGF died of MI in his early 70s.
- Mother recently finished treatment for ovarian cancer. Has
neuropathy from chemo
- A Brother and a sister with no medical issues.
Physical Exam:
Admission PE:
VSS: 97.7, 160/80, 84, 20, 98%2L
GEN: Uncomfortable
Pain: 0/10
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE, Right great toe with nail missing and ulcer in nail
bed
NEURO: CAOx3, Non-Focal
.
Discharge PE:
VS: 98.7 193/101 68 16 96% RA
GEN: NAD, resting calmly in bed
HEET: PER not reactive to light [**3-18**] cataract surgery. Sclera
anicteric. O/P clear without erythema or thrush. Mild facial
puffiness.
Neck: No JVD, no LAD
Pul: CTAB, no crackles or wheezes
Heart: RRR, 2/6 SEM loudest at R and L USB, harsh S2, does not
radiate to carotids
Abd: soft, non-tender or distended
Ext: WWP, 1+ pretibial edema. R hallux without nail, no erythema
or exudate at nail bed
Neuro: AOx3, EOMI, face symmetric, gait steady
Pertinent Results:
Labs on admission:
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] WBC-8.6 RBC-3.53* Hgb-9.8* Hct-28.3*
MCV-80* MCH-27.8 MCHC-34.7 RDW-14.9 Plt Ct-182
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] Neuts-85.1* Lymphs-12.1* Monos-1.6*
Eos-0.5 Baso-0.6
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] PT-11.9 PTT-23.9 INR(PT)-1.0
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] Glucose-383* UreaN-47* Creat-2.7* Na-136
K-4.5 Cl-95* HCO3-24 AnGap-22*
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] ALT-34 AST-37 AlkPhos-107* TotBili-0.4
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] Lipase-22
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] cTropnT-0.07*
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] proBNP-8244*
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] Albumin-3.8 Calcium-9.8 Phos-2.8 Mg-2.3
[**2150-8-3**] 11:30AM [**Month/Day/Year 3143**] HCG-<5
[**2150-8-3**] 05:16PM [**Month/Day/Year 3143**] Glucose-395* Na-137 K-4.0 Cl-100
calHCO3-24
[**2150-8-3**] 11:46AM [**Month/Day/Year 3143**] Glucose-363* Na-135 K-4.4 Cl-97*
calHCO3-23
[**2150-8-3**] 11:46AM [**Month/Day/Year 3143**] Hgb-9.8* calcHCT-29
.
CHEST (PORTABLE AP) Study Date of [**2150-8-3**] 12:24 PM
IMPRESSION: Findings compatible with fluid overload.
.
CT HEAD W/O CONTRAST Study Date of [**2150-8-3**] 12:33 PM
Wet Read: SHSf MON [**2150-8-3**] 2:22 PM
No acute intracranial process.
.
Right Foot Xray:
Soft tissues are suboptimally evaluated in the great toe. Also
noted is a
healing non-displaced fracture of the fourth metatarsal shaft.
.
Discharge Labs:
[**2150-8-5**] 06:03AM [**Month/Day/Year 3143**] WBC-6.7 RBC-2.86* Hgb-8.3* Hct-24.1*
MCV-84 MCH-29.0 MCHC-34.5 RDW-15.0 Plt Ct-159
[**2150-8-5**] 06:03AM [**Month/Day/Year 3143**] Glucose-88 UreaN-48* Creat-2.8* Na-141
K-4.6 Cl-107 HCO3-29 AnGap-10
[**2150-8-4**] 08:20AM [**Month/Day/Year 3143**] CK-MB-7 cTropnT-0.17*
[**2150-8-4**] 07:30PM [**Month/Day/Year 3143**] CK-MB-8 cTropnT-0.15*
[**2150-8-4**] 08:21AM [**Month/Day/Year 3143**] %HbA1c-8.0* eAG-183*
Brief Hospital Course:
30F with poorly controlled TIDM c/b gastroparesis and
neuropathy, HTN, CKD, Diastolic CHF who presented to the ED
[**2150-8-3**] with headache and hypertensive urgency found to have
elevated FSBG to 300s, +AG, fluid overload, and [**Last Name (un) **] with unclear
precipitant, admitted to the MICU and stabilized on insulin drip
and antihypertensive, transferred to the floor on home [**Last Name (un) **]
and [**Last Name (un) **] pressure medications.
.
#. DKA/T1DM: Pt's CBGs ranged 400-500s for 1-2 days. Patient was
admitted with CBG of 383 and AG 17. She was admitted to the ICU
for initiation of insulin drip. Her AG normalized following
insulin drip and she was restarted on her home glargine and
sliding scale confirmed with [**Last Name (un) **] consultation. Etiology of
elevated [**Last Name (un) **] sugars remains unclear. [**Name2 (NI) **] infectious w/u
negative. In addition, podiatry felt that her right toe lesion
was not infected. Possible etiologies include poor PO intake and
reduced insulin dosing [**3-18**] vomiting and headache caused by her
high BP. Admission HA1C 8.0. She was discharged with [**Month/Day (2) **]
sugars between 88-139 with keto dip sticks and an emergency
glucagon kit and [**Last Name (un) **] follow up.
.
#. Hypertensive Urgency: Etiology of acute increase in BP
despite medication unclear. [**Name2 (NI) **] likely acute worsening of
chronically progressive diabetic macrovascular disease despite
recent medication increase. HA and N/V likely related to
elevated BP (consistent with prior episodes), CT negative for
acute intracranial process. Patient was restarted on home
verapamil and hydralazine but lisinopril was initially held [**3-18**]
elevated Cr. Her BP was in goal range (SBP 140-150) on transfer
from the ICU but increased to 180/100 on the morning of [**2150-8-5**].
Lisinopril was added back. Pt insisted on discharge despite
elevated [**Date Range **] pressures. The risks and benefits of leaving the
hospital including headache, nausea, worsening heart failure,
worsening kidney function and intracranial hemorrhage were
discussed with the patient; however, patient elected to leave on
her home verapamil, hydralazine and lisinopril with discharge
clinic f/u on Friday [**2150-8-7**].
.
# Acute on Chronic Diastolic HF: Patient's presentation is
consistent with acute on chronic worsening of diastolic CHF (BNP
elevated >8000) with hypertension leading to increased
afterload, reduced filling and pulmonary and peripheral edema
that also likely contributed to patient's renal injury. Patient
was initially volume overloaded and received lasix in the ED and
ICU. On transfer to the floor patient appeared euvolemic with
clear lung exam and no peripheral edema so lasix was held in
light of her worsening renal function. This can be re-addressed
at [**Hospital 1944**] clinic appointment.
.
# Acute on Chronic Renal Insufficiency: Pt's Cr was 1.0 in
[**1-/2150**] worsening to 1.8 in the past 6 months, elevated to 2.8
on admission. Unclear etiology. Renal ultrasound [**3-/2150**] showed
worsening parenchymal disease, UPEP was normal. Most likely
multifactorial namely acute pre-renal azotemia (admission BUN:Cr
~20:1) [**3-18**] hypertension, poor PO, and osmotic diuresis from DKA,
coupled with sub-acute worsening of intrinsic renal disease [**3-18**]
T1DM and HTN. Pt initially received gentle lasix diuresis to
euvolemia. Urine output remained adequate, u/a positive for
glucose, ketones and protein, negative for infection. Her
lisinopril was initially held but then restarted as her BP
elevated. Her outpatient nephrologist was contact[**Name (NI) **] and will
follow up with her one week after discharge.
.
# Elevated troponin: Pt had troponin elevated to 0.07 on
admission most likely secondary to demand ischemia from
increased afterload in hypertensive urgency and worsened by
decreased renal clearance. Pt was asx with negative EKGs;
however, troponins were trended given her high risk as a
diabetic and possibility of atypical chest pain with neuropathy.
Repeat troponins stablized, CK-MB were trended and negative.
.
#. Hypoxia: Mild hypoxemia in the ED in the context of patient
anxiety as well as hypertension, increasing afterload on chronic
diastolic HF (BNP >8000) leading to pulmonary vascular
congestion (confirmed on CXR). Oxygenation improved on arrival
in the MICU, where she received mild lasix diuresis, and
resolved on arrival to the floor.
.
# Rt Toe Lesion: Toe showed no signs of drainage or pus, no
erythema noted. FXR was negative for osteo. Podiatry consulted
and recommended dry sterile dressing with clinic follow up if
patient developed symptoms.
.
# Cataracts: Continued on Prednisone, vigamox and ciprofloxacin
eye gtt
.
# Hypothyroidism: Continued on home synthroid dose.
.
# Depression/Anxiety: Mood stable. Continued on Fluoxetine and
risperdone.
.
# Neuropathy: continued home gabapentin
.
# Gastroparesis: Diabetic diet with home reglan PRN.
.
# Code: FULL CODE
.
# Transitional Issues:
- patient to follow-up in post discharge clinic for BP and
glycemic control monitoring
- will need electrolytes checked at post discharge clinic as
well
- volume status and renal function will need assessment at post
discharge clinic as well, as her lasix was held on discharge,
may need to be restarted
- patient provided with number for podiatry for right toe lesion
if any signs of worsening
Medications on Admission:
FLUOXETINE - (Prescribed by Other Provider: [**Name Initial (NameIs) 16471**]) - 40 mg
Capsule - 2 Capsule(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 3
Tablet(s) by mouth qday
GABAPENTIN - (Dose adjustment - no new Rx) - 300 mg Capsule - 1
Capsule(s) by mouth twice a day
HYDRALAZINE - (Dose adjustment - no new Rx) - 10 mg Tablet -
three Tablet(s) by mouth four times a day
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 100 unit/mL Cartridge - 20units/ day
once a day
INSULIN GLULISINE [APIDRA] - (Prescribed by Other Provider) -
100 unit/mL Cartridge - per sliding scale as needed
LEVOTHYROXINE - 100 mcg Tablet - 1 Tablet(s) by mouth DAILY
(Daily)
LISINOPRIL - (Prescribed by Other Provider) (On Hold from
[**2150-4-29**] to unknown for elevated Cr) - 10 mg Tablet -
Tablet(s)
by mouth
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth before dinner
RISPERIDONE - (Prescribed by Other Provider: [**Name Initial (NameIs) 16471**]) - 0.5 mg
Tablet - 1 Tablet(s) by mouth HS (at bedtime)
VERAPAMIL - 360 mg Cap,Ext Release Pellets 24 hr - 1 Cap(s) by
mouth at bedtime
Medications - OTC
ASPIRIN [ASPIR-81] - (OTC) - 81 mg Tablet, Delayed Release
(E.C.) - Tablet(s) by mouth
CALCIUM CARBONATE-VIT D3-MIN - (Prescribed by Other Provider) -
600 mg-400 unit Tablet - 1 Tablet(s) by mouth qday
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - 2,000 unit Capsule -
1
Capsule(s) by mouth qday start daily after you finish the 8
weeks
replacement
COMPRESSION SOCKS, MEDIUM [DIABETIC SOCKS MEDIUM] - Misc -
apply first thing in the AM daily
DIGESTIVE ADVANTAGE IBS OR PEARL IC - (OTC) - - 1 capsule or
tablet once a day
FERROUS GLUCONATE - 240 mg (27 mg iron) Tablet - 1 Tablet(s) by
mouth three times a day do not take with levothyroxine; take
with
colace
Eye Drops:
Pred Forte drops Directions: 1 gtt qid OS
vigamox Directions: 1 qtt qhs
Discharge Medications:
1. Vigamox 0.5 % Drops Sig: One (1) Ophthalmic qHS ().
2. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. risperidone 0.25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
9. hydralazine 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
10. verapamil 180 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q24H (every 24 hours).
11. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day).
12. ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic QHS
(once a day (at bedtime)).
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day.
17. Humalog 100 unit/mL Solution Sig: 0-10 units Subcutaneous as
per sliding scale.
18. Keto-Diastix Strip Sig: [**2-15**] Miscellaneous three times a
day as needed for Please check your urine for ketones using the
stick when you feel ill, are nauseous or vomiting or have missed
a dose of your insulin: If your urine is positive for ketones
please call your doctor. .
Disp:*1 box* Refills:*2*
19. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
20. prednisolone acetate 1 % Drops, Suspension Sig: One (1) OS
Ophthalmic QID (4 times a day).
21. Glucagon Emergency 1 mg Kit Sig: One (1) emergency kit
Injection as needed for low [**Month/Day (2) **] sugar.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Hypertensive urgency
2. Diabetic Ketoacidosis
.
Secondary diagnosis
1. Acute on chronic kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You came in with high [**Hospital1 **] sugars, and high
[**Hospital1 **] pressure, which caused nausea, vomiting and some damage to
your kidneys. We admitted you to the intensive care unit so that
we could give you continuous insulin and carefully monitor your
[**Hospital1 **] sugars. We also gave you medications to decrease your
[**Hospital1 **] pressure and fluids to help your kidneys. Your sugars
improved on the insulin and, with the help of your doctors [**First Name8 (NamePattern2) 767**] [**Name5 (PTitle) 4372**] [**Name5 (PTitle) **], we transitioned you to your home [**Name5 (PTitle) **]
medicines.
Your [**Name5 (PTitle) **] pressue slightly improved, but remained elevated
on discharge. We discussed that we would prefer to keep you in
the hospital given your elevated [**Name5 (PTitle) **] pressure, but you decided
against this. We discussed the risks of leaving the hospital
with an elevated [**Name5 (PTitle) **] pressure with you and you felt that you
still would like to leave.
.
On discharge, please continue to hold your furosemide (lasix)
and address this on Friday, during your post discharge clinic
appointment.
.
Please continue to bandage your toe in dry sterile gauze as the
podiatry doctors have [**Name5 (PTitle) **] during your admission. You can
continue to care for the wound yourself but please call them at
([**Telephone/Fax (1) 4335**] if you develop pain, redness, swelling or
drainage from the toe.
.
MEDICATION CHANGES:
- hold lasix until post discharge appointment
.
Your sliding scale insulin will be as below:
-------- Breakfast Lunch Dinner Bedtime
71-110: 3 3 3 0
111-160: 4 4 5 0
161-210: 5 6 6 0
211-260: 6 7 7 0
261-310: 6 8 8 2
311-360: 7 9 9 2
[**Telephone/Fax (2) 36191**]
[**Telephone/Fax (2) 36192**]0 3
.
Please seek medical attention for worsening nausea, vomiting,
inability to take oral intake, high [**Telephone/Fax (2) **] sugars, or any other
concerning symptoms. Please measure your urine ketones using the
keto dip sticks if you feel unwell and call your doctor if your
urine is positive for ketones.
Followup Instructions:
Please attend the following appointments below:
.
Department: [**Hospital3 249**]
When: FRIDAY [**2150-8-7**] at 8:20 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC/ Dr. [**Last Name (STitle) **] [**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 appointment is for follow up to your hospitalization.
You will then be connected to your Primary Care provider after
this visit.
.
Department: [**Hospital3 249**]
When: THURSDAY [**2150-8-13**] at 11:00 AM
With: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2150-8-19**] at 9:30 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2150-10-15**] at 8:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please make an appointment with your outpatient nephrologist Dr
[**First Name (STitle) 10083**] next week. You can call his office at ([**Telephone/Fax (1) 817**].
Completed by:[**2150-8-6**]
|
[
"403.00",
"250.63",
"707.15",
"V58.67",
"428.0",
"585.2",
"536.3",
"411.89",
"250.13",
"244.9",
"300.4",
"428.33",
"366.9",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16833, 16839
|
7316, 12292
|
346, 353
|
17007, 17007
|
5284, 5289
|
19460, 21167
|
4292, 4462
|
14708, 16810
|
16860, 16860
|
12737, 14685
|
17158, 18664
|
6830, 7293
|
4477, 4739
|
18684, 19437
|
4753, 5265
|
242, 308
|
381, 3188
|
16879, 16986
|
5303, 6814
|
17022, 17134
|
12315, 12711
|
3210, 3881
|
3897, 4276
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,586
| 155,606
|
33538
|
Discharge summary
|
report
|
Admission Date: [**2194-5-19**] Discharge Date: [**2194-5-26**]
Date of Birth: [**2158-5-18**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**Known firstname 2724**]
Chief Complaint:
neck pain
Major Surgical or Invasive Procedure:
Posterior cervical fusion
History of Present Illness:
HPI: Mr. [**Known lastname 41766**] is a 36 yo M who was transferred from an OSH
after
a MCV. Per EMS report, he was unrestrained and found
self-ejected
from the car. He was noted to have + EtOH with slurred speech at
the scene. He was placed in a C-Collar and taken to an OSH where
he was found to have a C7 fracture. He was given Narcan for
drowsiness which improved his mental status. Later in his course
at the ED he was given Ativan 1mg x 2 and then 4 mg of morphine.
He was transferred here for further evaluation.
In our ED, he was very drowsy and was given Narcan again with
good results. Afterwards, however he stated that he was very
anxious and had pain "all over". He requested Dilaudid as
morphine makes him too sleepy.
Mr. [**Known lastname 41766**] states that he has been in detox for alcohol for the
last 4 days and decided to leave today, prior to discharge
because "I was going crazy". He states that he typically drinks
about 6 beers or 2 "40's" per night as well as a "pint". He is
uncertain of how much he drank this evening. He denies having
taken other drugs tonite but states that he has used heroin in
the past. In the ED, the patient was found to have a small blue
bag with a white power in it. The patient states he is not sure
what is in it, "I don't remember".
Past Medical History:
PMHx:
-polysubstance abuse, IVDU
-denies DT's
-HCV
-Asthma
-Anxiety
-GERD
-HTN
Social History:
Social Hx: polysubstance dependance as above but denies ; +
tobacco
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
O: T: AF BP: 104/58 HR: 86 R 18 O2Sats 99% on 15L
Gen: WD/WN, anxious, shaking arms and legs asymmetrically and
requesting Dilaudid
Neck: in hard collar
Lungs: CTA bilaterally anteriorly
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, anxious but cooperative with
exam
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5
Sensation: pt thinks sensation is intact to light touch but is
very anxious and not certain
Reflexes: areflexic but very anxious and all muscles are
contracted during exam despite repeated attempts to relax him
Toes downgoing bilaterally
Pertinent Results:
CT C-spine: Nondisplaced fractures through the pedicles at C7
bilaterally, with extension into the transverse processes. No
evidence of vertebral artery or other vascular injury. Recons
are
pending.
5.6\ 12.7 /273
36.4
Tox screen + benzos, opiates and EtOH
PT: 12.1 PTT: 24.7 INR: 1.0
Fibrinogen: 212
Na:141 K:4.2 Cl:104 TCO2:22 Glu:76 Lactate:1.4
Brief Hospital Course:
Pt was admitted to the trauma service and monitored closely in
the ICU. MRI of c-spine showed ligamentous injury. He was kept
in a hard collar at all times. On HD#2 he was transferred to
neurosurgery service and the floor. He was pre-oped for the OR.
On [**2194-5-22**] he was brought to the OR where under general
anesthesia a posterior cervical fusion was performed. He
tolerated this procedure well, was extubated, transferred PACU
and then to floor when stable. He was given pain medication by
PCA and ultimately transitioned to PO. Diet and activity were
advanced. Foley was removed. Drain was removed POD#2. Staples
were clean/dry/intact. He remained in Aspen collar.He was
evaluated by PT and was cleared for discharge to home. Pt agreed
with this plan.
Medications on Admission:
Medications prior to admission:
trazodone, Advair, Claritin, lisinopril, Xopenex, Nasonex,
Zantac
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**1-22**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on pain med.
Disp:*60 Capsule(s)* Refills:*1*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-22**]
Inhalation q4-6h prn ().
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*80 Tablet(s)* Refills:*0*
11. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks: 1 [**Hospital1 **] for 1 week, then 1 qd for 1 week then
dc.
Disp:*21 Tablet(s)* Refills:*0*
12. Methocarbamol 750 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
bilateral C7 facet fracture
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up / begin daily showers [**2194-5-26**].
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? You are required to wear cervical collar as instructed
?????? You may shower briefly without the collar
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
* You may not drive while in cervical collar.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN [**7-31**] DAYS FOR REMOVAL OF YOUR
STAPLES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT
Completed by:[**2194-5-26**]
|
[
"305.90",
"805.07",
"300.00",
"493.90",
"070.54",
"401.9",
"530.81",
"305.00",
"305.1",
"E815.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"03.53",
"81.63",
"81.03",
"77.79"
] |
icd9pcs
|
[
[
[]
]
] |
5362, 5368
|
3120, 3886
|
294, 322
|
5440, 5464
|
2736, 3097
|
6931, 7205
|
1847, 1851
|
4035, 5339
|
5389, 5419
|
3912, 3912
|
5488, 6908
|
1881, 2150
|
3944, 4012
|
245, 256
|
350, 1644
|
2165, 2717
|
1666, 1746
|
1762, 1831
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,166
| 149,440
|
44246
|
Discharge summary
|
report
|
Admission Date: [**2158-4-26**] Discharge Date: [**2158-4-28**]
Date of Birth: [**2076-9-5**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
bradycardia
Major Surgical or Invasive Procedure:
[**Company 1543**] DDD Sensia pacemaker placement via cephalic vein
History of Present Illness:
81 yo M w/ HTN, HL, DM type 1 (A1C 9.4%), bladder cancer,
dementia and long standing history of RBBB/LAFB who now presents
to the ED with weakness and malaise, found to be in CHB but
asymptomatic, now being transferred to CCU for observation after
another episode lasting 30 mins w/ 6 sec. pause s/p R
transcutaneous pacer.
.
Pt was in USOH until afternoon of the day of admission, when
after eating lunch, he noted a sensation of nearly passing out.
He sat down with some improvement in sx. Thereafter, he reports
feeling generalized weakness and fatigue. He returned home and
continued to have similar sensation of near faintness. After
three more similar episodes and continuing to feel ill after
laying flat, EMS was called. His wife notes that over the past
2mo or so, he has reported occasional sx of vision going
[**Doctor Last Name 352**]/black intermittently, lasting seconds with a sensation of
lightheadedness. He has not had frank syncope, no hx of
seizures. No CP, SOB, though does note feelings of SOB when
laying flat, that improves with clearing of his nose. At times
reports awakening from SOB, that also improves w/ clearing of
his nose. He has chronic nasal congestion. No recent med
changes.
.
Upon arrival, his BP was wnl by report and HR was noted to be
30-40s, with high degree AV block. He was transferred to [**Hospital1 18**]
where upon arrival he was noted to have a conversion to his
usual rhythm spontaneously, SR w/ RBBB/LAFB, however within ~
1hr, was found to be again in 3:1 AV block. This presented with
an asymptomatic six second pause. Due to recurrence, he
underwent R temporary pacer wire placement in the ED and prior
to completion of placement, he converted to SR again. At time
of transfer, his VS were HR 72, BP 161/78, RR10, 95-98%RA. He
received only fentanyl/midaz for sedation. Labs and imaging
significant for Cr of 1.3 and an unremarkable CXR.
.
In the CCU, VS were 60 157/64 12 96% RA. He c/o of a right
sided HA w/o vision changes. Per fellow, pacer was
intermittenly capturing at 5 amps.
.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains. He has intermittent
cough. No recent fevers, chills or rigors. No exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, ankle edema, palpitations, syncope or
presyncope.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes type 1, Dyslipidemia,
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none until today
3. OTHER PAST MEDICAL HISTORY:
- Diverticulosis-
- Colon polyps on colonoscopy in [**2156**].
- Memory loss
- Bladder cancer
- vascular vs. mixed dementia with paranoid delusions apparent
but improved
- chronic constipation with motility disorder associated with
bloating, distention, and significant diverticulosis
- Sciatica
Social History:
perOMR and confirmed.
Family History:
Lives with his wife in a single-floor condominium. He worked as
a businessman distributing hardware and building materials. He
later did volunteer work in [**Country **]. He also served in the army
during
World War II.
Physical Exam:
On admission:
GENERAL: NAD. Oriented x3. Mood, affect appropriate. DOWb
intact.
HEENT: NCAT. Sclera anicteric. arcus senilis, conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, R temp wire in place, unable to assess JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, physiologically split S2. + S4.
LUNGS: No chest wall deformities. CTA laterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Brief Neuro: PERRL, symmetric face, V intact, tongue midline,
palate symmetric as is shoulder shrug. EOMI, no nystagmus, mild
upgaze limitation.
Paratonia, slight cogwheeling in R elbow, otherwise nl strength
and tone. Toes down. Intact to LT.
On discharge: unchanged
Pertinent Results:
Labs on admission:
[**2158-4-26**] 05:15PM BLOOD WBC-7.5 RBC-3.81* Hgb-12.1* Hct-36.3*
MCV-95 MCH-31.6 MCHC-33.2 RDW-12.9 Plt Ct-235
[**2158-4-26**] 05:15PM BLOOD Neuts-66.4 Lymphs-22.9 Monos-5.3 Eos-5.0*
Baso-0.4
[**2158-4-26**] 05:15PM BLOOD PT-12.9 PTT-25.1 INR(PT)-1.1
[**2158-4-26**] 05:15PM BLOOD Glucose-364* UreaN-36* Creat-1.3* Na-140
K-4.7 Cl-105 HCO3-27 AnGap-13
[**2158-4-27**] 06:00AM BLOOD ALT-17 AST-17 LD(LDH)-171 AlkPhos-70
TotBili-0.6
[**2158-4-26**] 05:15PM BLOOD Calcium-8.9 Phos-2.9 Mg-2.2
[**2158-4-27**] 06:00AM BLOOD TSH-1.8
MICROBIOLOGY: none
OTHER STUDIES:
EKG: Normal sinus rhythm. Left axis deviation. Right
bundle-branch block with left anterior fascicular block.
Compared to the previous tracing of [**2157-3-23**] the frequent
ventricular ectopy is no longer appreciated.
IMAGING:
CXR on admission: FINDINGS: Single AP upright portable chest
radiograph is obtained. Multiple
overlying wires are noted which somewhat limit the evaluation,
though allowing
for this, there is no focal consolidation, effusion, or
pneumothorax. No
signs of congestive heart failure. Cardiomediastinal silhouette
appears
stable with atherosclerotic calcifications at the aortic knob.
Bony
structures are intact.
IMPRESSION: No acute intrathoracic process.
.
TTE: The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild to moderate global left ventricular
hypokinesis (LVEF = 40 %). Right ventricular chamber size and
free wall motion are normal. There are focal calcifications in
the aortic arch. 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 left ventricular inflow pattern
suggests impaired relaxation. There is no pericardial effusion.
.
CXR (prior to discharge): FINDINGS: In comparison with study of
[**4-27**], there is no interval change in the appearance of the heart
and lungs or the pacemaker device. Mild atelectatic changes are
seen, especially at the left base.
Brief Hospital Course:
81 yo M w/ HTN, HL, DM type 1, bladder cancer, dementia and long
standing history of RBBB/LAFB who now presents to the ED with
weakness and malaise, found to be in CHB but asymptomatic,
transferred to CCU for observation after another episode lasting
30 mins w/ 6 second pause, now s/p dual chamber pacemaker
placement.
.
ACTIVE ISSUES
.
# High degree AV block. Likely infra-AV nodal block, at times
it seems to be 1:3 but not consistently so, it appears
paroxysmal given spontanous conversions. On one telemetry strip
he is noted to go into block s/p a VPC with no escape rhythm
with a pause of ~ 6 seconds. Given high degree AV block, IJV
pacer wire was placed, that captured at 5amps w/ a back up rate
of 50. Etiology of this is uncertain, but likely related to
chronically diseased conduction system (given RBBB/LAFB he was
already at high risk of high degree AVB). He is on no nodal
agents abd electrolytes wnl. His sx are most likely due to
block and appear to have been going on for at least a couple of
months (no signs to suggest seizure or posterior circulation
disease). He was monitored on telemetry, with temporary pacer
set at 50bpm, occasionally kicking in. He was taken by the
Electrophysiology service for a dual-chamber pacemaker placement
without complications. He was given a dose of Vancomycin prior
to starting Clindamycin, which he will continue as an outpatient
for 2 additional days. He will be followed-up closely in Device
Clinic and was provided strict instructions on how to care for
his wound/pocket s/p placement.
.
# PUMP: No evidence of CHF, last ECHO w/ concentric LVH and
likely diastolic dysfunction. Unable to assess JVD but has sx
of CHF. He was restarted on valsartan for afterload reduction
once pacer was in place, but it was held initially given
potential for low BPs. TTE showed LVEF of 40% with mild mitral
regurgitation. E/A ratio <1 concerning for diastolic
dysfunction.
.
INACTIVE ISSUES
.
# DM1. Poorly controlled at baseline. He was continued on NPH
at home regimen and SSI.
.
# BPH: He was continued on finasteride and terazosin at home
doses.
.
# Hypertension: Valsartan was initially held, but then
restarted prior to discharge. He was continued on ASA for
primary prevention.
.
# Hyperlipidemia: He was continued on simvastatin at home dose.
.
# Dementia: He was continued on Namenda and Seroquel per home
dosing.
.
# Glaucoma: He was continued on Lumigan per home dosing.
.
# Bladder CA: Work-up is currently in progress as an
outpatient. He will follow-up with his providers.
.
TRANSITIONAL ISSUES
.
# Follow-up: He will follow up with Device Clinic
(electrophysiology) and his providers as previously scheduled.
Medications on Admission:
LUMIGAN - 0.03 % Drops 1 qtt both eyes HS
FINASTERIDE - 5 mg daily
Humalog SS
LUBIPROSTONE 24 mcg HS
NAMENDA 5 mg HS
OMEPRAZOLE 20 mg HS
QUETIAPINE 12.5 mg HS
SIMVASTATIN 10 mg daily
TERAZOSIN 5 mg HS
VALSARTAN 160 mg daily
ASPIRIN 325mg HS
BISACODYL 5 mg AM
VITAMIN D3 1,000 unit daily
NPH INSULIN 35 U in AM and 6 u in pm
MIRALAX 17g nightly
Discharge Medications:
1. Lumigan 0.01 % Drops Sig: One (1) drop Ophthalmic QHS (once a
day (at bedtime)).
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. insulin lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous four times a day: per hoe sliding scale.
4. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
Five (35) units Subcutaneous once a day: 6 units at night.
5. lubiprostone 24 mcg Capsule Sig: One (1) Capsule PO at
bedtime.
6. memantine 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
8. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. terazosin 5 mg Capsule Sig: One (1) Capsule PO at bedtime.
11. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
13. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO at bedtime as needed for constipation .
16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
17. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 2 days.
Disp:*16 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Complete heart block
hypertension
diabetes mellitus type 1
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had episodes of dizziness that we think is caused by
complete heart block, a slow rhythm of the heart. A pacemaker
was placed to prevent your heart from beating slowly and should
prevent these severe episodes. You will need to take antibiotics
for two days after you get home and limit your activity as
described in the discharge sheet you were given. You will return
to the pacemaker device clinic in 1 week to have the pacemaker
site checked. You will need to keep the dressing on for 3 days,
do not get the dressing wet. After 3 days you can take it off,
leaving the tape strips in place. You can then shower and pat
the area dry. Do not soak the area by swimming or taking baths
until after the device clinic check.
.
We made the following changes in your medicines:
1. Start taking clindamycin four times a day to prevent an
infection at the pacer site
2. Start taking tylenol as needed for pain at the pacer site
Followup Instructions:
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2158-7-5**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GERONTOLOGY
When: THURSDAY [**2158-9-21**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2158-9-28**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 277**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"290.42",
"564.09",
"272.4",
"600.00",
"426.0",
"401.9",
"428.33",
"188.8",
"562.10",
"250.01",
"V58.67",
"428.0",
"724.3",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72",
"37.78"
] |
icd9pcs
|
[
[
[]
]
] |
11497, 11555
|
6898, 9591
|
282, 352
|
11673, 11673
|
4701, 4706
|
12771, 13725
|
3496, 3719
|
9985, 11474
|
11576, 11652
|
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|
11824, 12748
|
3734, 3734
|
3024, 3112
|
4671, 4682
|
231, 244
|
380, 2913
|
5535, 6875
|
11688, 11800
|
3143, 3441
|
2935, 3004
|
3457, 3480
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,954
| 119,548
|
6256
|
Discharge summary
|
report
|
Admission Date: [**2174-8-8**] Discharge Date: [**2174-8-23**]
Date of Birth: [**2125-1-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Darvon
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2174-8-10**]: TUNNELLED CATH PLACEMENT SC
[**2174-8-17**] CABG x 3 (LIMA to LAD, lesser saph VG to OM, lesser
saph VG to RCA)
History of Present Illness:
49 y/o female with very complex past medical histroy, c/o
shortness of breath, with known CAD with previous PCI to LAD.
She initially presented to OSH with CHF and NSTEMI. Then
transferred to [**Hospital1 18**] for further care.
Past Medical History:
Type I DM w/ neuropathy, nephropathy (failing transplant),
bilateral retinopathy s/p retinal detachment.
Failing kidney transplant
- most recent creatinine of 5.3
- pt was scheduled for repeat transplant on [**2174-8-23**] but was
cancelled because of her PVD history
HTN
significant PVD history with multiple prior LE bypass surgeries
Prior GI bleeding on ASA and plavix
CAD s/p MI, s/p LAD stents
Meningitis
chronic anemia
- likely multifactorial due to renal failure, hx of antral
erosions and mild esophagitis on EGD
CVA x 2
hyperlipidemia
Social History:
Two children in their 20s. She lives with her boyfriend. She
formerly worked at the post-office. She has a 30-pack-year
history of smoking and quit in [**2165**]. She does not drink
alcohol.
Family History:
Her mother is alive at age 77 without significant medical
problems. [**Name (NI) **] father died at age 76 of sepsis. He also had
type 2 diabetes and prostate cancer. She has a sister age 51
and another sister age 41 who has type 1 diabetes. There is no
family history of blood disorders or colon cancer.
Physical Exam:
VS: T 96.0, BP 154/65, P98, RR 20, SaO2 93%2L
Pt reported weight and height: 152 lbs; 5'5''
Gen: WDWN middle aged woman in NAD. Oriented x3. Mood slightly
depressed, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple without JVD
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. III/VI systolic ejection murmur hear best at
LUSB, No r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased breath sounds
at the bases bilaterally 1/4th of the way up, with associated
dullness to percussion. No wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: 1+ edema bilaterally half to half way pt from snkle to
knee. No cyanosis.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**8-11**] Cardiac Cath: 1. Coronary angiography in this right
dominant system revealed three vessel coronary artery disease.
The LMCA was noted to be a short almost cloacl vessel and was
heavily calcified. The LAD had diffuse disease proximally and a
70& proximal stent edge restenosis in the mid LAD. Septal
collateral were noted to the distal RCA. The LCX had a near
ostial heavily calcified 90% lesion with proximal 40% stenosis
before OM!. Diffuse palquing was noted in OM2 and a 50% stenosis
was noted near the takeoff of AV groove CX from OM2. OM
collaterals to distal RCA were noted as well. The RCA was small
and occluded proximally. 2. Resting hemodynamics revealed mildly
elevated left sided filling pressures with an LVEPD of 16 mmHg.
There was moderate systolic arterial hypertension with an SPB of
176 mmHg. The cardiac index was preserved at 3.94 L/min/m2.o
evidence of aortic stenosis as there was no pressure gradient on
pullback from LV to aorta. There was no evidence of mitral
stenosis upon analysis of PCWP and LVEDP.
[**8-12**] CNIS: There is less than 40% stenosis within bilateral
internal carotid arteries.
[**8-12**] Vein Mapping: Lesser saphenous veins patent bilaterally
with diameters described as above and no visualization of the
greater saphenous veins bilaterally.
[**8-17**] Echo: Pre bypass: The left atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy. There is
mild regional left ventricular systolic dysfunction with mild
inferior hypokinesis. The remaining left ventricular segments
contract normally. Right ventricular chamber size and free wall
motion are normal. There are multiple severe complex (>4mm)
atheroma in the aortic arch and descending thoracic aorta.
Epiaortic scans of the intended sites of proximal anastamosis,
cannulation, and cross clamp are clear. A long axis epiaortic
pull through from valve up confirms substatial plaque in the
arch, but not at the above mentioned sites..The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Trace eccentric
aortic regurgitation is seen. The annular portion of the
posterior leaflet of the mitral valve is partialy calcified but
the tip and central portion move and coapt well.. With
provacative manuvers and sbp 150's, Mild to moderate ([**12-14**]+)
mitral regurgitation is seen. Vena contracta meansures 4 mm at
worst. There is a small pericardial effusion. There are
pericardial calcifications. Post Bypass: Patient is A paced, on
epinephreine, phenylepherine infusions. LVEF remains 50% with
mild inferior hypokinesis. Note is made of moderate anteroseptal
hypokinesis which improves with nitroglycerin. MR is now mild.
Aortic contours are intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
[**8-21**] Chest CT: 1. New tiny left anterior pneumothorax. 2. Small
bilateral pleural effusions with associated compressive
atelectasis. 3. Sub 5 mm pulmonary nodules. In the absence of
known malignancy or smoking, no further followup is necessary.
4. No retroperitoneal hematoma. 5. Prominent ovaries.
Questionable soft tissue nodule in the left ovary. Further
evaluation with pelvic ultrasound is recommended.
[**2174-8-9**] 05:50AM BLOOD WBC-9.7 RBC-3.36* Hgb-8.8* Hct-26.9*
MCV-80*# MCH-26.1* MCHC-32.5 RDW-16.6* Plt Ct-373
[**2174-8-15**] 06:00AM BLOOD WBC-12.7* RBC-3.76* Hgb-10.4* Hct-31.5*
MCV-84 MCH-27.7 MCHC-32.9 RDW-16.9* Plt Ct-337
[**2174-8-22**] 05:06AM BLOOD WBC-10.0 RBC-3.31*# Hgb-9.9*# Hct-28.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-15.9* Plt Ct-268
[**2174-8-9**] 05:50AM BLOOD PT-12.4 PTT-26.4 INR(PT)-1.1
[**2174-8-21**] 05:15AM BLOOD PT-13.6* PTT-32.4 INR(PT)-1.2*
[**2174-8-9**] 05:50AM BLOOD Glucose-91 UreaN-105* Creat-6.3* Na-143
K-3.3 Cl-102 HCO3-22 AnGap-22*
[**2174-8-16**] 05:00AM BLOOD Glucose-260* UreaN-36* Creat-3.4* Na-138
K-4.0 Cl-100 HCO3-28 AnGap-14
[**2174-8-23**] 01:43PM BLOOD Glucose-258* UreaN-27* Creat-3.7*# Na-136
K-4.5 Cl-107 HCO3-19* AnGap-15
[**2174-8-23**] 01:43PM BLOOD Calcium-8.4 Phos-3.2# Mg-2.1
Brief Hospital Course:
Pt was admitted to the [**Hospital1 1516**] service on [**8-8**] )cardiology floor)
at [**Hospital1 18**] for work-up and treatment of CHF exacerbation, NSTEMI,
and her failing renal transplant.
.
Pt was found to be volume overloaded with bilateral pleural
effusions and peripheral edema. The decision was made to not
continue levofloxacin since it appeared very unlikely to be
infection (afebrile, no cough). CHF was treated with agressive
diuresis with Furosemide 120 mg IV BID as well as Metolazone 2.5
mg PO BID with the goal of diuresis of at least 1L/day which she
exceeded by about 1L on the first 2 days with decreases in her
weight by about 2kg per day as well (for 2 days). Clinically, pt
improved also coming off oxygen at then end of HOD#2.
.
Pt was admitted with what was thought consistent with NSEMI in
the setting of previously known CAD s/p MI, s/p LAD stents and
acute on chronic renal failure with failing renal transplant.
Pt was monitored on telemetry and cardiac enzymes were followed.
The enzymes consistently trended downward indicating that pt
had an NSEMI prior to presentation to the OSH. The initial
approach was medical management as there was an obvious concern
over the patients renal function. A renal transplant consult
was placed; their recommendation was to initiate HD, as there
was no reason to delay (now that transplant was not going to
happen) and had a fragile volume window. Pt had tunnelled cath
placed on [**8-12**], with HD initiated that same day.
The following day pt had coronary catheterization showing three
vessel coronary artery disease, including a near ostial LCX
lesion not favorable for PCI, as one would have to stent back
into the LMCA jailing the LAD, and "LMCA" supplies the entire
LV. HD was planned post-coronary cath but as pt appeared
depressed about the news that she would have to have a CABG and
tired from a long day. HD was performed early the following
morning and was from thereon continued qd for 2 days before
transitioning to qod HD. After initiation of HD pt was taken
off standing diuretics and given one-time doses as needed for
diuresis.
.
The night of the coronary cath pt had an episode of nausea and
vomiting associated with some diaphoresis. EKG with ?ST
elevations in V2, V3. Heparin was started and pt had not
further episodes. Cardiac enzymes were still downtrending and
so it likley was not an ACS. Heparin was stopped after 48 hrs
since there was no active concern over ACS and pt had developed
a small R groin hematoma, and a mild nosebleed with 6pt hct drop
after coronary cath. 2 units of blood was given with good
effect prior to stopping heparin treatment. HCt remined stable
at around 30 from this pt on until surgery.
.
Regarding her failing kidney transplant, pt was continued on
cellcept 1000mg po bid, and Rapamune 4 mg PO QAM despite
initiating HD in the case there was any chance that her kidneys
were going to recover.
.
Pt was also hypertensive throughout much of the hospital stay
despite clonidine patch, 100mg po bid of metoprolol, and 60 mg
po bid of nifedipine. Her metoprolol was increased to 125 mg po
bid on HOD#6. On this dose her supine bp was 140s/50-60s and
standing bp 110s/50s. BP meds were titrated to this standing bp
given her hx of autonomic neuropathy and orhtostatic
hypotension.
.
Regarding her chronic anemia, the etiology was thought to likely
be due to renal failure. Aside from the transient hct drop as
mentioned above after the cath, her hct remained at about her
baseline of 30. On HOD#5, epogen 6000 units given at the time
of HD was initiated.
Referred to Dr. [**Last Name (STitle) 914**] for CABG and vein mapping showed the
presence of bilat. lesser saph, veins.Underwent CABG on [**2174-8-17**].
Transferred to the CVICU in stable condition on nitroglycerin,
propofol and epinephrine drips. Extubated early the next
morning. Renal sevice continued to follow pt.for her dialysis
management. Transferred to the floor on POD #1 to begin
increasing her activity level. Beta blockade titrated and chest
tubes and pacing wires removed without incident.Tranfused 2 u
PRBCs for anemia, but CTA negative for retroperitoneal bleed.A 5
mm pulm. nodule was noted. Mutliple agents titrated for BP
management. Cleared for discharge to home with services on POD
#6. Pt. to make all followup appts. as per discharge
instructions as well as maintaining her outpt. hemodialysis
schedule.
Medications on Admission:
Lasix 120mg IV every 12 hours, Zaroxylin 2.5mg, asa 81,
catapress patch once a week, Lantus 6 units q am, Humalog
sliding scale, Levaquin (for possible pneumonia), Metoprolol
100mg po bid, cellcept 1000mg po bid, Nifedipine 60 mg PO BID,
Zocor 80mg po bid, Rapamune 4 mg PO QAM
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*0*
3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 * Refills:*0*
9. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) for 1 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTUES (every Tuesday).
Disp:*QS 1 month* Refills:*0*
11. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
Disp:*QS 1 month* Refills:*0*
12. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: per sliding scale.
Disp:*QS 1 month* Refills:*0*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
pulmonary nodule
PMH: IDDM, ESRD, CHF, ^chol., PVD, s/p CVA x2 [**2165**], anemia, s/p
GI bleed, NSTEMI [**2172**], DES->LAD, retinopathy, neuropathy,
meningitis, s/p ileo bifem, s/p R profunda-> [**Doctor Last Name **], s/p L fem-[**Doctor Last Name **],
s/p renal transplant-failing, s/p cataract surgery, s/p TAH
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] 2 weeks
Hemodialysis monday, wednesday friday@11AM.
Already scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2174-9-30**] 11:20
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2175-7-24**]
9:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2175-7-24**] 10:00
Completed by:[**2174-9-12**]
|
[
"E849.8",
"410.71",
"428.0",
"E879.0",
"E849.7",
"585.6",
"250.52",
"362.01",
"250.62",
"996.72",
"E878.0",
"414.01",
"996.81",
"357.2",
"584.9",
"440.20",
"428.40",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"38.93",
"39.61",
"39.95",
"36.12",
"36.15",
"88.56",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13124, 13189
|
6846, 11269
|
291, 421
|
13610, 13616
|
2737, 6823
|
13915, 14605
|
1475, 1785
|
11597, 13101
|
13210, 13589
|
11295, 11574
|
13640, 13892
|
1800, 2718
|
232, 253
|
449, 679
|
701, 1246
|
1262, 1459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,132
| 157,699
|
3115
|
Discharge summary
|
report
|
Admission Date: [**2157-2-24**] Discharge Date: [**2157-3-2**]
Date of Birth: [**2087-5-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
CABG x4 [**2157-2-25**] (LIMA to LAD, SVG to Ramus, SVG to OM, SVG to
RCA)
cardiac catheterization [**2157-2-24**]
History of Present Illness:
69 yo male with history of chest discomfort, increasing with
exertion several days ago. Went to OSH and diagnosed with
NSTEMI. Transferred to [**Hospital1 18**] for cath and evaluation.
Past Medical History:
HTN
IMI 20 years ago
NSTEMI
NIDDM
elev. lipids
carpal tunnel syndrome
right knee cartilage problems
anxiety
Social History:
lives alone
works as auto mechanic
rare ETOH
no tobacco use
Family History:
non-contrib.
Physical Exam:
HR 87 RR 16 145/88 right 96% RA sat.
83 kg 64"
NAD
skin/HEENT unremarkable
neck supple, full rROM, no carotid bruits appreciated
CTAB
RRR no murmur
soft, Nt, ND, obese abd, + BS
extrems warm, well-perfused, no edema or varicosities
neuro grossly intact; on bedrest, unable to assess gait
Pertinent Results:
[**2157-3-1**] 07:10AM BLOOD WBC-7.7 RBC-2.89* Hgb-9.0* Hct-25.5*
MCV-88 MCH-31.2 MCHC-35.3* RDW-14.9 Plt Ct-200
[**2157-3-1**] 07:10AM BLOOD Plt Ct-200
[**2157-2-28**] 06:45AM BLOOD PT-12.0 PTT-26.0 INR(PT)-1.0
[**2157-3-1**] 07:10AM BLOOD Glucose-244* UreaN-31* Creat-0.7 Na-137
K-4.2 Cl-100 HCO3-29 AnGap-12
[**2157-3-1**] 07:10AM BLOOD ALT-23 AST-20 LD(LDH)-260* AlkPhos-41
Amylase-31 TotBili-0.9
[**2157-3-1**] 07:10AM BLOOD Albumin-3.4 Calcium-8.8 Phos-2.8 Mg-2.5
[**2157-3-1**] 07:10AM BLOOD VitB12-541 Folate-11.8
[**2157-2-24**] 04:00PM BLOOD %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE
[**2157-3-1**] 07:10AM BLOOD TSH-0.84
RADIOLOGY Final Report
CHEST (PA & LAT) [**2157-3-1**] 12:03 PM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
69 year old man s/p CABG
REASON FOR THIS EXAMINATION:
evaluate effusion
REASON FOR EXAM: S/P CABG followup atelectasis and pleural
effusion.
Comparison is made with prior study dated [**2157-2-27**].
PA AND LATERAL VIEWS OF THE CHEST: Bilateral pleural effusions
are small. There has been interval resolution of bibasilar
atelectasis, the lungs are clear. Cardiac size is top normal.
Post-operative left mediastinal widening is persistent,
attention on this area should be paid in the followup study.
Patient is post-median sternotomy and CABG. There is no
pneumothorax. Cardiac size is top normal.
Findings were discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14777**], nurse practitioner,
at the time of the interpretation of the study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2157-3-2**] 6:10 AM
Cardiology Report ECHO Study Date of [**2157-2-25**]
PATIENT/TEST INFORMATION:
Indication: Chest pain. Dizziness. Hypertension. Shortness of
breath.
Status: Inpatient
Date/Time: [**2157-2-25**] at 09:12
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:01
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aorta - Arch: 2.4 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.2 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 4 mm Hg
Aortic Valve - LVOT Diam: 2.0 cm
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Left-to-right shunt across the
interatrial
septum at rest. Small secundum ASD.
LEFT VENTRICLE: Overall normal LVEF (>55%).
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal
inferoseptal - hypo; mid inferoseptal - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Calcified tips of papillary muscles. No MS.
Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. Results were personally reviewed with the MD
caring for the
patient.
Conclusions:
Prebypass:
1. A left-to-right shunt across the interatrial septum is seen
at rest. A
trivial small secundum atrial septal defect is present.
2. Overall left ventricular systolic function is normal
(LVEF>55%). The basal
and mid portions of the septum appear hypokinetic.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in
the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion.
6. There is no aortic valve stenosis. No aortic regurgitation is
seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
Post Bypass:
1. Biventricular function is preserved.
2. No new aortic or valvular abnormalities are observed.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2157-2-25**] 12:52.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 14778**])
Brief Hospital Course:
Admitted [**2157-2-24**] for cardiac cath which revealed 80% LM, pLAD
70%, CX 80%, RCA 100%. Referred to Dr. [**Last Name (STitle) 914**] for surgical
evlauation and underwent cabg x4 on [**2157-2-25**]. Transferred to the
CSRU in stable condition on phenylephrine and propofol drips.
Extubated that evening and transferred to the floor to begin
increasing his activity level on POD #1. Went into A fib on [**2-27**]
and was treated with amiodarone. Chest tubes and pacing wires
removed without incident. Difficulty voiding requiring foley
reinsertion and started on flomax.Continued to make good
progress and was cleared for discharge to rehab on POD #5. Pt.
to make all follow-up appts. as per discharge instructions. If
BS > 150 for 3 days, the increase lantus to 20 units every
evening [**First Name8 (NamePattern2) **] [**Last Name (un) **] consult. [**Last Name (un) **] also recommends increasing
metformin today, and avandia may be restarted when pt. is
euvolemic.
Medications on Admission:
(unsure of all home meds):
atenolol 50 mg daily
ASA 162 mg daily
glipizide ? dose daily
tranxene 7.5 mg [**Hospital1 **] prn
zocor 80 mg daily
avandia?
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Tablet(s)
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO twice a day for 7 days: for 7
days; then 20 mEq once a day for 7 days.
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: for 7 days, then 200 mg daily ongoing.
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
13. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO DAILY (Daily) for 3 days:
then titrate up to 75 mg daily.
14. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day
for 7 days: for 7 days;then 40 mg daily for 7 days.
15. lantus Sig: Ten (10) units Injection at bedtime: IF BS> 150
for 3 days, the increase lantus to 20 units qhs.
16 . restart avandia when euvolemic.
17. please cover with sliding scale insulin.
18 tranxene 7.5 mg [**Hospital1 **] prn
Discharge Disposition:
Extended Care
Facility:
Five Star at [**Location (un) 1110**]
Discharge Diagnosis:
CAD
MI [**69**] years
NIDDM
HTN
carpal tunnel syndrome
elev. lipids
right knee cartilage problems
anxiety
depression
Discharge Condition:
stable
Discharge Instructions:
may shower over incisions and pat dry
no lotions, creams, or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 14779**] in [**12-14**] weeks
See Dr. [**Last Name (STitle) 11493**] in [**1-15**] weeks
see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14780**] ( therapist) in [**Location (un) 1514**]. Get referral from your
PCP.
Completed by:[**2157-3-2**]
|
[
"414.01",
"410.71",
"997.1",
"401.9",
"427.31",
"788.20",
"250.00",
"300.00",
"272.4",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"88.53",
"39.61",
"36.13",
"88.56",
"36.15",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8849, 8913
|
6018, 6994
|
336, 456
|
9074, 9083
|
1239, 1980
|
9344, 9714
|
895, 909
|
7197, 8826
|
2017, 2042
|
8934, 9053
|
7020, 7174
|
9107, 9321
|
3147, 5922
|
924, 1220
|
280, 298
|
2071, 3121
|
484, 671
|
5957, 5995
|
693, 802
|
818, 879
|
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