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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
14,005
| 193,721
|
17941+17942
|
Discharge summary
|
report+report
|
Admission Date: [**2173-3-11**] Discharge Date: [**2173-3-22**]
Date of Birth: [**2103-5-5**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 60 year old male who
is status post fall and was being worked up for rotator cuff
repair when he had an abnormal electrocardiogram. He has a
history of chronic obstructive pulmonary disease, diet
controlled diabetes mellitus, high cholesterol and
pericarditis. He had an exercise treadmill test on [**2173-3-10**],
which was negative for chest pain but revealed moderate to
severe anterior apical ischemia with an ejection fraction of
54%. He underwent cardiac catheterization on [**2173-3-11**], which
showed left main short nonobstructive, nonobstructive left
anterior descending, heavily obstructed proximal 60%, distal
100% occluded, filled by bridging collaterals, left
circumflex midsection 50% stenosed, right coronary artery
proximal 50% stenosed, left ventricular ejection fraction of
55% with no mitral regurgitation.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Diet controlled diabetes mellitus.
3. High cholesterol.
4. Pericarditis.
5. Back surgery.
6. Carpal tunnel surgery.
7. Transurethral resection of prostate.
8. Hypertension.
MEDICATIONS ON ADMISSION:
1. Ecotrin.
2. Lopressor.
3. Lisinopril.
4. Atorvastatin.
5. Zantac.
ALLERGIES: Codeine which causes nausea and vomiting.
SOCIAL HISTORY: The patient is an ex-smoker and quit 33
years ago.
FAMILY HISTORY: Positive for coronary artery disease. He
has two brothers who both have had coronary artery bypass
grafts.
PHYSICAL EXAMINATION: In general, the patient is alert and
oriented in no acute distress. His neurologic examination is
grossly intact. No carotid bruits noted. Pulmonary - The
lungs are clear to auscultation bilaterally. Cardiac -
Regular rate and rhythm, no murmurs noted. The abdomen is
soft, nontender, nondistended. Extremities - Cool feet,
positive dorsalis pedis and popliteal pulses bilaterally. No
edema and no varicosities.
HOSPITAL COURSE: The patient was admitted on [**2173-3-11**], and
taken to the operating room on [**2173-3-12**], where coronary
artery bypass graft times three was performed.
Postoperatively, the patient required Propofol and
Neo-Synephrine drip. He left the operating room as well with
chest tubes and pacing wires in place. He received four
doses of perioperative Vancomycin as antimicrobial
prophylaxis. The patient initially did quite well and was
started on his postoperative medications of Lopressor and
Lasix. His diet was advanced successfully. His drips were
eventually weaned. His chest tubes and pacing wires were
removed at the appropriate time. The patient was initially
going to leave the Intensive Care Unit on postoperative day
number one but once he arrived to the floor, the patient had
an episode of rapid atrial fibrillation. He received 8 mg of
Lopressor which caused his blood pressure to drop
precipitously. He was then transferred back to the Intensive
Care Unit where he required a Neo-Synephrine drip again and
close observation. The patient subsequently did well and he
was started on Amiodarone and continued on his Lopressor.
While in the Intensive Care Unit, the patient required a unit
of packed red blood cells for acute anemia. When the patient
was adequately stable, he was transferred to the regular
cardiothoracic floor where he continued to do well. He was
seen by physical therapy who were happy with his progress and
eventually cleared him to go home without continuing physical
therapy. The patient was also seen by the Electrophysiology
team regarding his rapid atrial fibrillation. They made
recommendations for anticoagulation and continued Lopressor
and Amiodarone treatment. Over the next couple days, the
patient continued to have short bursts of rapid atrial
fibrillation that would spontaneously break within
approximately two minutes. Finally on [**2173-3-20**], the patient
had another episode of rapid atrial fibrillation although
this episode did not break quickly. He required 10 mg of
Lopressor and 150 mg of intravenous Amiodarone bolus to break
the episode. Electrophysiology again was notified and they
recommended Lopressor 100 mg twice a day, Amiodarone 400 mg
twice a day times five days, Amiodarone 400 mg once daily
thereafter with follow-up in a couple weeks. They also
recommended [**Doctor Last Name **] of Hearts for discharge. They did indicate
that the patient would be safe for discharge.
It is now [**2173-3-20**], and the patient is ready for discharge.
He will likely go home in the morning on [**2173-3-21**], once INR
monitoring and [**Doctor Last Name **] of Hearts are organized. The patient
will be discharged in good condition.
FOLLOW-UP: He is to follow-up with Dr. [**Last Name (STitle) 70**] in four
weeks. He is to follow-up with Dr. [**Last Name (STitle) **] in two weeks and
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17887**] in one to two weeks.
MEDICATIONS ON DISCHARGE:
1. Lopressor 100 mg twice a day.
2. Amiodarone 400 mg twice a day times five days and then
once daily.
3. Coumadin dose daily per recommendations of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 17887**] after daily INR checks.
4. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
5. Atorvastatin 20 mg p.o. once daily.
6. Ranitidine 150 mg p.o. twice a day.
7. Enteric Coated Aspirin 325 mg p.o. once daily.
8. Colace 100 mg p.o. twice a day p.r.n.
The patient may shower but should not take baths. The
patient should not drive while on pain medication. The
patient should avoid strenuous activity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2173-3-21**] 11:16
T: [**2173-3-21**] 12:06
JOB#: [**Job Number 49682**]
Admission Date: [**2173-3-11**] Discharge Date: [**2173-3-25**]
Date of Birth: [**2103-5-5**] Sex: M
Service:
CHIEF COMPLAINT: The patient is a 69-year-old male referred
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for an outpatient cardiac catheterization
secondary to a positive stress test.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 27060**] was referred for
a stress test after having abnormal preoperative EKGs prior
to this workup for rotator cuff surgery. The patient did not
have chest pain or shortness of breath at that time. The
stress test was done on [**2173-3-10**]. During that time, the
patient did have chest pain and the test was stopped due to
fatigue. Nuclear imaging revealed moderate to severe
anteroapical ischemia with an ejection fraction of 54%.
The patient had a catheterization on [**2173-3-11**] at the
[**Hospital6 256**]. The final assessment
was occlusive LAD disease with left circumflex and right
coronary artery disease. At that time, Cardiothoracic
Surgery was consulted.
PAST MEDICAL HISTORY:
1. COPD.
2. Diet-controlled diabetes mellitus.
3. Hypercholesterolemia.
4. Pericarditis.
5. Carpal tunnel surgery in [**2163**].
6. Back surgery in [**2140**].
7. TURP in [**2164**].
8. Hypertension.
PREOPERATIVE MEDICATIONS:
1. Aspirin.
2. Lopressor 25 mg p.o. b.i.d.
3. Lisinopril 40 mg p.o. q.d.
4. Atorvostatin 20 mg p.o. q.d.
5. Zantac 150 mg p.o. q.d.
PHYSICAL EXAMINATION ON ADMISSION: Lungs: Clear to
auscultation bilaterally. Cardiac: Regular rate and rhythm.
No murmurs detected. Abdomen: Soft, nontender,
nondistended. Positive bowel sounds. Extremities: Cool
feet. Positive DP and PT bilaterally. No edema. No
varicosities.
HOSPITAL COURSE: The patient was admitted with the
preoperative diagnosis of coronary artery disease. The
patient was brought to the Operating Room on [**2173-3-12**] and had
a CABG times three. The patient had a LIMA to the LAD, and a
saphenous vein graft to the OM and then to the PDA. Surgery
was performed by Dr. [**Last Name (STitle) 70**] and Dr. [**Last Name (STitle) 7625**]. The patient
was transported to the CSRU in stable condition.
On postoperative day number one, the patient complained of
increased pain which was treated with morphine, Toradol, and
Dilaudid. The patient had his Swan discontinued and was out
of bed and walking.
On postoperative day number two and three, the patient
continued to do well, although had several bouts of rapid
atrial fibrillation which responded to Amiodarone boluses and
Lopressor. At that time, beta blockers and Lasix were
initiated.
On postoperative day number four, the patient's hematocrit
was 24.6 and was transfused 1 unit of packed red blood cells.
On postoperative day number five, the patient was transferred
to the cardiac floor.
On the floor, this patient continued to do well. The
patient's physical therapy level quickly returned to a level
V. The patient had numerous bouts of rapid atrial
fibrillation into the 150 and 180 range. Electrophysiology
was consulted and recommended gentle diuresis and treatment
with Amiodarone in combination with beta blockers.
Throughout the patient's hospitalization stay, his atrial
fibrillation continued to be rapid in the 150-180 range
intermittently. Electrophysiology concluded that the patient
was not a candidate for nodal ablation or pacemaker. At this
time, it was decided that we would maximize medical therapy.
The Amiodarone and Lopressor doses were increased
appropriately.
On [**2173-3-25**], the patient was well enough to be discharged to
home in stable condition.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature
maximum 98, temperature current 98, heart rate 60 and sinus
with intermittent atrial fibrillation, BP 156/76, respiratory
rate 20, 02 saturation 96% on room air. The patient was at
his preoperative weight.
Predischarge x-ray showed small bilateral effusions.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting times three
with left internal mammary artery to the left anterior
descending artery, saphenous vein graft to the obtuse
marginal and posterior descending artery.
2. Chronic obstructive pulmonary disease.
3. Diet-controlled diabetes mellitus.
4. Hypercholesterolemia.
5. Pericarditis.
6. Status post transurethral resection of the prostate in
[**2164**].
7. Status post carpal tunnel surgery.
8. Status post vascular surgery in [**2140**].
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg p.o. b.i.d.
2. Diltiazem 120 mg p.o. q.d.
3. Amiodarone 400 mg p.o. q.d.
4. Ativan 0.5 mg t.i.d.
5. Coumadin 2 mg p.o. q.o.d., 1 mg p.o. q.o.d.
6. Percocet 5/325 one to two tablets p.o. q. four to six
hours.
7. Atorvostatin 20 mg p.o. q.d.
8. Zantac 150 mg p.o. b.i.d.
9. Aspirin 325 mg p.o. q.d.
10. Colace 100 mg p.o. b.i.d.
DISPOSITION: The patient will be discharged home in good
stable condition with VNA.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 70**] in
six weeks. The patient will also follow-up with his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 49683**], in one week. The
patient's Coumadin will be drawn by the visiting nurse and
called into the primary care office once a day. Prior to
discharge, Dr. [**Last Name (STitle) 49683**] was contact[**Name (NI) **] by the Cardiothoracic
Service and agreed to monitor the patient's Coumadin during
the postoperative period. The patient will call Dr.[**Name (NI) 45666**] office with any questions or concerns.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2173-3-29**] 08:42
T: [**2173-3-29**] 20:56
JOB#: [**Job Number 49684**]
|
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47,519
| 143,536
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4190
|
Discharge summary
|
report
|
Admission Date: [**2193-5-10**] Discharge Date: [**2193-5-11**]
Date of Birth: [**2113-9-9**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
CC:[**CC Contact Info 18245**]
Major Surgical or Invasive Procedure:
IV TPA, IA TPA, [**Hospital1 **] and Penumbra capture devices, all
unsuccessful
History of Present Illness:
79 year old right-handed woman (currently using left hand-only
because of R hemiparesis due to MS), with secondary progressive
MS (R hemiparesis from MS for 25 years), DM who presented with L
visual field cut, dysarthria at 10:30am,
followed by L neglect, L hemiparesis s/p IV tPA at 12:25pm at
OSH; transferred to [**Hospital1 18**]; family opted for trial of IA tPA.
Patient reports that at 10:30am she was [**Location (un) 1131**] and she
noticed that there was a white are in her visual field ("I
thought it was on the right eye"); she was also dysarthric. Her
husband called EMS. The husband did not notice any new weakness
at that time (baseline pt has R hemiparesis from MS for 25
years; she walks with a walker for limited distance; she uses
wheelchair when she leaves the house). At OSH she was noticed to
have a L hemiparesis as well and a L sided neglect at 11am. Her
vitals were: T 97.3 BP 151/85 HR 63. She had a CT head which
showed no ICH. [**Last Name (un) **] 27. She had no contraindications of tPA and
IV tPA bolus was given at 12:15pm and the infusion was completed
at 13:29pm. She was then transferred here. Her exam was
unchanged with L hemiparesis
(besides baseline R hemiparesis), R gaze deviation, L neglect
and L visual field cut. [**Last Name (un) 18246**] 27. A CTA head and neck showed an
extensive R MCA territory stroke and occlusion of R carotid
artery. After discussion with family of risks and benefits of
further procedures, family opted for IA tPA.
ROS:
The patient denied hearing changes, difficulty speaking,
language problems, memory difficulty, , vertigo, unsteady gait,
paresthesias.
The patient denied fever, wt loss, appetite changes, cp,
palpitations, DOE, sob, cough, wheeze, nausea, vomiting,
diarrhea, constipation, abd pain, fecal incont, dysuria,
nocturia, urinary incontinence, muscle or joint pain, hot/cold
intolerance, polyuria, polydipsia, easy bruising, depression,
anxiety, stress, or psychotic sx.
Past Medical History:
-DM
-secondary progressive MS (R hemiparesis from MS for 25 years).
She was diagnosed in her 40's. She has been off treatment for
decades.
Social History:
pt lives with her husband, she uses a walker at home and
wheelcheer to leave home, she quit smoking 40 years ago
Family History:
Her father died of [**Name (NI) 2481**] diseas and he mother had a
heart attack
Physical Exam:
T-98 BP-182/58 HR-62 RR-16 100O2Sat
Gen: Lying in bed, [**Name (NI) 18247**]
[**Name (NI) 4459**]: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
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: [**Name (NI) 18247**], [**Name2 (NI) 18248**] to voice, R gaze preference,
L sided neglect, dysarthric, she could say [**Doctor Last Name 1841**] backwards, she is
fluent and her comprehension is intact, normal naming.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2mm
bilaterally. L visual field cut. R gaze preference; she can
cross midline to the left side. Sensation intact V1-V3. L
Facial weakness. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact
Motor: Spasticity of R arm and R leg. Patient had no movement on
any
extremity, even against gravity.
Sensation: Patient reports that she could feel pinprick and
temperature BL and symmetrically
Reflexes: B T Br Pa Pl
Right 0 0 0 0 0
Left 0 0 0 0 0
Toes were UPgoing bilaterally.
Coordination: unable to perform
Gait: unable to perform
Romberg: Negative
Pertinent Results:
Labs:
Trop-T: <0.01
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
137 103 21 170 AGap=12
------------<
4.9 27 0.7
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
estGFR: >75 (click for details)
Ca: 10.0 Mg: 1.6 P: 4.8
WBC14.5 Hb12.4 plat198 Ht39.0
N:80.1 L:14.0 M:4.0 E:1.4 Bas:0.4
PT: 13.6 PTT: 28.6 INR: 1.2
Imaging: A CTA head and neck showed an extensive R MCA territory
stroke and occlusion of R carotid artery
Brief Hospital Course:
ADMISSION ASSESSMENT/PLAN:
A/P: 79 year old right-handed woman (currently using left
hand-only because of R paralysis due to MS), with secondary
progressive MS (R hemiparesis from MS for 25 years), DM who
presented with L visual field cut, dysarthria at 10:30am,
followed by L neglect, L hemiparesis; s/p IV tPA at 12:25pm at
OSH; transferred to [**Hospital1 18**] where she was found to have a L
neglect, R gaze preference (she can cross midline on L gaze)
dysarthria, L facial weakness, L visual field cut, and L
hemiparesis besides baseline R hemiparesis from MS. [**Last Name (Titles) 18246**] 27. A
CTA head and neck showed an extensive R MCA territory stroke and
occlusion of R carotid artery. After discussion with family of
further procedures, family opted for IA tPA.
HOSPITAL COURSE:
NEURO: The patient was transferred to the angiogram suite with
the IR team where she underwent IA TPA. She was admitted to the
neurology ICU under Attending Physician [**Name9 (PRE) 18249**] [**Name9 (PRE) **].
Follow-up head CT the next morning revealed extensive edema nad
midline shift with possible contrast extravasation versus
hemorrhagic conversion. In conversation with the family, they
brought the [**Hospital 228**] health care proxy documentation to the
attention of the medical team who requested that the patient be
made comfort measures only given her poor prognosis. She was
therefore transferred to the floor on a morphine drip and
expired at 21:16.
In accordance with the patient's wishes, the MS tissue bank was
[**Hospital 653**] prior to her death regarding brain donation.
Unfortunately given funding constraints donation was no longer
possible out-of-state. Alternative tissue banks in [**State 4565**],
[**State 18250**], [**State 12000**], and [**State 350**] were [**Name (NI) 653**], however
given her medical issues of stroke and multiple sclerosis her
brain was not appropriate for donation. Therefore, in
accordance with her healthcare proxy documentation, her brain
was designated to undergo autopsy for donation to research and
education purposes at the request of her family. Pathology was
[**Name (NI) 653**].
Medications on Admission:
-metformin 1000mg
-glipizide 2 tabs [**Hospital1 **]
-lantus
-medroxyprogesterone 5-10mg
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Stroke
Discharge Condition:
Expired
Discharge Instructions:
Not applicable.
Followup Instructions:
Not applicable.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2193-5-12**]
|
[
"V45.88",
"784.51",
"V58.67",
"344.2",
"401.9",
"348.5",
"V15.82",
"250.00",
"V66.7",
"433.11",
"340"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"00.40",
"39.74",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
6983, 6992
|
4667, 5445
|
345, 426
|
7042, 7051
|
4173, 4644
|
7115, 7253
|
2726, 2808
|
6953, 6960
|
7013, 7021
|
6839, 6930
|
5462, 6813
|
7075, 7092
|
2823, 3196
|
275, 307
|
454, 2418
|
3471, 4154
|
3235, 3455
|
3220, 3220
|
2440, 2580
|
2596, 2710
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,619
| 100,937
|
37574
|
Discharge summary
|
report
|
Admission Date: [**2170-10-10**] Discharge Date: [**2170-10-18**]
Date of Birth: [**2126-9-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
left posterior fossa mass
Major Surgical or Invasive Procedure:
History of Present Illness:
Patient is a 44M electively admitted for surgical resection of
left posterior fossa mass, and angiographic embolization of mass
blood supply
Past Medical History:
1. Anxiety/Depression
2. Meniere's Disease with total deafness L ear
3. Hypertension
Social History:
Married, resides at home with wife and two children
Family History:
non-contributory
Physical Exam:
On Admission:
Patient is alert, oriented to person, place and date.
PERRL.EOMI, face symmetric; tongue is midline. No pronator
drift. Slight left sided dysmetria. Full strength and sensation
in the upper and lower extremities.
On Discharge:
Patient is alert, oriented to person, place and date.
PERRL.EOMI, face symmetric; tongue is midline. No pronator
drift. Full strength and sensation in the upper and lower
extremities.
Pertinent Results:
Labs on Admission:
[**2170-10-11**] 01:38AM BLOOD WBC-10.1 RBC-4.89 Hgb-14.6 Hct-41.7
MCV-85 MCH-29.9 MCHC-35.1* RDW-13.8 Plt Ct-219
[**2170-10-11**] 01:38AM BLOOD PT-11.3 PTT-22.5 INR(PT)-0.9
[**2170-10-11**] 01:38AM BLOOD Glucose-127* UreaN-13 Creat-0.8 Na-140
K-4.7 Cl-105 HCO3-24 AnGap-16
[**2170-10-11**] 09:20PM BLOOD Calcium-9.3 Phos-4.7*# Mg-2.0
[**2170-10-11**] 09:20PM BLOOD Osmolal-299
Post-op MRI Head [**10-12**]:
showing adequadte decompression of left temporal mass.
Brief Hospital Course:
Patient was electively admitted on [**2170-10-10**] for left posterior
fossa craniotomy for mass resection. He was taken to the OR on
[**2170-10-11**], after an uneventful/successful embolization procedure
the evening prior. Prior to incision; an external ventricular
drain was placed, to assist with post-operative intracranial
volume managment. Post-operatively, the patient was returned to
the ICU. On POD#1, he had an MRI which revealed significant
decompression of intracranial lesion. His EVD remained in the
event it was required for post-surgical hydrocephalus. On POD#4,
the EVD was clamped and tolerated well. Subsequently, the EVD
was discontinued on POD#5. He was tapered off steroids and
mannitol. On [**10-16**], he was transferred from the ICU to the
NSURG floor. He was seen and evaluated by PT and OT who
determined he would be appropriate for disposition to rehab. He
was discharged accordingly on [**2170-10-18**].
Medications on Admission:
Ativan 1mg", Propanolol SA 60mg',Lamictal 150mg", Cymbalta
60mg', Ibuprofen 600mg PRN
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
11. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Left posterior fossa Mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**6-15**] days (from your date of
surgery) for removal of your staples/sutures and a wound
check(including abdomen-these stitches are dissolvable). This
appointment can be made with the Nurse Practitioner, or they can
be removed during rehabilitation. Please make this appointment
by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**11-19**] at 3
pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your hospitalization.
Completed by:[**2170-10-18**]
|
[
"386.00",
"237.5",
"213.0",
"351.0",
"300.00",
"212.0",
"388.5",
"389.21",
"401.9",
"348.5",
"731.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"20.49",
"19.9",
"02.39",
"01.24",
"01.6",
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
3940, 4012
|
1699, 2636
|
348, 348
|
4082, 4106
|
1192, 1197
|
9088, 10112
|
713, 731
|
2772, 3917
|
4033, 4061
|
2662, 2749
|
4130, 4151
|
746, 746
|
988, 1173
|
7257, 9065
|
282, 309
|
4163, 7230
|
376, 518
|
1211, 1676
|
540, 627
|
643, 697
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,822
| 125,824
|
36773
|
Discharge summary
|
report
|
Admission Date: [**2164-10-16**] Discharge Date: [**2164-12-6**]
Date of Birth: [**2112-2-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
painless BRBPR and hypotension
Major Surgical or Invasive Procedure:
[**2164-10-17**]: Exploratory laparotomy, gastrotomy, duodenotomy
with suturing of bleeding vessel, draining jejunostomy.
[**2164-10-19**]: exploratory laparotomy, abdominal washout, ligation of
gastroduodenal artery, placement of jejunostomy tube and complex
closure of abdomen.
History of Present Illness:
52M with ETOH cirrhosis (Child C, MELD 20) complicated by
esophageal and rectal varices with prior episodes of bleeding
admitted with painless BRBPR and hypotension. Recently
hospitalized at [**Hospital1 18**] [**Date range (1) 83129**] for UGIB due to duodenal
ulcer, alcoholic hepatitis treated with corticosteroids,
hepatorenal syndrome, and respiratory failure requiring
mechanical ventilation. Started having BRBPR earlier today at
home. Otherwise asymptomatic.
Past Medical History:
ETOH cirrhosis
s/p bilateral knee replacements [**2-6**] OA
Chronic GIB [**2-6**] internal hemorrhoids
Leg fracture 25years ago
Grade 1 esophageal varices seen in [**9-/2163**] (grade 1 on EGD
[**2164-8-13**])
bleeding duodenal ulcer
Social History:
Currently disabled. Lives with wife and 16 [**Name2 (NI) **] daughter. Drank
[**1-6**] -1 pint of vodka daily for many years until quitting [**7-30**] [**2164**]. Non-smoker. Never used IVD. No tattoos
Family History:
Dad died of ETOH cirrhosis
Brief Hospital Course:
Neuro: At the time of admission the patient was neurologically
intact. Post-operatively and throughout his admission his pain
control was maintained using narcotic pain medications. He was
seen by psychiatry for delirium early in the course of his
admission and was intermittently encaphalopathic throughout,
managed with rifaximin and lactulose. Prior to discharge the
patient was determined to be neurologically intact and capable
of his own decision making prior to his decision to withdraw and
cease escalation of care.
CV - The patient was initially taken to the OR after management
of a bleeding duodenal ulcer at an OSH. Post-operatively his
hematocrits drifted downward and required multiple transfusion,
but no further acute bleeding episodes were identified. He had
no further cardiovascular issues.
Pulm - The patient had no significant pulmonary issues, and
saturations were fine throughout admission. He occasionally
required paracentesis to prevent SOB and had some difficulty
with respiration prior to sessions of dialysis.
Renal - The patient experienced worsening renal failure likely
secondary to hepatorenal syndrome throughout his admission, and
eventually required three x weekly dialysis. He required albumin
to maintain his pressures, especially during dialysis.
GI -Pt was admitted to [**Hospital1 18**] after management of a bleeding
duodenal ulcer at an OSH. An upper endoscopy was performed which
did not show any evidence of bleeding, and this was followed by
a tagged red cell scan that indicated likely bleeding in the
duodenum. The patient was taken emergently to the OR for an
ex-lap, gastrotomy, duodenotomy and draining jejunostomy, which
were significantly more extensive than originally planned. The
patient tolerated the procedure and was admitted to the ICU with
an open abdomen. On POD #3 he was taken back to the OR for
washout, gastroduodenal ulcer ligation and abdominal closure,
all of which were tolerated without difficulty. Additionally, IR
was involved to attempt embolization of this bleeding source. He
was maintained on octreotide and midodrine for HRS throughout
the admission and followed by the hepatology service. The
patient was followed for potential liver transplant throughout
the admission until his decision to withdraw or deny care.
Heme - The patient required multiple transfusions to maintain
his hematocrit throughout the admission. He had no further
hematological issues outside of his bleeding.
ID - The patient had persistent peritonitis throughout his
admission. He was followed by ID for this and maintained on
broad spectrum IV antibiotics per speciations/sensitivities.
Blood cultures were intermittently positive including
stenotrophomonas from his peritoneal fluid. At the time of DC,
recent blood cultures showed EColi, but no further
stenotrophomonas.
Psych - The patient was followed by the psychiatry service for
intermittent delirium. At the time of discharge he was alert but
delirious. The patient was seen by the psychiatry prior to his
decision to deny/withdraw care and was deemed to be capable of
his own decision making.
Dispo - The patient was seen by the palliative care service, and
at the time of discharge was DNR/DNI per his own wishes and was
discharged to hospice for management.
Medications on Admission:
Thiamine HCl 100 mg
Pantoprazole 40 mg Tablet
Ursodiol 300 mg
Therapeutic Multivitamin
Nadolol 20 mg
Lactulose 10 gram/15
Spironolactone 50 mg
Furosemide 20 mg
Prednisone 20 mg
Calcium Carbonate 500 mg
Cholecalciferol (Vitamin D3)
Discharge Medications:
Micafungin 100 mg IV Q24H Order date: [**12-3**] @ 1044
Nystatin Oral Suspension 5 mL PO QID Order date: [**12-3**] @ 0024
Calcium Acetate 1334 mg PO TID W/MEALS Order date: [**12-3**] @ 0024
20. Octreotide Acetate 100 mcg SC Q8H Order date: [**12-3**] @ 0024
Ondansetron 4 mg IV Q8H:PRN nausea Order date: [**12-3**] @ 0024
HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain Order date:
[**12-3**] @ 0024 23. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE
TO MAP>55 Order date: [**12-3**] @ 0106
Piperacillin-Tazobactam 2.25 g IV Q8H Order date: [**12-3**] @ 0024
Simethicone 40-80 mg PO/NG QID:PRN bloating Order date: [**12-3**] @
0024
Insulin SC (per Insulin Flowsheet)
Lactulose 30 mL PO/NG Q4H:PRN encephalopathy Order date: [**12-3**]
@ 0024 30. Sucralfate 1 gm PO QID Order date: [**12-3**] @ 0024
Discharge Disposition:
Extended Care
Facility:
The [**Hospital **] care Center
Discharge Diagnosis:
End stage liver disease
Discharge Condition:
Guarded
|
[
"303.93",
"263.9",
"572.3",
"572.2",
"785.52",
"567.29",
"276.2",
"112.5",
"452",
"276.3",
"584.5",
"572.4",
"285.1",
"518.81",
"571.2",
"456.21",
"995.92",
"577.0",
"532.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.72",
"39.95",
"33.24",
"43.0",
"46.39",
"44.42",
"99.15",
"88.47",
"54.62",
"00.14",
"39.79",
"96.6",
"45.13",
"38.95",
"38.91",
"54.91",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
6074, 6132
|
1670, 4952
|
346, 628
|
6199, 6209
|
1619, 1647
|
5233, 6051
|
6153, 6178
|
4978, 5210
|
276, 308
|
656, 1125
|
1147, 1383
|
1399, 1603
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,300
| 108,151
|
6685
|
Discharge summary
|
report
|
Admission Date: [**2159-10-25**] Discharge Date: [**2159-11-5**]
Date of Birth: [**2076-11-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
acute Non STEMI
Major Surgical or Invasive Procedure:
coronary artery bypass grafts
x4(LIMA-LAD,SVG-OM1-OM2,SVG-dg)[**2159-10-26**]
left and right heart catheterization [**2159-10-25**]
History of Present Illness:
Mr. [**Known lastname **] is an 82 year old malewith prior MI who has refused
catheterization. This morning of admission he developed chest
pressure which was located in the mid-epigastrum , with
indigestion. The sensation was similar in quality to the chest
pressure he had when he presented in 9/[**2159**]. Did not take
anything for the pain. Of note, the patient presented to his
outpatient cardiologist 1 week after his prior discharge and was
still having indigestion type chest pain at that time and was
started on Imdur with some relief.
.
The patient presented initially to [**Hospital3 1280**] Hospital where a
CXR showed pulmonary edema vs. consolidation. He received lasix,
BiPAP, morphine, levaquin and ceftriaxone and nitro paste.
Troponins initially were 0.01. He was transferred to [**Hospital1 18**].
Past Medical History:
Hyperlipidemia
hypertension
Asthma
Bronchitits
obstructive sleep apnea
noninsulin dependent diabetes mellitus
Renal calculi
Social History:
Mr. [**Known lastname **] worked as policeman for many years. He is now retired,
working at a car auction two days weekly. He denies smoking,
alcohol use, and illicit drugs.
Family History:
No family history of early myocardial infarction, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
On Admission:
VS: 98.6 150/77 81 20 100%3L
GENERAL: Lying in bed in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Good air entry b/l. Mild wheezing throughout lung fields.
Mild-moderate crackles at bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Conclusions
PRE-BYPASS:
-No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No spontaneous echo
contrast is seen in the body of the right atrium.
-No atrial septal defect is seen by 2D or color Doppler.
-Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 %) with normal free wall contractility.
-There are simple atheroma in the descending thoracic aorta.
-The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. No
aortic regurgitation is seen.
-The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
-There is no pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results at the time of the study.
POSTBYPASS:
The patient is A-paced on low dose phenyleprhrine infusion.
Right ventricularr function is maintained. Left ventricular
function is mildly decreased from baseline, EF 35-40% with
cardiac output of 4.48. Mitral regurgitation is now moderate.
The remaining valves remain unchanged. The aorta remains intact.
[**2159-11-5**] 05:30AM BLOOD WBC-11.5* RBC-3.70* Hgb-10.4* Hct-32.3*
MCV-87 MCH-28.1 MCHC-32.1 RDW-13.6 Plt Ct-276
[**2159-11-4**] 06:00AM BLOOD WBC-14.0*
[**2159-11-3**] 09:25AM BLOOD WBC-10.8 RBC-3.93* Hgb-11.3* Hct-34.3*
MCV-87 MCH-28.8 MCHC-33.1 RDW-13.6 Plt Ct-280
[**2159-11-5**] 05:30AM BLOOD Glucose-101* UreaN-36* Creat-2.1* Na-142
K-4.2 Cl-105 HCO3-28 AnGap-13
[**2159-11-4**] 06:00AM BLOOD UreaN-36* Creat-2.7* Na-144 K-4.0 Cl-103
Brief Hospital Course:
Following transfer he ruled in with positive troponins. He had
continued angina and underwent catheterization to revealed
triple vessel diseae. He went the following morning for urgent
revascularization. See operative note for details. He weaned
from bypass on Neo Synephrine and Propofol. He weaned from the
ventilator and was extubated on POD 1. Beta blockade was started
and he was diuresed towards his preoperative weight. Diuresis
was increased due to persistent left effusion which was present
pre-operatively. His foley was removed and he was able to void
in small amounts with an 850cc residual- foley was replaced and
will need a repeat voiding trial. Physical Therapy worked with
him for strength and mobility. Chest tubes and temporary pacing
wires were removed according to protocol. He was placed on
antibiotics for sternal drainage. He was discharged to [**First Name8 (NamePattern2) 1495**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] for futher recovery prior to returning home.
Appointments for follow up were arranged and medications were as
listed.
Medications on Admission:
1. Levemir 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous at bedtime.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO three times a day.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
7. Asmanex Twisthaler 220 mcg (30 doses) Aerosol Powdr Breath
Activated Sig: One (1) Inhalation twice a day.
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
13. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation.
15. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: start
[**10-3**].
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*
16. IMDUR 30mg Daily
17. MVI
Discharge Medications:
1. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day.
16. cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a
day for 7 days.
17. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: per sliding scale.
19. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 20 Units Glargine with breakfast.
20. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
21. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 25499**] [**Hospital 731**] - [**Location (un) 47**]
Discharge Diagnosis:
Non STEMI with unstable angina
s/p coronary artery bypass grafts
coronary artery disease
hypertension
Asthma
Bronchitits
obstructive sleep apnea
noninsulin dependent diabetes mellitus
Renal calculi
hyperlipidemia
s/p left nephrectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait and assist of one
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema/ serosang drainage
Leg Left - healing well, no erythema or drainage.
Edema 2+
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:
You are scheduled for the following appointments:
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2159-12-3**] 1:15pm in the
[**Hospital **] medical office building [**Hospital Unit Name **].
Cardiologist: Dr. [**Last Name (STitle) 25500**] on [**11-30**] at 1:30pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6051**]([**Telephone/Fax (1) 25493**]) in [**4-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2159-11-5**]
|
[
"414.01",
"593.9",
"V45.73",
"410.71",
"401.9",
"250.00",
"428.0",
"410.72",
"493.20",
"327.23",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"36.15",
"36.13",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
8875, 8966
|
4262, 5360
|
327, 461
|
9244, 9487
|
2605, 4239
|
10327, 11027
|
1669, 1803
|
6893, 8852
|
8987, 9223
|
5386, 6870
|
9511, 10304
|
1818, 1818
|
272, 289
|
489, 1312
|
1832, 2586
|
1334, 1459
|
1475, 1653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,173
| 154,817
|
3464
|
Discharge summary
|
report
|
Admission Date: [**2108-9-26**] Discharge Date: [**2108-9-26**]
Date of Birth: [**2060-4-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC:[**CC Contact Info 15958**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 48F well known at [**Hospital1 18**] for numerous med problems incl EtOH
and drug abuse, HepB, HepC, seizures, and past Left SDH (06) who
signed out AMA of detox rehab earlier today. She was found down
at home this evening. EMT intubated in field. Admitted at NWH
where she was found to have to have GCS of 3, non reactive
pupils bilat. CT head showed large acute SDH w/midline shift. Tx
to [**Hospital1 18**] for neurosurgical eval. received Ativan at OSH but no
report of any paralytics given at any time.
Past Medical History:
- Hepatitis B: dxed [**2098**] per pt
- Hepatitis C: dxed [**2098**] per pt
- Pancreatitis: h/o pseudocyst drainage
- EtOH abuse, h/o withdrawal seizures
- h/o heroin abuse
- Cardiomyopathy: dx in [**2-24**] at NWH. EF 20%. Unknown etiology
(likely [**2-20**] EtOH), recent echo [**4-23**] with NL EF.
- h/o NSVT: at OSH in [**2-24**]
- h/o depression: dx at NWH in [**2-24**], unsure if bipolar d/o.
- h/o SDH in [**3-22**] in setting of [**4-17**] generalized tonic clonic
seizure from EtOH withdrawal.
Social History:
The patient is married and lives in [**Location 745**] with husband. [**Name (NI) **] 2
children, ages 24 and 29 who do not live with her. She says that
she drinks anywhere from [**4-27**] shots of Smirnoff daily. She
reports sniffing cocaine 2 weeks ago and using IV cocaine last
month (for which she was admitted for cellulitis).
Family History:
Father with hx of HTN and alcoholism. No h/o seizure disorder in
the family. Her sister has a history of drug use but is now
clean for 7 years.
Physical Exam:
PHYSICAL EXAM:
96.6 70/43 93 14 100%
Intubated. Ventilated. No spontaneous breathing. Not sedated.
Pupils 4mm non reactive bilat.
No corneal rx.
No motor movement to painful stimulation throughout.
Pertinent Results:
CT head (OSH): 2-3.7 cm thick acute SDH on left with massive m/l
shift (not measurable), diffuse loss of grey-white matter
differenciation; herniation under falx, into foramen magnum;
Plt count: 28
Brief Hospital Course:
Pt was admitted to ICU. Her neurologic exam remained poor.
Brain death exam done and she met requirement for brain death.
Medications on Admission:
unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
SDH
Discharge Condition:
none
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2108-9-27**]
|
[
"070.70",
"348.4",
"305.90",
"425.4",
"070.30",
"E888.9",
"852.25",
"305.01",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
2605, 2614
|
2395, 2518
|
346, 353
|
2662, 2669
|
2171, 2372
|
2722, 2758
|
1789, 1934
|
2576, 2582
|
2635, 2641
|
2544, 2553
|
2693, 2699
|
1964, 2152
|
277, 308
|
381, 895
|
917, 1423
|
1439, 1773
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,264
| 143,408
|
34365+57922
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-2-24**] Discharge Date: [**2123-2-27**]
Date of Birth: [**2063-11-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
respiratory distress, increased secretions
Major Surgical or Invasive Procedure:
1. Rigid bronchoscopy with both black and yellow Dumon
tracheoscopes.
2. Foreign body removal (Y-stent).
3. Granulation tissue ablation left main stem using
cryotherapy.
History of Present Illness:
Pt is 59 y/o female with Resp Failure s/p trach,
Tracheobronchomalacia s/p y-stent ,COPD, OSA, Pulmonary HTN
,HTN,
Chronic renal insufficiency ,ischemic bowel s/p colectomy. Last
at [**Hospital1 18**] [**8-/2122**] and underwent stent revision due to granulation
tissue. Has been at [**Hospital1 **] since.
Over the last few months, has been on and off the vent but never
capable of being d/c to home. More recently, has had increase
in
secretions and suctioning requirements. Transferred for eval of
stent +/- post ob PNA.
Past Medical History:
Tracheobronchomalacia
COPD
OSA
Pulmonary HTN
systemic HTN
Chronic renal insufficiency
ischemic bowel s/p colectomy
Depression
Social History:
30 pack year former smoker
married, lives with family
Family History:
non contributory
Physical Exam:
VS: 100.1, 84, 121/64, 14, 100% on 4L NC
Gen: NAD, resting comfortably
HEENT: 6-0 portex trach
NECK: trachea midline, no stridor, supple
LYMPHATICS: no cervical or supraclavicular lymphadenopathy, no
thyromegaly
Chest: diminished BS throughout
CV: reg rate, nl S1/S2, no MRG
ABD: colostomy, soft, NT/ND, NABS
EXT: minimal bilat LE edema
NEURO: mouths words
Pertinent Results:
[**2123-2-24**] 06:40PM GLUCOSE-129* UREA N-33* CREAT-1.7* SODIUM-142
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-36* ANION GAP-13
[**2123-2-24**] 06:40PM estGFR-Using this
[**2123-2-24**] 06:40PM CALCIUM-10.1 PHOSPHATE-2.8# MAGNESIUM-1.5*
[**2123-2-24**] 06:40PM WBC-9.2 RBC-4.10* HGB-12.6 HCT-37.4 MCV-91
MCH-30.7 MCHC-33.7 RDW-14.8
[**2123-2-24**] 06:40PM PLT COUNT-345
[**2123-2-24**] 06:40PM PT-13.3 PTT-23.6 INR(PT)-1.1
Brief Hospital Course:
Ms. [**Known lastname **] was admitted on [**2123-2-24**] and underwent flexible
bronchoscopy at the bedside that same day, which revealed
significant granulation tissue in the left mainstem bronchus
causing occlusion during exhalation. She also had mild to
moderte granulation tissue in the right mainstem bronchus.
On [**2123-2-25**] she was planned to go to the operating room for
rigid bronchoscopy and debridement; however, ST depressions were
noted on her telemetry tracing and although she did not complain
of symptoms of chest pain or pressure, and she remained
hemodynamically stable, it was thought prudent to cycle her
cardiac enzymes prior to taking her to the operating room.
Troponins x3 were negative (<0.1), and the ST depressions
resolved, likely representing mild demand ischemia and not an
MI.
She was taken to the operating room on [**2123-2-26**] for rigid
bronchoscopy as planned. Through the working channel of the
flexible bronchoscope, cryotherapy was
performed to the granulation tissue with a reduction in
granulation tissue of approximately 25%. As the majority of the
granulation tissue could not be extracted, it was determined
that the patient should not have her Y stent replaced and allow
the granulation tissue to regress for the next month and be
reevaluated for Y stent replacement. Her 7- 0 Portex
tracheostomy tube was then reinserted and she was
then transferred back to the intensive care unit in stable
condition.
She was discharged to rehab on [**2123-2-27**] in stable condition.
She was on her regular pureed diet and tolerating O2 by nasal
cannula with CPAP as needed.
Medications on Admission:
1. zofran prn
2. trazadone 50 qhs prn
3. senna
4. percocet prn
5. ativan prn
6. miconazole TP
7. lasix 40 qday
8. remeron 30 qhs
9. prednisone 20 qday
10. effexor 37.5 qday
11. zocor 10 qday
12. prevacid 30 qday
13. colace
14. reglan 10 4x/day
15. lopresor 50 [**Hospital1 **]
16. digoxin 0.125 qday
17. SQH
18. RISS
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Insulin Regular Human 100 unit/mL Solution Sig: Zero (0) U
Injection ASDIR (AS DIRECTED): BS(mg/dL) ISS dose
0-60 1 amp D50
61-150 0 Units
151-200 2 Units
201-250 4 Units
251-300 6 Units
301-350 8 Units 351-400 10 Units
> 400 mg/dL Notify M.D. .
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
19. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
1. Tracheobronchomalacia
2. Respiratory distress
Discharge Condition:
stable
Discharge Instructions:
1. Call office or go to ER if fever/chills, chest pain,
increasing shortness of breath, abdominal pain or distention.
2. Resume medications and treatments as directed.
3. Follow up with Interventional Pulmonology as needed.
Followup Instructions:
Follow up with Interventional Pulmonology as needed.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Name: [**Known lastname **],[**Known firstname 4193**] Unit No: [**Numeric Identifier 12732**]
Admission Date: [**2123-2-24**] Discharge Date: [**2123-2-27**]
Date of Birth: [**2063-11-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10926**]
Addendum:
ADDENDUM TO DISCHARGE SUMMARY [**2123-2-27**]:
Patient will need to have a follow-up CT scan for a RUL nodule
identified on previous scan in 9/[**2121**]. Will plan to obtain scan
at time of return visit in 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Hospital1 1947**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 10927**]
Completed by:[**2123-2-27**]
|
[
"707.03",
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"403.90",
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"311",
"707.23",
"496",
"V15.82",
"519.19",
"327.23",
"486",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.78",
"96.72",
"33.22",
"32.01"
] |
icd9pcs
|
[
[
[]
]
] |
7234, 7457
|
2205, 3826
|
363, 543
|
6152, 6161
|
1751, 2182
|
6434, 7211
|
1340, 1358
|
4194, 5961
|
6080, 6131
|
3852, 4171
|
6185, 6411
|
1373, 1732
|
281, 325
|
571, 1102
|
1124, 1252
|
1268, 1324
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,375
| 107,743
|
41517
|
Discharge summary
|
report
|
Admission Date: [**2117-3-10**] Discharge Date: [**2117-3-14**]
Date of Birth: [**2030-2-17**] Sex: M
Service: MEDICINE
Allergies:
Omeprazole / Sulfa (Sulfonamide Antibiotics) / Tetracycline /
ibuprofen
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Hypotension/ dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87M history of cardiomyopathy with both systolic/diastolic CHF
(LVEF 50-55%), mitral and aortic valve insufficiency, atrial
fibrillation on coumadin, CKD Stage IV (baseline Cr 2.4-3),
myeloproliferative disease, PVD, Ileostomy secondary to total
colectomy from C. diff colitis in [**2111**] that presented to the
emergency department complaining of shortness of breath over the
last several days which is getting worse.
He states that for the shortness of breath that this has
resulted in difficulty walking from the bed to the bathroom. His
normal level of activity includes being able to walk on a
treadmill. He denies PND and states that he has slept on 2
pillows for quite sometimes. He denies dietary indiscretion. He
also feels like he is having a little more fluid on legs.
He does endorse associated central chest discomfort during
exertion. He denies a history of angina, and this is the first
time he has experienced chest discomfort with activity. He
denies chest discomfort at rest, at night, or with meals. He
notes this with activity like going up the stairs.
He also endorses feeling dizzy characterized by dysequilibrium
and lightheadedness. He denies any falls or trauma.
He also endorses that his heat works at home.
He denies any medication changes except starting thyroid
medication for a TSH ~ 9 recently.
In the ED inital vitals were, 15:02 Pain 0 HR 54 BP 87/42 RR 20
pOx 100% (oxygen therapy not given).
Initial ECG showed atrial fibrillation at 40 bpm with T-wave
flattening laterally consistent with previous non-stemi.
Bedside ultrasound reveals no pericardial effusion but apparent
hypokinesis.
Temperature was noted to be 89.6 (rectal) with improvement to 90
(rectal) with [**Last Name (un) **] Hugger.
Labs showing WBC 4.3, Hgb 12.3, Plt 418 Diff 88% N. [**Name (NI) 2591**] PTT
53.2, INR 3.4 (H).
Chemistry panel Na 134, K 6.2 (H), Cl 104, HCO3 12 (H), BUN 184,
Cr 5.9 with anion gap.
ALT 69 (H), AST 65 (H), CPK 184, Tbili 1.
CK-MB 48 (H), MB Indx 26.1 (H), cTropnT 0.06, proBNP 7492.
TG 88
Osm 327
TSH 7.4, T4 7.5
Recent cortisol was 15.3 ([**2117-3-2**])
Digoxin was 0.8.
Serum tox was negative.
Recent SPEP/UPEP was negative.
In the ER, his BP ran 80/40-90/50, HR 40-50. He was given
bicarbonate, insulin, dextrose, sodium polystyrene. He also
received 1121 mL of fluid including NS and D5W with 3 amps
bicarb. Pressures appeared to be responsive to IVF. Of note,
baseline SBP 90-100 per Atrius records.
Renal was consulted and recommended bicarbonate infusion.
Patient has avoided dialysis in the past. Further plans will be
discussed in AM.
Patient was admitted to the ICU for bradycardia, hypotension,
hypothermia, lethargy.
I requested that blood cultures be drawn and that broad spectrum
antimicrobials be started (vancomycin/zosyn) given ? hypothermic
sepsis.
Patient's vital signs were T 90, HR 46, RR 12, BP 89/40, pOx
100, 10L neb mask.
On arrival to the ICU, patient was cool to touch. He was AAOx3.
He related the above history.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough or wheezing. Denies 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:
- Cardiomyopathy with systolic/diastolic CHF (LVEF 50-55%)
- Mitral and Aortic Valve Insufficiency
- Atrial Fibrillation on coumadin
- CKD (stage IV) - baseline Cr 2.4- 3.0
- Myeloproliferative Disease - thrombocytosis
- GERD
- PVD
- Onychomycosis
- Osteoarthritis (knee)
- Ileostomy [**3-4**] total colectomy [**3-4**] c-diff in [**2111**]
- Glaucoma left eye
Social History:
Patient is married 60 years.
Has 6 children, used to work as letter carrier and a basist
(mucsician).
Also was in Navy worked as radio operator.
Smoked 1 yr while in Navy.
Has not had etoh in [**8-8**] yrs.
No other drugs.
Lives independently with wife at home.
He denies any occupational exposure, such as asbestos.
Family History:
Mother died at 93 secondary to unknown cause.
Father died at 83 with heart disease and emphysema.
Sister died in 40s in cardiac surgery for valves.
Physical Exam:
Admission:
General Appearance: No acute distress, cool to touch
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: heart sounds distant
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bibasilar)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Warm
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed, AAOx3
Discharge:
Pertinent Results:
Admission:
[**2117-3-10**] 04:10PM BLOOD WBC-4.3 RBC-3.80* Hgb-12.3* Hct-37.3*
MCV-98 MCH-32.2* MCHC-32.9 RDW-20.0* Plt Ct-418
[**2117-3-10**] 04:10PM BLOOD Neuts-88* Bands-0 Lymphs-6* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3*
[**2117-3-10**] 04:10PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+ Ellipto-OCCASIONAL
[**2117-3-10**] 04:10PM BLOOD PT-35.2* PTT-53.2* INR(PT)-3.4*
[**2117-3-11**] 12:41AM BLOOD Fibrino-188
[**2117-3-10**] 04:10PM BLOOD Glucose-90 UreaN-184* Creat-5.9*# Na-134
K-6.2* Cl-104 HCO3-12* AnGap-24*
[**2117-3-10**] 04:10PM BLOOD ALT-69* AST-65* CK(CPK)-184 AlkPhos-126
TotBili-1.0
[**2117-3-10**] 04:10PM BLOOD CK-MB-48* MB Indx-26.1* cTropnT-0.06*
proBNP-7492*
[**2117-3-10**] 04:10PM BLOOD Albumin-4.1
[**2117-3-11**] 12:41AM BLOOD Calcium-6.7* Phos-7.7*# Mg-1.7
[**2117-3-11**] 12:41AM BLOOD Triglyc-122
[**2117-3-10**] 04:10PM BLOOD TSH-7.4*
[**2117-3-10**] 04:10PM BLOOD T4-7.5
[**2117-3-12**] 06:15AM BLOOD Vanco-10.7
[**2117-3-10**] 04:10PM BLOOD Digoxin-0.8*
[**2117-3-10**] 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2117-3-11**] 01:20AM BLOOD Type-[**Last Name (un) **] Temp-34.6 pO2-64* pCO2-32*
pH-7.45 calTCO2-23 Base XS-0
[**2117-3-10**] 05:03PM BLOOD Lactate-1.9 K-5.9*
[**2117-3-11**] 02:28PM BLOOD freeCa-0.88*
[**2117-3-10**] 06:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2117-3-10**] 06:10PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2117-3-10**] 06:10PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
[**2117-3-10**] 06:10PM URINE CastHy-11*
[**2117-3-12**] 03:13AM URINE Eos-POSITIVE
[**2117-3-10**] 06:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Blood cultures pending x2
Urine culture pending
CHEST (PORTABLE AP) Study Date of [**2117-3-10**] 4:35 PM
FINDINGS: There is evidence of emphysema, although no focal
consolidation is seen. There is no evidence of pulmonary edema.
Mild-to-moderate cardiomegaly is not significantly changed.
There are no pleural effusions. No pneumothorax is seen. Aortic
calcifications are noted.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Mild-to-moderate cardiomegaly, not significantly changed.
ECG Study Date of [**2117-3-10**] 3:30:56 PM
Atrial fibrillation with a slow ventricular response and a
ventricular
premature beat. Non-specific intraventricular conduction delay.
Poor R wave progression. Cannot exclude a prior anterior
myocardial infarction. Compared to the previous tracing of
[**2117-2-28**] no significant change.
Brief Hospital Course:
87M history of cardiomyopathy with both systolic/diastolic CHF
(LVEF 50-55%), CKD Stage IV (baseline Cr 2.4-3) among other
issues that presented to the emergency department complaining of
shortness of breath with no overt evidence of heart failure
exacerbation in addition to hypothermia, acute on chronic renal
failure with toxic-metabolic derangements, and hypotension in
setting of hypovolemia.
#Hypotension/ Hypothermia, initially concerning for sepsis, but
he was found to have no infectious source.
Patient states normal temperature is around T 96. He has
underlying hypothyroidism and likely disturbance in
thermoregulation given elderly and underlying kidney
dysfunction. Recent cortisol within normal limits. Hypothermia
also concerning for sepsis, but patient has no obvious source of
infection. Patient's temperature has risen from 89 rectal to 95
rectal with passive re-warming and currently above 96 since [**3-12**]
orally. Patient was initially warmed passively with a Beir
hugger, which was then discontinued as patient stated that he
was too hot. Patient was treated emperically with zosyn and
vancomycin (1000mg given [**3-10**] 1900 and 1250mg given [**2117-3-12**] am)
and his antibiotics were stopped on [**3-13**] as he had no signs of
infection and a negative infectious workup including negative
blood and urine cultures a CXR with evidence of pneumonia. We
continued home thyroid medications.
# Acute on chronic renal failure: Patinet presented with a
creatinine of 5.9 up from 3.2 on discharge 7 days ago. He also
had metabolic acidosis and hyperkalemia on admission. His
metabolic disturbances improved after he was initially fluid
resucitated and given IV bicab and started on calcium acetate.
On Discharge his creatinine was 4.3, with a BUN of 113, and a
bicarb of 19. The patient was quite clear that he was not
interested in pursuing HD. Renal followed the patient here and
the patient has an outpatient nephrologist. Renal also
recommended sarna lotion for uremic itching.
# Chronic diastolic and systolic heart failure per prior notes,
though an echo from [**2117-1-31**] showed an EF 50-55% with [**Hospital1 **]-atrial
ennlargement, RV enlargement and severe TR. He had an ntBNP of
7000 similar to prior values. Diuretics were held during this
admission given ARF. He can resume torsemide on Monday [**3-15**]
with close attention to his electrolytes and volume status.
# Atrial fibrillation/bradycardia
Initially, patient likely with bradycardia secondary to
hypothermia. Rhythm is slow atrial fibrillation.
Metoprolol/digoxin were both held because of bradycardia.
Coumadin was held on admission as he had an INR of 3.4, and
coumadin 2mg was resumed on [**3-13**] when his INR was 2.3.
**Both digoxin and metoprol held at discharge given concerns of
bradycardia and hypotension with metoprolol, flucuating renal
function in respect to digoxin (level 0.8 on admit)
[]Digoxin can be resumed per his PCP
# Hypothyroidism continued on levothyroxine
# Myeloproliferative Disease His hydroxyurea was held in setting
of ARF and was resumed on discharge. Pharmacist confirmed that
his prior dose is OK even with his creatinine clearance of
[**11-15**]. He has been on this dose for a while # Glaucoma
continued latanoprost
#Goals of Care: Patient and family intersted in having more
services provided at home. He is already established with VNA,
but given daughter's concern to have daily help with his ostomy,
our CM referred her to [**Hospital 18639**] home health aides.
We discussed code status, but the patient seemed to want his
doctors to give [**Name5 (PTitle) **] a shot at CPR, even despite explaining how
the majority of patients do not survive a cardiac arrest and
with his illnesses it would be less likely and that cardiac
resuscitation can be just as invasive or more than dialysis and
if he survived he would need dialysis. The patient is not ready
for dialysis because his approach would be to return to the
hospital if he got sick again.
The patient can be referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who is a
palliative care provider with [**Name9 (PRE) 2287**] and discuss his chaning
health with her and his PCP.
Medications on Admission:
Verified from last discharge summary and Atrius records
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
6. torsemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 5X/WEEK
(MO,TU,WE,TH,FR).
8. econazole 1 % Cream Sig: One (1) application Topical twice a
day as needed for rash.
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
([**Doctor First Name **],MO,TU,TH,FR).
10. warfarin 1 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (WE,SA).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day).
12. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. baking soda
[**2-1**] teaspoon, by mouth, three times a week
14. Levothyroxine 100 mcg Oral Tablet
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
4. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 5 days a
week (not on sat, [**Last Name (un) **]).
6. econazole 1 % Cream Sig: One (1) Topical once a day.
7. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: TAKE
2 TABS ON SUNDAY, MONDAY, TUESDAY, THURSDAY, FRIDAY AND TAKE 1
TAB ON WED, SATURDAY.
Disp:*90 Tablet(s)* Refills:*0*
8. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*0*
9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. BAKING SODA Sig: [**2-1**] TEASPOON THREE TIMES A WEEK.
12. hospital bed
please call Clincial 1 Home Medical at [**Telephone/Fax (1) 90308**] to ask about
insurance coverage
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Hypotension
Hypothermia
ESRD, not on HD
Congestive heart failure, diastolic, chronic
atrial fibrillatin
ileostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - WALKER.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Your discharge weight was 144.5
You were hospitalized for low blood pressure and low body
temperature that have both improved. You continue to require
close attention to any symptoms of congestive heart failure
including shortness of breath, leg swelling, difficulty
breathing at night and kidney failure with less urination.
MEDICATION CHANGES:
[]TORSEMIDE WAS HELD THIS ADMISSION AND CAN BE RESUMED ON MONDAY
[**3-15**]
[]HYDROXYUREA DOSE HELD DURING ADMISSION, RESUMED ON DISCHARGE,
(we confirmed with pharmacist that this is an OK dose for your
creatinine clearance)
[]CALCIUM ACETATE STARTED
[]METOPROLOL STOPPED DURING THIS ADMISSION DUE TO BRADYCARDIA
[]DIGOXIN WAS NOT CONTINUED DURING HOSPITALIZATION, BUT CAN BE
RESUMED ON DISCHARGE PER YOUR PCP
TRANSITIONAL ISSUES
[]REFERRAL TO PALLIATIVE CARE TO DISCUSS GOALS OF CARE, CODE
STATUS AND POTENTIAL FOR HOSPICE IN THE FUTURE IF HE HAS
PROGRESSIVE ILLNESS
[]DECISIONS ABOUT METOPROLOL, DIGOXIN
[]MONITOR RENAL FUNCTION, INR,
[]discharge weight was:
Followup Instructions:
Please call your PCP on [**Name9 (PRE) 766**] to arrange an appointment for
this week:
Name: [**Name9 (PRE) 36023**],[**Name9 (PRE) **]
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 36024**]
Please discuss with Dr. [**Last Name (STitle) **] if he can make a referral to a
palliative care specialist at [**Location (un) 2274**]: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Please see your nephrologist as [**Last Name (NamePattern1) 1988**] Dr. [**Last Name (STitle) **] (confirm
appointments)
Please confirm appointments with your cardiologist.
|
[
"238.79",
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"428.0",
"244.9",
"530.81",
"365.9",
"V66.7",
"715.36",
"276.7",
"780.65",
"396.3",
"276.2",
"V44.2",
"427.31",
"V45.72",
"458.9",
"585.5",
"275.41",
"584.9",
"V58.61",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14786, 14837
|
8122, 12355
|
353, 359
|
14994, 14994
|
5388, 8099
|
16263, 16970
|
4538, 4687
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13597, 14763
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14858, 14973
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12381, 13574
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15139, 15557
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4702, 5369
|
3408, 3804
|
15577, 16240
|
293, 315
|
387, 3389
|
15009, 15115
|
3826, 4188
|
4204, 4522
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,297
| 169,870
|
44466
|
Discharge summary
|
report
|
Admission Date: [**2121-10-4**] Discharge Date: [**2121-10-11**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2121-10-5**]: 1. [**Location (un) **] patch repair of a perforated pyloric channel
ulcer.
2. Placement of a transgastric feeding jejunostomy tube.
History of Present Illness:
[**Age over 90 **] y/o F transferred from [**Location (un) 620**] for free air and abd pain
found earlier today. Per the [**Location (un) 620**] note she is a [**Age over 90 **] F who fell
at home in early [**Month (only) 359**] and fractured her left hip. She
subsequently underwent ORIF of the left hip on [**9-22**], was
discharged to rehab, but had a dislocation of the repaired hip
and was readmitted for open reduction. She was discharged again
just yesterday. This morning she began complaining of abdominal
pain, that she says is worst at her right mid abdomen. She has
had some nausea but no emesis, and has not had a bowel movement
in several days. She is unsure whether she is passing gas. Her
PO intake has been poor but she did eat dinner last night
without
any issues. She denies any fevers or chills, and denies any
changes in her urine habits. She does also complain of pain in
her left hip since the surgery.
She was transferred here for possible surgical repair and
management. En route she has received 1 unit of FFP. She
continues to have abd pain and has been afebrile and vitals have
been stable during transport.
Past Medical History:
PMH: depression, hypothyroid, diverticulosis
PSH: ORIF L hip [**2121-9-22**]; open reduction L hip dislocation
[**2121-10-1**]
Social History:
SocHx: Denies any tobacco, alchohol, or recreational drugs. Was
living alone and independent before her recent hospitalizations.
Family History:
FamHx: NC
Physical Exam:
PE: 99.5 100 140/71 16 98% 2L
Gen: NAD. A&Ox3.
HEENT: Anicteric. Dry mucosal membranes.
Neck: No JVD. No LAD. No TM.
CV: RRR.
Pulm: expiratory wheezes b/l.
Abd: firm, nondistended, diffusely tender to palp, with
rebound. No hernias/masses, no surgical scars. L hip dsg
C/D/I.
Ext: Warm and well perfused L leg mildly swollen from hip down,
trace edema b/L. Motor/sensation intact
Pertinent Results:
Labs: [**Location (un) 620**]
14.4>----<439 132| 98| 23|
33 ------------<137
89% N 4.8|21.6|1.3|
Ca 8.3
PT 23.6, INR 2.4
ALT 32, AST 30, ALP 87, TB 0.6, TP 5.8, Alb 2.4, Lip 68
U/A: + nitrates, 2+ bacteria, [**1-4**] WBC, no epis
[**Hospital1 18**] labs: INR 2.1
138/ 105/ 23< 109
4.8/ 25/ 1.2
Imaging: RUQ US: thickened 6mm GB wall, 9mm CBD, + murphys, no
evidence of stones/sludge (wet read).
CXR: Positive for free air
Endoscopy: Colonoscopy in the distant past reportedly normal.
Never had an EGD.
Swallow study [**2121-10-10**]:
No evidence of leaks with administration of Optiray contrast.
Brief Hospital Course:
Ms. [**Known lastname 2262**] was admitted to the ACS service on [**2121-10-5**] with
abdominal pain and perforated viscus on [**2121-10-5**]. She was taken
emergently to the operating room for [**Location (un) **] patch repair of a
perforated pyloric channel ulcer and Placement of a transgastric
feeding jejunostomy tube. A 5 mm perforated ulcer was noted at
the pyloric channel with copious fibrin as well as an acutely
inflamed stomach and duodenum. She underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] patch
repair with G/J tube placement on [**2121-10-5**].
Neurologic: She was extubated without problem postoperatively
and was initially watched in the ICU and then transferred to
floor on POD 1. She initially had inadequate pain control but
was transitioned to tylenol, Ultram,a nd small dose oxycodone
with adequate control.
Cardiovascular: She had no acute issues during this
hospitalization and remained hemodynamically stable throughout.
Pulmonary: She was noted to have crackles on exam POD3 and was
given IV lasix 20mg x2 with good urine response and improved
exam. She was then restarted on her spironolactone and was
saturating well on room air.
Gastrointestinal / Abdomen: She had exploratory laparotomy with
placement of a jejunal and gastric feeding tubes. Initially the
J-tube was capped and the G-tube was kept to gravity. Tube feeds
were started on POD 2 and patient was quickly advanced to goal
feed rate of 55cc/hr without any issues. She had a speech and
swallow evaluation on POD 5 that showed no leak and was started
on a regular diet, which she tolerated. Her PO intake was
limited in quantity despite lack of symptoms so her tube feeds
were continued on discharge at goal rate of 55cc/hr. H. pylori
testing was done that was negative. Patient was instructed to
get an outpatient EGD and told to discuss this with Dr. [**First Name (STitle) **] and
PCP at follow up appointment.
Nutrition:
See gastrointestinal above.
Renal: She initially had a foley placed that was discontinued
on POD 2. she had good urine output throughout this admission.
Hematology: On admission her INR was 2.1. since she was being
taken to the OR she was given 1 unit FFP preoperatively. She ahd
good hemostasis at the end of the case and her hematocrit was
stable postoperatively. She was kept on heparin 5000 units subq
TID during this hospitalization and had her coumadin held. this
coumadin was prophylactic after orthopedic surgery and so was
not restarted but instead patient was continued on subcutaneous
heparin.
Endocrine: Known hypothyroid condition. She was restarted on her
synthroid postoperatively and had no issues.
Infectious disease: On meropenem and fluconazole x 48 hours.
Peritoneal fluid showed multiple organisms including GNR, GPR,
and yeast. Blood cultures were drawn on [**2121-10-10**] that showed no
growth to date. Patient was afebrile and not tachycardic
throughout admission and so no further antibiotic treatment was
necessary. At time of discharge she had blood and urine cultures
pending.
Tubes/lines/drains: As stated above she ahd G/J tube placed in
the oeprting room as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain. The [**Doctor Last Name **] drain
continued to put out minimal serosanguinous fluid. The JP drain
was left in place at time of discharge. She walso had a PICC
line placed for difficult access on POD 2. The PICC was
confirmed to be in the correct position and was used for IV
access for the remainder of hospitalization.
Medications on Admission:
[**Last Name (un) 1724**]:
Celexa 20'
Synthroid 100'
Evista 60'
Latanoprost
Timolol
Senna PRN
Vitamin D
Roxicodone PRN
Coumadin 5'
Duclolax PRN
Milk of Mag PRN
Tylenol PRN
Zofran 4 PRN
Trazodone 50'
Calcium
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheezing.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection 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 for
constipation.
5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
15. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
16. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Perforated pyloric channel ulcer
Secondary:
Depression
Hypothyroid
Diverticulosis
s/p ORIF L hip [**2121-9-22**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Mechanical lift transfer.
Discharge Instructions:
You were transferred from an outside hospital after you were
found to have free air in your abdomen, which was attributed to
a perrforated ulcer in the pyloric channel of your stomach. You
were taken to the operating room soon after your arrival to the
[**Hospital 18**] hospital and had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] patch repair placed over this
hole. You also had a gastric and jejunal tube placed during this
operation to assist with feeding options postoperatively. You
have done well after the operation. You have been passing gas
and had a speech and swallow exam, which showed no evidence of
leak. You were started on a regular diet in addition to getting
tube feeds through your J-tube. You were tolerating the regular
food but not taking a large amount and so your tube feeds were
continued.
Please make your appointment for follow up as listed below:
You are not to resume your coumadin on discharge but instead
continue subcutaneous heparin.
General Discharge Instructions:
You have had an abdominal operation. This sheet goes over some
questions and concerns you or your family may have. If you have
additional questions, or [**Male First Name (un) **]??????t understand something about your
operation, please call your [**Male First Name (un) 5059**].
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside. But avoid traveling long distances until you
see your [**Male First Name (un) 5059**] at your next visit.
[**Male First Name (un) **]??????t lift more than 20-25 pounds for 6 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or ??????washed out?????? for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All these feelings and reactions are normal and should go away
in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that, it??????s OK.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as Milk
of Magnesia, 1 tablespoon) twice a day. You can get both of
these medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
After some operations, diarrhea can occur. If you get diarrhea,
[**Male First Name (un) **]??????t take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Male First Name (un) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as ??????soreness.??????
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important you take this
medicine as directed. Do not take it more frequently than
prescribed. Do not take more medicine at one time than
prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine.
If you are experiencing no pain, it is OK to skip a dose of pain
medicine.
To reduce pain, remember to exhale with any exertion or when you
change positions.
Remember to use your ??????cough pillow?????? for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
[**Name2 (NI) 5059**]:
sharp pain or any severe pain that lasts several hours
pain that is getting worse over time
pain accompanied by fever of more than 101
a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases, you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] [**Location (un) 620**] in [**6-8**]
days after your discharge. The number to call and make this
appointment is ([**Telephone/Fax (1) 6347**]. Her office location is [**Hospital1 18**]
[**Location (un) 620**], [**Street Address(2) 3001**] [**Location (un) 620**] [**Numeric Identifier **].
Completed by:[**2121-10-11**]
|
[
"311",
"733.00",
"244.9",
"585.2",
"562.10",
"567.29",
"V58.61",
"531.10",
"V15.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.41",
"96.6",
"38.97",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
8216, 8361
|
2995, 6540
|
266, 418
|
8519, 8519
|
2337, 2972
|
14513, 14949
|
1907, 1918
|
6798, 8193
|
8382, 8498
|
6566, 6775
|
8670, 9660
|
1933, 2318
|
9692, 14490
|
212, 228
|
446, 1592
|
8534, 8646
|
1614, 1743
|
1759, 1891
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,415
| 136,066
|
47033
|
Discharge summary
|
report
|
Admission Date: [**2111-12-20**] Discharge Date: [**2111-12-23**]
Service: MEDICINE
Allergies:
Ether
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
lethargy, AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]yoF with h/o Alzheimer's dementia with sensorium
disturbances, HTN, atherosclerotic disease, mitral
regurgitation, and bilateral lower extremity edema (? CHF) who
presented to the ED from her nursing home with increased
lethargy x1 day and altered mental status, with baseline AOx3.
She had reportedly fallen asleep at 930 pm and was more
difficult to arouse.
.
In the ED, initial vitals were 98.3 74 135/46 18 95%
(unclear O2). She had no specific complaints there, no cough,
fevers, anorexia, recent falls. Her exam in the ED was
reportedly non focal.
Her EKG was non-acute, CXR was with low lung volumes, but no
acute process. UA was negative and UCx pending.
.
In the ED, there was apparently a prolonged discussion with the
family about risks and benefits of admissions for unclear
etiology of non-specific lethargy and she was felt to be
improved, without signs of infection. The initial plan was to
observe her overnight with plan for family to pick her up in the
morning. However while sleeping she was noted to have some
stridorous, squeaky noises and she desatted to the mid 80's. She
was apparently uptitrated to a NRB with sats 95% but went down
to 84% on RA. She was not started on non-invasive ventilation.
She had an ABG showing a chronic respiratory acidosis:
7.29/71/123/36.
.
She is admitted to [**Hospital Unit Name 153**] for further management of NRB
requirement in the setting of a full code [**Age over 90 **] year old.
.
Of note, pt was last seen by her PCP [**2111-11-19**] at which point she
was without acute complaint other than chronic arthritic pain,
walking with her walker, fatiguing easily but getting around
with assistance. Other prior OMR notes indicate treatment with
Lasix for increasing BLE edema for ? CHF, but no echo reports
are in our system.
Past Medical History:
- Alzheimer's dementia with delusions and sundowning
- arteriosclerotic heart disease
- mitral regurgitation
- hypertension
- h/o UTI's with Klebsiella and E.coli
- depression
- lower extremity edema, ? CHF
- diffuse degenerative arthritis of the spine and arthritis of
the right knee
- S/p radical thyroidectomy for cancer of the thyroid
- S/p left knee replacement
- hearing aide in her left ear
- GERD
- varicose veins with venous stasis
- hypercholesterolemia
- s/p cataract surgery in her left eye.
Social History:
Lives in nursing home, [**Last Name (un) **] [**Last Name (un) 43131**] House, walks with walker. She
does not smoke or drink alcohol.
Family History:
NC
Physical Exam:
Exam on Admission to [**Hospital Unit Name 153**]:
p93 114/49 96% 6L NC --> 94-97% 2L NC --> 94-97% RA -->
Cheynes [**Doctor Last Name 6056**] breathing with 5-10 second apneic episodes in
which she desaturates to the mid 80's, however after taking a
breath she comes back up to the 90's. This is a cyclic pattern
witnessed through this morning.
Elderly appearing F in no distress, sleeping peacefully and
tired-appearing upon arrival to [**Hospital Unit Name 153**] in early am, however
answers questions appropriately and is conversant. Knows "[**Hospital 61**]" but think it's [**2100**].
Mouth extremely dry appearing, but is mouth breathing while
sleeping
Jugular pulsations noted just below ear
CTAB anteriorly but with mouth breathing noises
RRR with prominent mid-systolic whooshing murmur, loudest at
BUSB.
Protuberant, soft, ND abdomen with some reported tenderness in
LLQ but no grimacing, guarding, or rigidity
BLE pitting edema to mid shin with associated chronic venous
stasis changes
Pertinent Results:
LABS:
[**2111-12-19**] 11:00PM WBC-4.5 RBC-3.38* HGB-11.1* HCT-32.8* MCV-97
MCH-32.7* MCHC-33.7 RDW-13.9
[**2111-12-19**] 11:00PM GLUCOSE-176* UREA N-44* CREAT-1.8* SODIUM-137
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-31 ANION GAP-14
[**2111-12-19**] 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2111-12-19**] 11:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2111-12-20**] 05:25AM TYPE-ART PO2-123* PCO2-71* PH-7.29* TOTAL
CO2-36* BASE XS-5
CXR [**12-20**]:
Bilateral low lung volumes with minimal crowding of
bronchovascular markings, no focal consolidation, effusions, or
PTX noted. Borderline cardiomegaly.
Brief Hospital Course:
[**Age over 90 **]yoF with h/o Alzheimer's dementia with sensorium
disturbances, HTN, atherosclerotic disease, mitral
regurgitation, and bilateral lower extremity edema who presented
with lethargy and altered mental status of 1 day duration.
.
1. Hypercarbic respiratory acidosis: Pt observed to have apneic
spells while sleeping for 5-10 seconds during which time she
desaturates. It is possible that she has a component of central
sleep apnea. This may have been made worse by the recent
addition of zyprexa to her medication regimen. While being
monitored in the ICU pt declined a CPAP titration study. She and
her family would prefer not to have this study as an outpt
either as they do not feel this is consistent with pt's goals of
care. We did hold her zyprexa. Patient was saturating well on
1L NC when she was called out to the medical floor. On the
medical wards she was stable albeit mildly chronically confused.
It would be advisable to keep her off all psychotropic
medications unless absolutely needed. She was maintained on the
Citalopram as discontinuing the med may cause side effects such
as dizziness which would put her at risk for falls, and it is
unlikely that it caused her presenting symptoms.
.
2. Lethargy: Pt alert and interactive after discontinuation of
the Zyprexa. No evidence of infection including unremarkable
labs, cxr and urine cx.
.
3. LLQ pain: Only complaint on admission LLQ pain. She states
she's had this pain a long time and it comes and goes away on
its own. Abdomen was benign and not tender at all to palpation.
Suspect constipation vs other benign age-related non-specific
abdominal pain. Labs are unimpressive. Would recommend bowel
regimen as outpt. No intervention was necessary.
.
4. Chronic renal insufficiency: Her Cr of 1.8 in the ED improved
to 1.5 with IV hydration. Baseline 1.4-1.7.
.
5. Polypharmacy - given her age, several medications that were
felt to be unnecessary were disscontinued. They are: Amlodipine
(her BP was not abnormally high), Zyprexa, Lasix, Kcl, and
CIprofloxacin.
Pt was DNR/DNI on this admission
She is alert and oriented to place but not date, though did
sundown at night. She is hard of hearing. She is easily
redirectable and has not been agitated while here.
Medications on Admission:
AMLODIPINE [NORVASC] - 10 mg Tablet - one Tablet(s) by mouth
daily
CIPROFLOXACIN - 500 mg Tablet - one Tablet(s) by mouth twice a
day
CITALOPRAM - 10 mg Tablet - one Tablet(s) by mouth daily
FOLIC ACID - 1 mg Tablet - one Tablet(s) by mouth daily
FUROSEMIDE - 40 mg Tablet - one Tablet(s) by mouth b.i.d. ( a.c.
breakfast and supper)
LOVASTATIN [MEVACOR] - 20 mg Tablet - one Tablet(s) by mouth
daily
OLANZAPINE [ZYPREXA] - 5 mg Tablet - pne Tablet(s) by mouth
daily
@hs;
OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) -
one Capsule(s) by mouth daily
POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. Particle/Crystal - one
Tab(s) by mouth b.i.d. (a.c. breakfast and supper)
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (OTC) - Dosage
uncertain
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) -
Tablet
- one Tablet(s) by mouth daily
VITAMIN E - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].[**Last Name (STitle) **] [**Last Name (NamePattern4) 11378**]) - 200
unit Capsule - one Capsule(s) by mouth daily
Discharge Medications:
CITALOPRAM 10 MG PO DAILY
FOLIC ACID 1MG PO DAILY
LOVASTATIN 20 MG PO DAILY
OMEPRAZOLE 20 MG PO DAILY
CALCIUM = VITAMIN D 500MG/400 UNITS DAILY
MULTIVITAMINS ONE DAILY
VITAMIN E SUPPLEMENTS -ONE PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Chronic respiratory acidosis, likely secondary to chronic sleep
apnea
Diffuse weakness secondary to deconditioning
Chronic confusion - likely Alzheimer's dementia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to the hospital because your oxygen levels
were dropping while you were asleep. We think that this is
likely a chronic problem. [**Name (NI) **] should follow this up with your
PCP and could benefit from a device at home to treat this or
some home oxygen. Your PCP can discuss the risks and benefits of
each of these options with you. Your strength and endurance have
declined due to the hospitalization, and we believe you would
benefit from rehabilitation in a skilled nursing facility.
Followup Instructions:
Department: INTERNAL MEDICINE
When: MONDAY [**2111-12-21**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GERONTOLOGY
When: WEDNESDAY [**2112-1-13**] at 3:00 PM
With: [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11793**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"276.2",
"780.79",
"272.0",
"294.10",
"V10.87",
"454.1",
"403.90",
"327.23",
"789.04",
"331.0",
"414.01",
"715.96",
"298.9",
"721.90",
"585.9",
"424.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8118, 8184
|
4549, 6798
|
229, 236
|
8391, 8513
|
3811, 4526
|
9107, 9737
|
2769, 2773
|
7890, 8095
|
8205, 8370
|
6824, 7867
|
8576, 9084
|
2788, 3792
|
176, 191
|
264, 2074
|
8528, 8552
|
2096, 2601
|
2617, 2753
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,091
| 111,816
|
46862
|
Discharge summary
|
report
|
Admission Date: [**2115-8-17**] Discharge Date: [**2115-8-21**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
male with a history of pulmonary tuberculosis as a teenager,
and more recent history of vertebral Pott's disease treated
with 18 months of anti-tuberculous therapy as well as
vertebral stabilization, off TB therapy for the past 6
months, who presented to the Emergency Room at [**Hospital1 346**] on [**2115-8-16**] after a day of malaise
and fever. The patient reported a day of feeling unwell; he
had been taking Tylenol at home for this for at least one
day. On the morning of the 26th, he fell at home after
getting out of bed. Subsequently, the patient's wife noted a
fever to 100.6 and he received Tylenol. Later that day, he
was lethargic so his family brought him to the Emergency
Room. In the Emergency Room a chest x-ray was performed,
which showed changes in his right lung consistent with his
prior tuberculosis. A head CT and an LP were performed which
were both unremarkable. Prior to the head CT and LP, the
patient received empiric Vancomycin and Ceftriaxone for
possible meningitis. An erythematous rash was noted at the
time of presentation to the Emergency Room. The patient was
then admitted to the general medicine service for further
evaluation.
PAST MEDICAL HISTORY: 1) Pulmonary TB as a teenager in
[**Country 651**]. 2) Pott's disease status post stabilization and
debridement and 18 months of anti-TB therapy. 3) Chronic
renal failure - creatinine 1.6 - thought secondary to
Rifampin induced nephritis. Was on hemodialysis for a year
but this was stopped as his renal function improved. 4)
Hypertension. 5) Hypothyroidism. 6) Prostate cancer status
post XRT. 7) Recurrent UTI's.
MEDICATIONS: Tylenol, Synthroid 50 mcg per day, Prilosec 20
mg per day, Nephrocaps one per day.
ALLERGIES: Vancomycin (red man's syndrome), Fluoroquinolones
(erythroderma), Unasyn (?), Benadryl (urinary retention),
Rifampin (nephritis), Pyrazinamide.
SOCIAL HISTORY: Former [**University/College **] professor of engineering. Quit
smoking many years in the past.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Rash for approximately one day.
PHYSICAL EXAMINATION: Temperature 100.6, heart rate 90's,
blood pressure 130's/80's, O2 sat 100% on room air. General:
The patient was alert but noted to be lethargic. HEENT:
Anicteric sclera. Oropharynx unremarkable. No JVD. Thorax,
lungs clear to auscultation bilaterally. Cardiac, regular
pulse, first and second heart sounds, regular rate and
rhythm, no murmurs. Abdomen, bowel sounds positive, soft,
nontender, nondistended. Extremities, no edema. Skin,
diffuse erythema over the back and portions of the lower
extremities.
LABORATORY DATA: On admission, white blood cell count 15.6,
hematocrit 40.2, platelet count 224,000, sodium 143,
potassium 4.5, chloride 103, CO2 22, BUN 31, creatinine 1.8,
glucose 120. Differential on the patient's CBC was 89%
neutrophils, 8% bands, 2% lymphocytes. Lumbar puncture
revealed one white blood cell and 89 red blood cells. The
protein was 29 and glucose 69. Gram stain was negative.
Chest x-ray, right lower lobe nodules and right upper lobe
calcified granulomas, unchanged in appearance.
Head CT, no acute process.
HOSPITAL COURSE:
1. Dermatologic: Over the first 36 hours of his hospital
course, the patient's initial erythematous rash progressed to
bullous changes with desquamation. The area most severely
involved initially was the patient's back. On the third
hospital day, the patient was transferred to the ICU for
better monitoring, wound care and management of his diffuse
erythroderma. The dermatology and plastic surgery services
were consulted. Aggressive fluid replacement for the
patient's insensible losses was provided. As there was
initial concern for a staph scalded skin syndrome,
anti-staphylococcal coverage was provided with Linezolid and
Clindamycin. The differential diagnosis for the patient's
skin condition was staph scalded skin syndrome vs toxic
epidermal necrolysis. Biopsies were performed of the
involved skin. An initial biopsy showed full thickness
necrosis consistent with toxic epidermal necrolysis; a
subsequent biopsy was more suggestive of bullous erythema
multiforme; however, the patient's clinical progression was
felt most consistent with TEN. Exposed areas of skin were
covered with Silver Sulfadiazine and Xeroderm dressings.
IVIG was initiated on [**2115-8-20**] when biopsy results were
obtained. The patient received two doses of 25 gm of IVIG.
Morphine was provided for pain control. The patient's skin
involvement progressed to involve approximately 70-80% of his
body surface area, including the back, abdomen, and all
extremities. The etiology of the TEN was unclear; his only
new preadmission medication was Tylenol; the TEN may have
represented a reaction to Tylenol. He did also receive
Vancomycin and Ceftriaxone in the Emergency Room empirically;
however, he clearly had a rash and developing illness prior
to admission.
2. Fluids, Electrolytes & Nutrition: Aggressive hydration
was provided due to the patient's large insensible losses.
Initially this was done with D5 .9 normal saline; this was
subsequently changed to .9 normal saline. The patient's
sodium remained stable in the 130 to 135 range. Electrolytes
were checked q 8 hours with frequent repletion necessary.
The patient's albumin declined to 2.4 by the fourth hospital
day. The patient continued to take an oral diet, but tube
feeds were to be initiated due to the patient's large
nutritional needs.
3. ID: All blood and tissue cultures were negative for
organisms. CSF culture was also negative. The Clindamycin
was discontinued after preliminary result suggested TEN. The
Linezolid was continued on the advice of the ID service.
Contact precautions were undertaken and Silver Sulfadiazine
was used to prophylax against skin infections. On the last
hospital day the patient spiked a fever to 101.5 and repeat
cultures were performed.
4. Renal: The patient has chronic renal failure. During
the second hospital day the patient's creatinine rose to 2.4,
but this acute renal failure resolved with aggressive fluid
repletion. A Foley catheter was placed on the last hospital
day after much discussion with his family, who is reluctant
to allow this in light of past problems with catheter
associated urinary tract infections.
5. Cardiovascular: The patient remained hemodynamically
stable throughout his ICU course.
6. Access: The patient had a left internal jugular catheter
placed on [**2115-8-19**].
7. Hematology: The patient's hematocrit dropped from an
initial level of 40 to a level of 30 following hydration. On
the last hospital day, the hematocrit fell to 27. White
blood cell count also fell to 3.8 from 8.2. The fall in
counts on the last hospital day raised the concern of an
affect of the Silver Sulfadiazine vs developing
superinfection.
DISPOSITION: In light of the patient's extensive skin
losses, a burn unit was felt to be the best location for
patient's further management. After contacting the local
burn units, the patient was accepted for transfer to [**Hospital6 99434**]. The patient was transferred to [**Hospital6 99434**] Burn Unit on [**2115-8-21**].
TRANSFER MEDICATIONS: Linezolid 600 mg po bid, Protonix 40
mg per day, Synthroid 50 mcg per day, Morphine prn, .9 normal
saline, IVIG status post two doses of 25 gm out of a planned
five day course, Silver Sulfadiazine to exposed areas.
DISCHARGE DIAGNOSIS:
1. Toxic epidermal necrolysis.
2. Acute renal failure.
3. Chronic renal failure.
4. Hypertension.
5. Hypothyroidism.
DISCHARGE STATUS: Stable.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 99435**]
MEDQUIST36
D: [**2115-8-27**] 18:18
T: [**2115-9-3**] 17:52
JOB#: [**Job Number 36802**]
|
[
"593.9",
"V12.01",
"287.5",
"E935.4",
"733.09",
"V45.1",
"276.5",
"584.9",
"695.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
2151, 2169
|
7595, 8035
|
3318, 7335
|
2245, 3301
|
2189, 2222
|
7358, 7574
|
111, 1318
|
1341, 2019
|
2036, 2134
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,687
| 155,442
|
14632
|
Discharge summary
|
report
|
Admission Date: [**2183-6-12**] Discharge Date: [**2183-6-24**]
Service: MEDICINE
Allergies:
Bactrim / Macrodantin / Cipro / Zithromax
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 yo woman with h/o dementia, orthostatic hypotension, TIA, PAF
(not on coumadin), severe CAD, and other medical problems listed
below. She was at her nursing home last night and had a
wittnessed fall. According to CRNA she 'got up" and "lost her
balance". She did not report any symptoms prior to
falling. Struck her head on the ground and was unresponsive for
about 5 seconds. Nursing notes from the nursing home report SBP
to be 190 and heart rate in 60s. No finger stick seen. Then was
per EMS confused, unable to follow commands, aggitated, but
apparently oriented to time of day and place.
At [**Hospital3 7571**]Hospital was reportedly "alert and confused at
baseline". Received Dilantin 1gm as well as 2mg Morphine for
pain control during laceration repair.
On arrival to [**Hospital1 18**] ED was noted to be responsive only to
sternal
rub, but spontaneously moving purposefully in all 4 extremities.
Has started waking up just slightly since arriving to ED.
Per Nursing home, patient is on Keflex (since [**6-9**] PM) for 7 day
course, treating UTI. Has h/o recurrent UTIs.
Per nursing home, patient has had "twitching" in her legs for
some time now, which they have been suspecting was "restless leg
syndrome". The patient was to be seeing a neurologist soon to
get
this worked up.
Past Medical History:
CAD:
-- s/p NSTEMI '[**77**]
-- CABGx4 [**6-7**] (Lima->LAD, SVG->PDA, OM2, D1)
-- [**3-9**] DES to LCX and RCA, all SVGs noted to be occluded
-- [**4-10**] DES to Lcx and RCA
-- stress testing last year per notes with possible inferior
ischemia
h/o PAF, s/p pacer for tachy-brady syndrome [**10-10**],
CHF diastolic dysfunction EF 60% 4/05
HTN
orthotatic hypotension
TIA
gerd
CRI baseline 1.8
DM2
h/o breast cancer s/p mastectomy
cataracts s/p lens implants
bladder cancer '[**68**] tx with chemo
chronic anemia
recurrent UTIs
dementia
h/o GIB
diverticulosis
Social History:
no tobacco, etoh, or illicits
Family History:
non-contributory
Physical Exam:
T- 98.0 BP-124/47 HR-60 RR-18 O2Sat96 RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
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: eyes closed. Occasionally moving spontaneously,
purposefully and antigravity in all 4 ext equally. Opens eyes
briefly to voice, fixes gaze, then closes eyes and refuses to
open. Does not follow any commands. Localizes pain in all 4
ext.
Cranial Nerves:
Pupils surgical bilaterally and fixed. Eyes conjugate and
crosses
slightly past midline bilaterally. Face symetric. Hearing
grossly intact. Could not participate with CN 9/10/11/12
testing.
Motor:
Atrophy in feet bilaterally with hammer toes. Tone mildly
paratonic left greater than right. Intermittent twitches/jerks
occuring every 1-2 seconds. Non-rythmic and not symetric.
Occuring in all 4 extremities as well as in trunk adn occuring
asynchronously.
Cannot assess pronator drift
Strength is antigravity in all 4 ext.
Sensation: withdraws equally x 4 to nox stim.
Reflexes:
+1 and symmetric throughout.
Toes up bilaterally
Coordination: could not assess
Gait: could not assess.
Romberg: could not assess
Brief Hospital Course:
84 yo woman with h/o dementia, orthostatic hypotension, PAF
(not on coumadin), CHF, and other multiple medical problems as
listed above, who presents as transfer from OSH with presumed
traumatic SAH in multiple locations.
.
# SAH: as above, thought to be due to fall/trauma. Pt was
evaluated by neuro and neurosurgery. Medical management
recommended. EEG completed without epileptiform wave patterns.
Pt completed a course of sz prophylaxis, 5 days dilantin
switched to Keppra for possibility of improvement of sedation
and 7day course completed; Repeat head CT was done because of
sedation, showed improvement in SAH. Sedation improved 2 days
prior to discharge with increased activity and improved PO
intake. Anticoagulants were held during this hospitalization. Pt
worked with physical therapy and occupation therapy. Infectious
workup for initial MS changes was negative. Swallow evaluations
were done [**2183-6-16**] recommendations were to advance to a diet of
thin liquids and soft consistency solids with 1:1 supervision to
assist with feeding, Pills should be given whole with thin
liquid.
.
# Fall: Her fall per report was from losing her balance, and
there was no report of pre-syncope. However, she does have
history of orthostatic hypotension and the fall could be
secondary to that. The patient also has h/o PAF, CHF and severe
CAD, so her fall could have been pre-syncope/sycnope secondary
to arrythmia. However, EP evaluated her pacer, which was
functioning well and showed no suspicous events. Pt was
monitored on telemetry without events and maintained on fall
precautions.
.
# Mental status change: on admission, pt's MS reportedly
significantly off baseline and worse than at [**Location (un) **]. The repeat
CT scan here does not show any SDH or intraventricular bleed,
but the SAH itself could be affecting her Mental status.
Subclinical seizures need to be considered. Additionally, her
recent Dilantin load and Morphine with renal failure could be
contributing to her depressed mental status. The patient's
movement disorder is difficult to classify. Per nursing home,
this is new within the last year. She also appears to have some
significant atrophy, particularly in the feet. Her mental status
improved significantly the last 3 days prior to discharge.
.
# long term care goals- Discussed pt's poor PO intake with
family over the phone; they would like to avoid NGT/PEG and
rather would like to keep pt comfortable. They understood pt's
poor prognosis if she is undernourished.
.
# CAD: s/p CABG, last stented ~1yr ago. ASA & plavix held b/c
of bleed. Troponin slightly elevated in setting of dehydration
and acute renal failure, EKG unchanged. CK not elevated.
.
# acute renal failure- due to dehydration. Improved with IVF
hydration.
.
# DM: treated with ISS
.
# Code: DNR/DNI
Medications on Admission:
Amiodarone 200 daily
Norvasc 2.5 daily
ASA 81 daily
FeS04 325 daily
Elvoxyl 50 mcg daily
Lipitor 80 daily
Plavix 75 daily
Prilosec OTC daily
Zetia 10 daily
Colace 100 [**Hospital1 **]
Labetolol 200 [**Hospital1 **]
Keflex 500 PO TID started [**6-9**] PM for 7 day course fo UTI
PRNs: Tylenol, Dulcolax, MOM, Oxycodone
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Ezetimibe 10 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. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Labetalol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed.
15. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): please see sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
primary
subarachnoid hemorrhage
secondary
mental status change
acute renal failure
Discharge Condition:
stable
Discharge Instructions:
Please notify your primary care physician if you have
fever/chills, chest pain/shortness of breath,
headache/dizzyness.
Please follow up with your appointments and take all of your
medications as directed.
Followup Instructions:
Please follow up with [**Last Name (LF) **],[**First Name11 (Name Pattern1) 2515**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 3947**]. [**Telephone/Fax (1) 17030**] within
2 weeks time.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"285.21",
"412",
"V10.51",
"276.51",
"585.9",
"428.30",
"276.0",
"403.90",
"852.02",
"V10.3",
"V45.81",
"250.00",
"294.8",
"584.9",
"414.00",
"427.31",
"E885.9",
"530.81",
"V45.82",
"599.0",
"311",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8036, 8122
|
3640, 6455
|
253, 260
|
8250, 8259
|
8513, 8840
|
2234, 2252
|
6824, 8013
|
8143, 8229
|
6481, 6801
|
8283, 8490
|
2267, 2612
|
209, 215
|
288, 1586
|
2905, 3617
|
2651, 2889
|
2636, 2636
|
1608, 2170
|
2186, 2218
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,930
| 103,429
|
9464
|
Discharge summary
|
report
|
Admission Date: [**2161-10-20**] Discharge Date: [**2161-10-25**]
Date of Birth: [**2078-12-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue and lightheadedness
Major Surgical or Invasive Procedure:
[**2161-10-20**] Aortic Valve Replacement (21 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic-tissue)
History of Present Illness:
82 year old female with known aortic stenosis which has been
followed by serial echocardiograms over the past 10 years. Her
most recent echocardiogram revealed an increased mean systolic
gradient from 72 mm Hg to 93 mmHg with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.3cm2. Ms.
[**Known lastname 32245**] is fairly adament that she does not experience any
symptoms related to her disease however, when pressed, over the
last couple of months she reports mild intermittent
lightheadedness and increasing fatigue. At one point she did
experience some chest pain with walking however this is not a
frequent occurrence. Overall she is very active, climbing a
couple of flights of stairs with laundry and or groceries daily.
She denies any palpitations or syncope. Given the severity of
her disease, she now presents for surgical consultation.
Past Medical History:
Aortic Stenosis s/p Aortic valve replacement
Past medical history:
- Moderate MR
- Non sustained VT, NSVT, multifocal VEA on Holter [**2157-12-22**]
- Peripheral vascular disease
- Mild Carotid Artery Disease
- Anemia - [**2152**] found incidentally, GI workup was negative
except
for the "beginning of Barrett's Esophagus. Received 11 units of
PRBC. No recent bleeding or further work. She avoids Aspirin.
- History of hematochezia. W/U negative and this resolved. FeSO4
started.
- Irritable Bowel Syndrome
- Dyslipidemia
- Hypertension
- Vulvodynia
- Rheumatic fever at age 7
- Vertigo
Past Surgical History:
- s/p Tonsillectomy
- s/p Vocal Chord Nodule Excision (benign)
- Cataract surgery OD. Awaiting surgery for OS.
- D+C
- Cystoscopy
- H/O Varicose vein sclerosing therapy. (Posteriorly in thighs
Social History:
Race: Caucasian
Last Dental Exam: 3 weeks ago
Lives alone. Widow and lost her husband in [**2160-11-12**] with
dementia. She lives in [**Hospital1 3494**] MA. She has three supportive
children.
Contact: Phone #
Occupation: Retired
Cigarettes: Smoked no [X] yes [] Hx:
Other Tobacco use:
ETOH: < 1 drink/week [X] [**1-19**] drinks/week [] >8 drinks/week []
Illicit drug use: Never
Family History:
No premature coronary artery disease. Father with valvular heart
disease and RHD. Died at 62.
Physical Exam:
Pulse: 60 Resp: 16 O2 sat: 99%
B/P Right: 148/75 Left: 149/69
Height: 5"3" Weight: 150 lbs
General: WDWN in NAD. Appears younger then stated age.
Skin: Warm, Dry and intact. Faint inframammary
erythematous/scaly
rash c/w fungal infection.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, NlS1-S2, IV/VI harsh systolic ejection murmur.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema- trace left, none
on right
Varicosities: Multiple distal lspider varicosities. Dilated
veins
posteriorly and laterally. GSV appears suitable on standing.
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Transmitted R>L
Pertinent Results:
[**2161-10-20**] Echo: PRE-BYPASS: 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
moderate 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. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. The
mitral valve leaflets are myxomatous. Mild to moderate ([**12-14**]+)
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 AV paced. The patient is on no
inotropes. Biventricular function is unchanged. There is a
well-seated bioprosthetic valve in the aortic position. There is
a mean gradient of 12 mmHg at a cardiac output of 3.2 L/min. No
aortic regurgitation is seen. No paravalvular leak is seen.
Mitral regurgitation is mild (1+). The aorta is intact
post-decannulation.
Brief Hospital Course:
The patient was brought to the operating room on [**10-18**] where the
patient underwent Aortic valve replacement 21-mm St. [**Hospital 923**]
Medical Biocor tissue valve.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. Pt went into afib post op. Amio
was started. pt in afib longer then 24 hrs. Coumadin was
iniated, Now on a amio taper with coumadin ofr new onset afib.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility.
By the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to rehab in good
condition with appropriate follow up instructions.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 0.5
(One half) Tablet(s) by mouth once a day
PREGABALIN [LYRICA] - (Prescribed by Other Provider) - 100 mg
Capsule - 1 (One) Capsule(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth once a day
Medications - OTC
FERROUS SULFATE - (OTC) - 325 mg (65 mg iron) Tablet - 1 (One)
Tablet(s) by mouth every other day
FOLIC ACID -
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. pregabalin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): TAPE 400 [**Hospital1 **] X 7 DAYS, THEN 200 [**Hospital1 **] X 7 DAYS, THEN 200
QD UNTILL F/U WITH PCP.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
GOAL IS 2=3, FOR AFIB. PLEASE FOLLOW INR.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days: HOLD FOR K
OF GREATER THEN 4.5.
16. INSULIN
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 0 Units
160-199 mg/dL 4 Units 4 Units 4 Units 2 Units
200-239 mg/dL 6 Units 6 Units 6 Units 4 Units
240-280 mg/dL 8 Units 8 Units 8 Units 6 Units
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic valve replacement
Past medical history:
- Moderate MR
- Non sustained VT, NSVT, multifocal VEA on Holter [**2157-12-22**]
- Peripheral vascular disease
- Mild Carotid Artery Disease
- Anemia - [**2152**] found incidentally, GI workup was negative
except
for the "beginning of Barrett's Esophagus. Received 11 units of
PRBC. No recent bleeding or further work. She avoids Aspirin.
- History of hematochezia. W/U negative and this resolved. FeSO4
started.
- Irritable Bowel Syndrome
- Dyslipidemia
- Hypertension
- Vulvodynia
- Rheumatic fever at age 7
- Vertigo
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
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) **] ([**Telephone/Fax (1) 170**]) on [**2161-11-25**] at 1pm in the
[**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **]., [**Hospital Unit Name **].
Cardiologist: Dr. [**Last Name (STitle) **] on [**2161-11-13**] at 1;30pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name (STitle) 15316**] [**Name (STitle) 12646**] ([**Telephone/Fax (1) 4615**]) in [**3-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2161-10-25**]
|
[
"E878.1",
"401.9",
"427.31",
"997.1",
"788.20",
"396.2",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
8764, 8835
|
5062, 6318
|
329, 454
|
9467, 9639
|
3642, 5039
|
10562, 11256
|
2606, 2701
|
6818, 8741
|
8856, 8901
|
6344, 6795
|
9663, 10539
|
1977, 2171
|
2716, 3623
|
262, 291
|
482, 1343
|
8923, 9446
|
2187, 2590
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,155
| 123,755
|
46986
|
Discharge summary
|
report
|
Admission Date: [**2116-11-9**] Discharge Date: [**2116-11-14**]
Date of Birth: [**2033-7-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Known Throacic Aortic Aneurysm
Major Surgical or Invasive Procedure:
[**2116-11-9**] - PROCEDURE: Endovascular thoracic aortic aneurysm
repair, one distal extension, left common iliac conduit 10-mm
Dacron
graft. [**Doctor Last Name 4726**] TAG 45-20 times two
[**2116-11-9**] - PROCEDURES:
1. Stent graft repair of thoracoabdominal aortic aneurysm
using two [**Doctor Last Name 4726**] TAG endoprostheses. The TAG graft data is
the following: The first [**Doctor Last Name 4726**] graft is catalog number
[**Serial Number 99640**], lot number [**Serial Number 99641**]. The second one is
reference catalog number [**Serial Number 99640**], lot number [**Serial Number 99642**].
2. Thoracic and abdominal aortography.
3. Left iliac conduit placement performed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and his colleagues for stent graft deployment.
History of Present Illness:
The patient is an elderly female with a known greater than 8-cm
thoracic aneurysm. She has been worked up by Dr.[**Last Name (STitle) **] as an
outpatient and presented to [**Hospital1 18**] on [**11-9**] for definitive repair
and magagement of her aneurysm.
[**Last Name (NamePattern4) **]dical History:
Coronary artery disease, hyperlipidemia, Hypertension, Diabetes
Mellitus II, Chronic renal insuficiency, hearing loss, macular
degeneration, thoracic aneurysm status post repair in [**2111-8-24**] by Dr. [**Last Name (STitle) **] Le [**Doctor Last Name **], sciatica, diverticulosis, colonic
polyps, cerebral microvascular disease, proteinuria,
cholelithiasis, venous stasis disease, hemorrhoids, sciatica,
and peripheral vascular disease.
Past surgical history is notable for hysterectomy, pilonidal
cyst surgery, multiple polypectomies, and an aortic repair in
[**2111-8-24**].
Social History:
Currently, she is retired. She lives in [**Location 1456**] with her
daughter. She is an active smoker for greater than 50 years.
Her last dental examination was oughly a year ago. She drinks
one or two drinks a couple of evenings per week.
Physical Exam:
On Discharge:
Temp 97.1, HR 66, BP 132/60, RR 20, O2 99%
Gen: Well, NAD, Alert and oriented
CV: RRR, No R/G/M
Resp: Lungs clear to ausculation bilaterally
ABD: Soft, Non-tender, non-distended
Ext: [**Name (NI) **] PT and DP signals in bilateral lower extremity
Groin: puncture site C/D/i with no erythema, hemotoma, or
swelling
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 99643**] (Complete)
Done [**2116-11-9**] at 9:20:00 AM FINAL
1. The left atrium and right atrium are normal in cavity size
with a hypertrophied septum. No atrial septal defect is seen by
2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic root is mildly dilated at the sinus level. The
ascending aorta graft material is seen. The aortic arch is
mildly dilated. The descending thoracic aorta is moderately
dilated. There are simple atheroma in the descending thoracic
aorta. There is spontaneous echo contrast and thrombus along the
wall (diameter measures 4.5x5cm).
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. Trace
aortic regurgitation is seen.
6. The mitral valve leaflets are structurally normal. Mild to
moderate ([**12-25**]+) mitral regurgitation is seen.
7. There is no pericardial effusion.
8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2116-11-9**]
at 930.
9. Surgeons used fluroscopy to check for endoleaks rather than
request TEE.
Brief Hospital Course:
Pt was admitted to [**Hospital1 18**] on [**2116-11-9**] and underwent endovascular
repair of her thoracic aortic aneurysm. Pt tolerated the
procedure well. For full detail please see operative reports. Pt
went to the ICU post-operatively and remained intubated due to
low tidal volumes. Pt remained on a fentanyl drip for pain
control and was placed on an insulin sliding scale for tight
glycemic control post-operatively. Pt was extubated the morning
of POD1 on [**11-10**]. Pt was weaned on nitroglycerin drip. On [**11-11**]
diet was begun and advanced to clears the lumbar drain was
removed. The pt was transferred from the ICU to the VICU
stepdown unit, the PA catheter and arterial line were removed.
BP was controlled with lopressor. Pt began to work with physical
therapy on [**11-12**]. BP management was transitioned to her home
medications of amlodipine, Atenolol, and enalapril. Home
medications were restarted. Noted on telemetry, pt had several
asymptomatic episodes of bradycardia. The cardiology service was
consulted who recommended changing her blood pressure management
to Losartan and discontinuing her previous home medications.
There were no further bradycardic events after this change was
made and her pressures were well controlled. On [**11-13**] physical
therapy continued as pt was still quite unsteady. Pt was
discharged home on [**11-14**] with home physical therapy, tolertating
a regular diet.
Medications on Admission:
Amlodipine 5, ASA 325, Atenolol 50, Diuril 250, Enalapril 20",
Metformin 250, Glipizide 5
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Chlorothiazide 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metformin 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Thoracic Aortic Aneurysm
Discharge Condition:
Good
Discharge Instructions:
Your heart rate was slow bradycardic seveal times while at
[**Hospital1 18**]. Per Cardiology recommendations your Amlodipine, Atenolol
and enalapril were stopped and you were started on a new
medication, Losartan. This medication may need to be increased
or decreased depending on your heart rate and blood pressure.
You should follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week
to determine if this medication needs to be adjusted.
Division of Vascular and Endovascular Surgery
Endovascular Aortic Aneurysm Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-26**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-29**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1241**]
Date/Time:[**2116-11-18**] 3:00
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2116-12-15**] 1:00
Please follow-up with your Primary Care Physician [**Last Name (NamePattern4) **] 1 week to
address your recent change in blood pressure medication.
|
[
"443.9",
"V12.72",
"585.9",
"459.81",
"272.4",
"427.89",
"403.90",
"724.3",
"562.10",
"E942.9",
"362.50",
"455.6",
"414.01",
"389.9",
"E942.6",
"250.00",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"39.73",
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
6105, 6180
|
4154, 5582
|
346, 1179
|
6249, 6256
|
2720, 4131
|
9313, 9767
|
5722, 6082
|
6201, 6228
|
5608, 5699
|
6280, 8733
|
8759, 9290
|
2372, 2372
|
2386, 2701
|
276, 308
|
1207, 2095
|
2111, 2357
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,827
| 148,365
|
3278
|
Discharge summary
|
report
|
Admission Date: [**2183-1-18**] Discharge Date: [**2183-1-24**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Intubation [**2183-1-18**], extubation [**2183-1-22**]
History of Present Illness:
HPI: This is a 82 year old man with PMH significant for cardiac
arrest 2 months ago complicated by prolongen intubation, ATN, GI
bleed, pneumonia, during G tube placement procedure, who
presents from [**Hospital3 **] after an episode of hypotension the
morning of [**2183-1-18**]. He was thought to still be mentating but
concern was raised for infection.
.
In the ED, he was found to be hypotensive to the 80's with a
temp of 103.8 degrees rectally. He was given 500 mg flagyl IV
and blood cultures were sent. O2 sat dropped to 77% and the
decision was made by his son in the room to reverse his DNR/DNI
status to intubate him. His blood pressure fell to SBP 70's and
dopamine was started, but this was changed to levophed after it
was not found to be effective. His SBP's remained in the 70's
but then gradually increased after fluid resissitation with 2L
of fluid and titrating up levophed. He was given 100 of
hydrocort once. A groin line was placed and he was transferred
to the MICU after confirming with the son that this patient
would want full medical measures administered.
Past Medical History:
PMH:
cardiac arrest [**9-20**]
pneumonia
Proteus bacteremia
GI bleed x 1 with small HCT drop 8/05
acute renal failure from ATN, baseline CR 1.5
adrenal insufficiency
Zosyn induced thrombocytopenia
hypopituitarism
pituitary adenoma
hypothyroidism
osteoarthritis
BPH
depression
UTI
OSA
traumatic encephalopathy in [**2168**]
cholecystecomy
Social History:
SH: The patient is a resident at [**Hospital3 **].
Family History:
FH: Noncontributory
Physical Exam:
PE: Tm 103.8 Tc 96.3 BP 109/63 P81 R17 O2 100%
Ventilated AC 650x16 80% PEEP 10 ABG 7.25/35/80
Gen: opens eyes, moves to simple command, intubated. larger
build.
HEENT: PERRLA, OP with ETT in place
Resp: coarse rhonchi bilaterally
CV: irreg rhythm, low pitched systolic murmur across precordium
Abd: soft NTND + normoactive bowel sounds. PEG tub in place
Ext: left arm erythmatous, legs with marked pedal edema
bilaterlly, warm to touch, 2+ radial pulses bilaterally
Neuro: nonverbal, intubated, responsive to pain
Pertinent Results:
CT Head:
1. No evidence of acute intracranial hemorrhage.
2. Pituitary macroadenoma as previously described.
3. Hypodensity within the cerebral periventricular white matter,
consistent with chronic microvascular disease.
4. Mucosal thickening within the visualized paranasal sinuses
and left mastoid air cells.
.
CT Abdomen/Pelvis:
1 Bibasilar consolidations versus atelectasis. This may
represent the source of the patient's fever. There is no acute
inflammatory pathology identified within the abdomen and pelvis
to account for the patient's symptoms otherwise.
2 Trace amount of free fluid in the abdomen, greatest in the
left upper quadrant surrounding the spleen and superior
posteriorly. There is also trace free fluid in the pelvis
adjacent to a loop of distal ileum that is unremarkable in
appearance.
3 Sluggish enhancement of the kidneys, consistent with medical
disease.
4 Ill-defined hypodensities within the liver, which may
represent irregular fatty infiltration.
5. Sclerosis and thickening of the left ileum, which may
represent Paget's disease.
.
EKG: Irregular sinus rhythm with PAC's. Low signal. No ST
changes or Q waves.
.
CXR: no acute cardiopulmonary process, left base with
atelectasis
.
Labs: See below for full. Notable for WBC = 30 with 73 N and no
bands, HCt 47-> 37 post hydration, lactate 8.4, creatinine
1.7->2.1 post fluid, bicarb 17-> 19 after 1 amp bicarb, ABG as
above
.
[**2183-1-18**] 11:56PM LACTATE-12.1*
[**2183-1-18**] 09:16PM TYPE-ART PO2-82* PCO2-23* PH-7.12* TOTAL
CO2-8* BASE XS--20
[**2183-1-18**] 09:16PM LACTATE-12.6*
[**2183-1-18**] 09:05PM GLUCOSE-255* UREA N-47* CREAT-1.9* SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-7* ANION GAP-30*
[**2183-1-18**] 09:05PM CK(CPK)-101
[**2183-1-18**] 09:05PM CK-MB-11* MB INDX-10.9* cTropnT-0.28*
[**2183-1-18**] 09:05PM CALCIUM-7.1* PHOSPHATE-4.4 MAGNESIUM-2.7*
[**2183-1-18**] 09:05PM WBC-38.4* RBC-4.48* HGB-13.6* HCT-41.5 MCV-93
MCH-30.4 MCHC-32.8 RDW-16.0*
[**2183-1-18**] 09:05PM NEUTS-91.8* LYMPHS-6.0* MONOS-1.9* EOS-0
BASOS-0.3
[**2183-1-18**] 09:05PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+
[**2183-1-18**] 09:05PM PLT COUNT-278
[**2183-1-18**] 08:15PM LACTATE-12.2*
[**2183-1-18**] 07:12PM LACTATE-11.8*
[**2183-1-18**] 06:29PM TYPE-ART TEMP-35.7 TIDAL VOL-650 PEEP-8 O2-60
PO2-90 PCO2-28* PH-7.14* TOTAL CO2-10* BASE XS--18
INTUBATED-INTUBATED
[**2183-1-18**] 06:29PM LACTATE-10.2*
[**2183-1-18**] 05:30PM CORTISOL-60.7*
[**2183-1-18**] 05:08PM TYPE-ART TEMP-35.7 RATES-16/ TIDAL VOL-650
PEEP-10 O2-100 PO2-93 PCO2-32* PH-7.16* TOTAL CO2-12* BASE
XS--16 AADO2-587 REQ O2-96 INTUBATED-INTUBATED
COMMENTS-MISMATCHED
[**2183-1-18**] 05:08PM LACTATE-9.2*
[**2183-1-18**] 05:00PM CORTISOL-74.2*
[**2183-1-18**] 04:48PM TYPE-MIX
[**2183-1-18**] 04:48PM HGB-13.3* calcHCT-40 O2 SAT-75
[**2183-1-18**] 03:54PM TEMP-35.7 RATES-14/8 TIDAL VOL-600 PEEP-8
O2-100 PO2-174* PCO2-35 PH-7.18* TOTAL CO2-14* BASE XS--14
AADO2-503 REQ O2-85 INTUBATED-INTUBATED
[**2183-1-18**] 03:54PM LACTATE-8.4*
[**2183-1-18**] 02:41PM GLUCOSE-155* UREA N-51* CREAT-2.1* SODIUM-141
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-19* ANION GAP-20
[**2183-1-18**] 02:41PM ALT(SGPT)-173* AST(SGOT)-165* LD(LDH)-447*
CK(CPK)-61 ALK PHOS-78 AMYLASE-83 TOT BILI-0.9
[**2183-1-18**] 02:41PM LIPASE-90*
[**2183-1-18**] 02:41PM CK-MB-NotDone cTropnT-0.34*
[**2183-1-18**] 02:41PM ALBUMIN-2.1* CALCIUM-7.0* PHOSPHATE-3.1
MAGNESIUM-1.3*
[**2183-1-18**] 02:41PM TSH-0.09*
[**2183-1-18**] 02:41PM FREE T4-0.7*
[**2183-1-18**] 02:41PM CORTISOL-83.4*
[**2183-1-18**] 02:41PM WBC-26.0* RBC-3.94* HGB-11.9*# HCT-37.3*#
MCV-95 MCH-30.1 MCHC-31.9 RDW-16.0*
[**2183-1-18**] 02:41PM PLT COUNT-240
[**2183-1-18**] 02:41PM PT-16.5* PTT-58.4* INR(PT)-1.9
[**2183-1-18**] 02:41PM FIBRINOGE-325 D-DIMER-2057*
[**2183-1-18**] 02:13PM TYPE-ART PO2-80* PCO2-35 PH-7.25* TOTAL
CO2-16* BASE XS--10
[**2183-1-18**] 02:13PM LACTATE-7.7* K+-3.5
[**2183-1-18**] 02:13PM O2 SAT-93
[**2183-1-18**] 02:13PM freeCa-1.04*
[**2183-1-18**] 11:55AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2183-1-18**] 11:55AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2183-1-18**] 11:55AM URINE RBC-[**4-20**]* WBC-[**4-20**] BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2183-1-18**] 11:55AM URINE URIC ACID-FEW
[**2183-1-18**] 11:52AM LACTATE-8.4*
[**2183-1-18**] 11:30AM GLUCOSE-133* UREA N-53* CREAT-1.7* SODIUM-134
POTASSIUM-5.3* CHLORIDE-97 TOTAL CO2-17* ANION GAP-25*
[**2183-1-18**] 11:30AM ALT(SGPT)-71* AST(SGOT)-89* LD(LDH)-546* ALK
PHOS-116 TOT BILI-1.1
[**2183-1-18**] 11:30AM LIPASE-95*
[**2183-1-18**] 11:30AM TSH-0.14*
[**2183-1-18**] 11:30AM WBC-30.9*# RBC-5.01 HGB-15.1 HCT-47.5 MCV-95
MCH-30.1 MCHC-31.7 RDW-15.5
[**2183-1-18**] 11:30AM NEUTS-73* BANDS-0 LYMPHS-17* MONOS-3 EOS-0
BASOS-1 ATYPS-6* METAS-0 MYELOS-0
[**2183-1-18**] 11:30AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2183-1-18**] 11:30AM PLT SMR-NORMAL PLT COUNT-334# PLTCLM-1+
Brief Hospital Course:
Hospital Course:
82 year old male with a history of panhypopituitarism, recent
cardiac arrest, pneumonia requiring intubation, admitted on
[**2183-1-18**] from [**Hospital3 **], with vancomycin-resistant
enterococcus (VRE) urosepsis and MRSA PNA.
.
# Septic Shock:
Etiology of septic shock was likely VRE urosepsis and MRSA
pneumonia, with positive urine culture and positive sputum
culture. Stool culture was negative, and C diff was also
negative x 1. CT abdomen/pelvis was negative for an
intraabdominal source. The patient was admitted to the MICU,
where he gradually improved on Linezolid and Ceftazidime (the
patient had briefly been on Vancomycin at the start of
admission). The patient had a RIJ and a left A line placed. He
was intubated, received one dose of hydrocort, and was supported
hemodynamically with Levophed (dopamine pressor was changed to
levophed, since dopamine was not working well). MAP readings
were maintained > 65. The patient improved and was weaned off
of pressors on [**2183-1-21**]. The patient was weaned off the
ventilator, with RSBI<80, and was extubated without complication
on [**2183-1-22**]. The patient's code was changed to DNR/DNI per
patient's son. [**Name (NI) **] on discharge is for ceftazidime and
linezolid to continue for 6 more days, to treat VRE in the urine
and MRSA in the sputum.
.
# Hypoxic Respiratory Failure:
The patient was hypoxic in the ED, with sats to 77%. Code
status was changed from DNR/DNI by patient's son (health care
proxy), and the patient was intubated. CXR and CT chest showed
a LLL pneumonia with effusion, with mild volume overload. By
ultrasound, the effusion was not large enough to tap. The
patient was status post ARDSnet protocol. Patient was treated
with linezolid to cover for VRE and MRSA, and with Ceftazidime
to cover for Pseudomonas/GNR (GNR had appeared in the gram stain
of the sputum culture), each for a 14 day course. Patient was
given Lasix prn to control volume overload.
.
# Anemia/Thrombocytopenia:
Patient's stool was brown/green-colored and was hemoccult
positive. Patient was given 1 U RBC, and was hemodynamically
stable. Goal Hct was maintained at > 21, and goal plts was
maintained at > 10. Since the patient has a history of HIT
antibodies, all heparin products were avoided. Coagulation labs
were stable throughout admission.
.
# Renal failure:
Patient's baseline Cr is 1.5. Renal failure was mild, due to
ATN due to hypotension (FENA was > 1.0), and improved with
fluids and improving hemodynamics.
Improving with fluids and improving hemodynamics. Spun urine
had no remarkable sediment or casts. Patient's hyponatremia
resolved with fluid resuscitation.
.
# Transaminitis:
LFTs were in the 1000s, and were trending down each day.
Etiology was likely due to shock liver from hypotension. CT
abdomen did not reveal any significant findings necessitating
intervention.
.
# Neurologic status:
CT head was negative, with findings of a chronic pituitary
macroadenoma causing panhypopituitarism. The patient grew more
and more responsive and developed a good gag reflex. The
patient was maintained on levothyroxine and was given one dose
of stress dose steroids.
.
# Low voltage EKG:
TTE showed no pericardial effusion. Patient was monitored with
no cardiac complication, and with recovering BP over time.
.
# Nutrition, DVT prophylaxis, Lines:
Patient was on TF, PPI IV, and pneumoboots, since no heparin was
used. Patient had a RIJ and [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **] placed during admission.
.
# Code:
[**Name (NI) **] son, [**Name (NI) 1158**], is the HCP, who determined that the patient
is DNR/DNI. Specifically, the HCP does not want the patient
given shocks or surgery. Medical management is acceptable and
in line with the patient's wishes per the HCP.
.
# Communication:
[**Name (NI) **] HCP is son [**Name (NI) 1158**] [**Name (NI) 15296**] [**Telephone/Fax (1) 15297**] (h) [**Telephone/Fax (1) 15298**].
Medications on Admission:
Meds at [**Hospital3 **]
prednisone 10 mg pgt QAM, 5 mg pgt QPM
levothyroxine 150 mcg pgt daily
prevacid 30 pgt daily
spironolactone 25 pgt daily
methylphenidate 5 mg pgt daily
ferrous sulfate 325 po daily
reglan 10 pgt q 12 h
lactobacillus pgt daily
Aranesp 300 mg sc Q friday
MVI QD
psyllum 1 pkt pgt daily
trypsin/castor oil topically PGT Q 12 H
Jevity 1.2 @ 75 cc per hour cycled over 18 hours with flush 200
qd and 1 scoop promod
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
2. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QAM.
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
6. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
9. Aranesp 300 mcg/0.6 mL Syringe Sig: 0.6 ml Injection Q Friday
as needed for anemia.
10. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY
(Daily).
11. Ceftazidime 2 g Recon Soln Sig: Two (2) grams Intravenous
Q24H for 6 days.
12. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous Q12H (every 12 hours) for 6 days.
13. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Three Hundred (300)
mg PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Septic shock due to VRE urosepsis and MRSA pneumonia
Discharge Condition:
Stable, vitals are stable, patient is afebrile and at baseline
mental status.
Discharge Instructions:
1. Please go to the emergency room for fevers, low blood
pressure, fatigue.
2. Please take all medications as prescribed.
Followup Instructions:
1. Your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15299**], [**First Name3 (LF) **] be visiting you
at [**Hospital3 2558**], to follow up regarding your hospital
admission.
|
[
"287.5",
"285.9",
"276.1",
"600.00",
"244.9",
"785.52",
"V09.80",
"584.5",
"599.0",
"227.3",
"253.2",
"255.4",
"038.9",
"518.81",
"995.92",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.14",
"96.04",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13174, 13245
|
7550, 7550
|
230, 287
|
13342, 13422
|
2417, 2417
|
13594, 13808
|
1845, 1866
|
12008, 13151
|
13266, 13321
|
11549, 11985
|
7567, 11523
|
13446, 13571
|
1881, 2398
|
179, 192
|
315, 1400
|
2426, 7527
|
1422, 1761
|
1777, 1829
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,174
| 189,681
|
183
|
Discharge summary
|
report
|
Admission Date: [**2118-12-7**] Discharge Date: [**2118-12-9**]
Date of Birth: [**2073-12-25**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Skull defect
Major Surgical or Invasive Procedure:
s/p cranioplasty on [**2118-12-7**]
History of Present Illness:
44 yo female with a h/o left frontal AVM in the supplementary
motor area. The AVM was treated with stereotactic radiosurgery
(Gamma Knife)in [**2114**]. In [**2116**], the patient developed a seizure
disorder. [**2118-5-27**] she developed
headaches and after an MRI and a digital angiogram showed no
residual pathological vessels, a contrast enhancing lesion
with massive focal residual edema was diagnosed- very
likely represents radionecrosis. The patient had midline
shift and mass effect. On [**2118-8-10**] she had a left craniotomy for
resection of the radionecrosis. She then presented to the office
in [**2118-8-27**] with increased left facial swelling and incision
drainage, she was taken to the OR for a wound washout and
craniectomy. She now returns for a cranioplasty after a long
course of outpatient IV antibiotic therapy.
Past Medical History:
seizures,h/o radio therapy for avm has resid edema causing
seizures; Dysrhythmia (palps w/ panic attacks), Recent Upper
Respiratory Infection
Palpitations with panic attacks
Panic, anxiety
Depression
h/o nephrolithiasis (at 20yrs old)
TB as a child (treated)
Social History:
Married. Lives with husband.
Family History:
Non-contributory
Physical Exam:
On admission:
AOx3, PERRL, Face symm, tongue midline. EOM intact w/o
nystagmus. Speech clear and fluent. Comprehension intact.
Follows commands. No pronator. MAE [**5-31**]
Upon discharge:
AOx3. Neuro intact. MAE [**5-31**]. Incision C/D/I. Ambulating,
tolerating POs
Pertinent Results:
CT Head [**2118-12-7**]: (Post-Op)
Patient is status post left frontal cranioplasty. Persistent
vasogenic edema in the left frontal lobe, unchanged. No shift of
normally
midline structures or acute hemorrhage identified.
*******************
[**2118-12-7**] 03:13PM WBC-13.8*# RBC-4.76 HGB-12.8 HCT-37.6 MCV-79*
MCH-27.0 MCHC-34.2 RDW-14.4
[**2118-12-7**] 03:13PM PLT COUNT-555*
[**2118-12-7**] 03:13PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.3
[**2118-12-7**] 03:13PM estGFR-Using this
[**2118-12-7**] 03:13PM GLUCOSE-128* CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13
Brief Hospital Course:
44 yo female who was electively admitted for a cranioplasty with
Dr. [**Last Name (STitle) **]. Immediately post-op she remained in the PACU
overnight. Overnight she voided 4L and received 1L NS bolus. POD
1 she was transferred to the floor. Prior to transfer she was
noted to have increase HR, low BP, and low urine output thus
received 1L of NS. On the floor, she was OOB to chair,
tolerating a regular diet. She was neurologically intact and
cleared for discharge on [**2118-12-9**].
Medications on Admission:
FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - 50 mcg
Spray, Suspension - 2 sprays(s) each nostril daily as needed for
nasal congestion
LEVETIRACETAM [KEPPRA] - 1,000 mg Tablet - 1 Tablet(s) by mouth
twice a day - No Substitution
LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 1 Tablet(s) by mouth at
bedtime - No Substitution
LEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth
four times a day - No Substitution
OSELTAMIVIR [TAMIFLU] - 75 mg Capsule - one Capsule(s) by mouth
twice a day x 5 days
VENLAFAXINE - 50 mg Tablet - One Tablet(s) by mouth twice a day
ACETAMINOPHEN [TYLENOL] - (OTC) - Dosage uncertain
IBUPROFEN [ADVIL MIGRAINE] - (OTC) - 200 mg Capsule - 1
Capsule(s) by mouth once a day as needed for headache
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/t>100/HA.
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).
Disp:*60 Capsule(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Venlafaxine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily) as needed for nasal congestion.
7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 6 days: Take 2mg Q6hrs [**Date range (1) 1855**], take 2mg Q12
[**Date range (1) 1856**], Take 2mg Q24 [**12-14**], then stop.
Disp:*16 Tablet(s)* Refills:*0*
8. Levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times
a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Skull defect
s/p cranioplasty
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? 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:
You will need to see the nurse practitioner 14 days
post-operatively for suture removal. Please call [**Telephone/Fax (1) 1669**]
for the appointment.
You will need to follow up with Dr. [**Last Name (STitle) **] in 4 weeks with a
Head CT of the brain.
Completed by:[**2118-12-9**]
|
[
"345.90",
"348.5",
"909.2",
"530.81",
"278.00",
"300.01",
"437.8",
"738.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.05"
] |
icd9pcs
|
[
[
[]
]
] |
4767, 4773
|
2491, 2979
|
286, 324
|
4847, 4871
|
1860, 2468
|
6247, 6531
|
1538, 1556
|
3771, 4744
|
4794, 4826
|
3005, 3748
|
4895, 6224
|
1571, 1571
|
234, 248
|
1761, 1841
|
352, 1193
|
1585, 1745
|
1215, 1476
|
1492, 1522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,349
| 116,517
|
18958
|
Discharge summary
|
report
|
Admission Date: [**2139-3-15**] Discharge Date: [**2139-3-20**]
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Mechanical Fall
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty
History of Present Illness:
This is a [**Age over 90 **] year-old woman with a history of hypertension who
presents with a right hip fracture. The patient was walking with
a nurses aide at home and fell at 8pm last night. Unclear if it
was mechanical fall, but no loss of conciousness and no head
trauma. This AM she was unable to ambulate to breakfast and was
taken to [**Hospital1 **] [**Location (un) 620**] for further eval. She was found to be
tachypneic ith scattered wheezes. She had an eleavted WBC of
14.8 and lactate of 4.0. She was given 2L IVF and given
Vancomycin and Zosyn. She also had a troponinT of 0.1, CK 216,
CK-MB 5.2 and creatinine of 1.4. She was started on heparin gtt.
The patient was oriented x2-3.She remained normotensive and
transferred to the [**Hospital1 **] ED.
.
In the ED, T: 99.6, 86 144/70 18 98% 2L NC. The patient had
plain films that showed "Right basicervical femoral neck
fracture with proximal and lateral displacement of the distal
fracture fragment." She was evaluated by ortho and the family
reversed her code status from DNR/DNI to full code. The family
would like her to undergo surgery. She also underwent a CTA of
her chest that did not show evidence of a PE. Her Trop 0.11, CK
233, MB 6. Cardiology was consulted and recommended d/c heparin
gtt given likely demand in the setting of her hip fracture. The
patient's peripheral lactate was 4.2. The patient became
confused and combative in the ED and was given 2.5mg IV Haldol.
On transfer her vital signs were HR: 82, BP 127/76 RR: 25-30 O2
sat 100% 2L.
.
On arrive the patient denied pain and had no further complaints.
The patient's daughter was present and was able to give a
history. She stated her mother had not been complaining of an
fevers, chills, cough, urinary complaints or symptoms of
illness. She states her mother is usually oriented x2 and is
able to ambulate independently.
Past Medical History:
hypertension
Mild Dementia
Social History:
Lives with her daughter at home. She has VNA and a nursing aide
at home.
Remote smoking history. No EtOH or drug use.
Family History:
non-contributory
Physical Exam:
Admission Exam:
GEN: no acute distress, oriented x1
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
[**Hospital1 **]: No C/C/E, right leg shortened and externally rotated
distal pulses present, but diminished b/l
NEURO: oriented to person only. CN II ?????? XII grossly intact.
Moves all extremities [**Hospital1 **] right leg secondary to pain. Patellar
DTR +1. Plantar reflex downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs:
[**2139-3-15**] 06:35PM PT-13.3 PTT-150* INR(PT)-1.1
[**2139-3-15**] 06:35PM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.7
[**2139-3-15**] 06:35PM CK-MB-6
[**2139-3-15**] 06:35PM cTropnT-0.11*
[**2139-3-15**] 06:35PM CK(CPK)-233*
[**2139-3-15**] 06:35PM GLUCOSE-165* UREA N-24* CREAT-1.0 SODIUM-138
POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-18* ANION GAP-23*
[**2139-3-15**] 06:39PM HGB-11.6* calcHCT-35
[**2139-3-15**] 06:39PM GLUCOSE-122* LACTATE-4.2* NA+-140 K+-4.8
[**2139-3-15**] 06:59PM WBC-13.8* RBC-4.63 HGB-13.7 HCT-41.5 MCV-90
MCH-29.7 MCHC-33.1 RDW-13.5
.
Cardiac Enzymes
[**2139-3-15**] 06:35PM BLOOD cTropnT-0.11*
[**2139-3-16**] 04:51AM BLOOD CK-MB-6 cTropnT-0.11*
[**2139-3-16**] 03:17PM BLOOD CK-MB-7 cTropnT-0.07*
.
Discharge Labs
[**2139-3-20**] 05:22AM BLOOD WBC-6.1 RBC-3.26* Hgb-9.9* Hct-29.9*
MCV-92 MCH-30.3 MCHC-33.2 RDW-13.8 Plt Ct-176
[**2139-3-20**] 05:22AM BLOOD Glucose-113* UreaN-19 Creat-0.7 Na-142
K-4.0 Cl-110* HCO3-26 AnGap-10
[**2139-3-20**] 05:22AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.9
.
[**2139-3-15**] Chest CT
IMPRESSION:
1. No pulmonary embolus or aortic dissection.
2. Extensive mural thrombus within the thoracic aorta,
particularly within
the aortic arch.
3. Evidence of prior granulomatous disease.
4. 7 mm nodule in the right lower lobe. If clinically indicated,
a chest CT in six months can be performed.
5. T10 compression deformity of uncertain age.
.
[**2139-3-15**] Hip Xrays
IMPRESSION: Right basicervical femoral neck fracture with
proximal and
lateral displacement of the distal fracture fragment.
.
[**2139-3-15**] Femur Xray
IMPRESSION: Right basicervical femoral neck fracture with
proximal and
lateral displacement of the distal fracture fragment.
.
[**2139-3-15**] Chest xray
IMPRESSION: Mild bibasilar atelectasis.
.
[**2139-3-17**] Femoral Pathology
Report not finalized.
Assigned Pathologist [**Last Name (LF) **],[**First Name3 (LF) **] L.
Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**]
PATHOLOGY # [**Numeric Identifier 51824**]
femoral head.
.
[**2139-3-17**] Hip films intra-op
Single AP radiograph of the right hip obtained in O.R. Since
exam two days
ago, the fractured and displaced right femoral neck and head
have been
replaced with a bipolar hemiarthroplasty with non-cemented
femoral stem. The distal tip of the stem is not imaged and a
single cerclage wire is present.
.
[**2139-3-17**] Chest xray
The ET tube tip is 4.5 cm above the carina. Cardiomediastinal
silhouette is stable. There is interval development of left
lower lobe opacity, consistent with atelectasis with obscuration
of the left hemidiaphragm. The rest of the lungs are essentially
clear. No pleural effusion or pneumothorax is present.
Brief Hospital Course:
Ms. [**Known lastname 51825**] is a [**Age over 90 **] year old woman with a history of hypertension
who presented with a right hip fracture.
.
#. Hip Fracture: She had a witnessed mechanical fall at home.
She underwent a right hip hemiarthroplasty on [**3-17**]. Her dressing
was changed on [**3-19**]. She was started on enoxaparin on [**3-19**]. She
is to continue enoxaparin for a total of four weeks. Last day is
[**4-14**]. Her weight bearing status was advanced to weight bearing
as tolerated by the orthopedic team. She has follow up scheduled
with the orthopedic service.
# Hypotensive episode: Follwoing her procedure she became
hypotensive. This was thought likely secondary to anesthesia
medications. She improved after brief treatment with levophed.
.
#. Demand Ischemia: On admission Ms. [**Known lastname 51825**] had an elevated
troponin of 0.11. However, CK was 233 which trended to 182 (MB 6
-> 6). Cardiology felt that this event was likely demand and not
an acute thrombus. She was initially started on a heparin gtt,
but this was discontinued on the advice of cardiology. She was
continued on aspirin and started on metoprolol.
.
#. Leukocytosis: She presented with an elevated white blood cell
count. She was intially treated with vancomycin and Zosyn
empirically. No evidence of infection was found. Her white count
gradually normalized. Her antibiotics were discontinued prior to
discharge.
.
#. Fall: Ms. [**Known lastname 51825**] had a witnessed fall while walking with
nurses aide. There was no head trauma and no evidence of
syncope.
.
#. Delerium: Ms. [**Known lastname 51825**] has dementia at baseline. Her mental
status was worsened in the MICU. Her delirium was improved with
pain control and maintenance of sleep wake cycles.
.
#. Hypertension: She was continued on home lisinopril ans
started on metoprolol as described above.
.
# Nutrition: She was evaluated by the speech and swallow out of
concern for aspiration. A diet of soft solids and thin liquids
was recommended. A discussion was held with the daughter about
the risks of aspiration. The decision was made by her daughter
to allow her to eat despite the risk of aspiration.
.
# s/p Bowel Obstruction: Ms. [**Known lastname 51825**] was seen by the wound care
nurse [**First Name (Titles) **] [**Last Name (Titles) **] of her ostomy. There was concern over the
low output from the ostomy. However, Ms. [**Known lastname 51826**] daughter had
changed the bag. She was having good output at the time of
discharge.
.
# Code status: Ms. [**Known lastname 51825**] was admitted with a DNR/DNI order.
However, this was changed during the procedure. Following
recovery from her surgery, it was changed back to DNR/DNI.
Medications on Admission:
Lisinopril 20mg daily
ASA 81mg daily
Colace
Prevacid
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous DAILY (Daily) for 24 days: Please continue until
[**4-14**].
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
13. Metoprolol tartrate 25 mg tablet Sig: 1 tablet PO every
eight hours. Please hold for HR<60 or SBP<95.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary Diagnosis:
Right Hip Fracture
Demand Ischemia
Delirium
Secondary Diagnosis:
Hypertension
Anemia
Dementia
s/p bowel obstruction with ostomy
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital because you had a mechanical fall at
home. You fractured your right hip. While you were in the
hospital, you were admitted to the intensive care unit because
there was concern about your heart function.
We started several new medications while in the hospital.
We started metoprolol, a medication to control your heart rate
and blood pressure.
We also started enoxaparin or Lovenox, a blood thinner that you
will take during the next month to reduce your risk of blood
clots.
We also started medication to help control your pain and help
move your bowels.
Followup Instructions:
We scheduled a follow up appointment for you with the orthopedic
department. Your appointment is scheduled on Tuesday, [**4-7**]
at 10:20. This is located at the [**Hospital Ward Name 23**] building, [**Location (un) 1773**].
|
[
"V44.3",
"820.03",
"518.0",
"288.60",
"458.29",
"294.8",
"733.13",
"444.1",
"285.9",
"401.9",
"276.2",
"414.8",
"293.0",
"E885.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
9974, 10052
|
5830, 8539
|
245, 274
|
10243, 10243
|
3064, 3064
|
11082, 11311
|
2369, 2387
|
8643, 9951
|
10073, 10073
|
8565, 8620
|
10414, 11059
|
2402, 3045
|
190, 207
|
302, 2166
|
10157, 10222
|
3080, 5807
|
10092, 10136
|
10257, 10390
|
2188, 2217
|
2233, 2353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,166
| 152,834
|
50459
|
Discharge summary
|
report
|
Admission Date: [**2145-2-18**] Discharge Date: [**2145-2-27**]
Date of Birth: [**2086-1-3**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old
man with a history of severe coronary artery disease, status
post CABG in [**2123**], [**2132**] with multiple stats, who presents on
[**2145-2-18**] from [**Hospital 1474**] Hospital experiencing pain during MIBI
scan. The patient had CABG times four in [**2123**], coronary
artery bypass graft times two in [**2132**] with LIMA to the LAD
and saphenous vein graft to PDA. The patient had a cardiac
catheterization in [**2142**], secondary to ongoing chest pain with
stents from the saphenous vein graft to the PDA times two.
At baseline, he required sublingual nitroglycerin for chest
pain four times a week. This has been excellerating over the
last two weeks to about four times a day. The pain was not
related to exertion. Substernal stabbing radiating to back
is how he describes the pain. It usually resolves in several
minutes with one sublingual nitroglycerin. The chest pain he
experienced during his MIBI scan was 4 out of 10, decreased
to 1 out of 10 with sublingual nitroglycerin times three.
The patient was sent to [**Hospital1 69**]
for probable catheterization. On arrival, he denied chest
pain.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG times four in
[**2123**], CABG times 2 in [**2132**], LIMA to the LAD, saphenous vein
graft to PDA, status post stents from saphenous vein graft to
PDS times two in [**2142**].
2. Hypothyroidism.
3. Hypercholesterolemia.
4. Depression.
5. Benign prostatic hypertrophy.
6. Costochondritis.
MEDICATIONS:
1. Flexeril 10 mg p.o.b.i.d.
2. Imdur 90 mg p.o.q.d.
3. Proscar 5 mg p.o.q.d.
4. Levoxyl 125 mcg p.o.q.d.
5. Metoprolol 50 mg p.o.b.i.d.
6. Zocor 54 mg p.o.q.d.
7. Niaspan 1000 mg p.o.q.d.
8. Prilosec 20 mg p.o.q.d.
9. Aspirin 325 mg p.o.q.d.
10. Colace 100 mg p.o.b.i.d.
11. Sublingual nitroglycerin tablets p.r.n.
ALLERGIES: The patient is allergic to PERCOCET, BACTRIM,
LIPITOR, MEVACOR, PREDNISONE, BACTRIM, TAPE, AND BETADINE.
PHYSICAL EXAMINATION: On examination, vital signs revealed
the following: Temperature 98.0, pulse 71, blood pressure
95/56, breathing at 18, saturating 100% on room air.
GENERAL: The patient is resting comfortably in no acute
distress. HEENT: PERRLA, EOMI, tongue midline, oropharynx
clear. NECK: No JVD, no LAD. CARDIOVASCULAR: Regular rate
and rhythm, no murmurs, rubs, or gallops. LUNGS: Clear to
auscultation bilaterally. ABDOMEN: Bowel sounds soft,
nontender, nondistended. EXTREMITIES: No clubbing, edema,
or cyanosis; 2+ DP pulses bilaterally. NEUROLOGICAL: The
patient was alert and oriented, conversive. Cranial nerves
II through XII intact. No motor deficits.
LABORATORY DATA: Laboratory data revealed the platelet count
of 6.5, hematocrit 41, platelet count 183,000. Chem 7: 137,
5.4, 105, 26, 11, 1.1, and 84.
HOSPITAL COURSE: The patient was admitted on [**2145-2-18**] and
started on a heparin drip. The patient was continued on
nitrates, beta-blocker and aspirin. The patient had cardiac
catheterization plans for [**2145-2-19**]. The cardiac
catheterization demonstrated patent left main, mid LAD
occlusion with patent LIMA to the LAD, high need of LAD
diagonal stented and patent left circumflex with large patent
OM1, diffuse disease, small OM2. RCA occluded post conus,
saphenous vein graft to RCA, PDA/occluded at origin from
aorta proximal to the proximal RCA stents and LIMA to the LAD
is widely patent.
The Department of Cardiothoracic Surgery was consulted
regarding bypass of the occlusion of the saphenous vein to
RCA graft. CABG times one was planned and the patient went
to the operating room on [**2145-2-23**] for off-pump radioCABG
times one with using saphenous vein graft to the posterior
descending artery.
On postoperative day #1, the patient did well. Chest tubes
were removed. On postoperative day #1, the patient remained
on a Neodrip so he remained in the Intensive Care Unit until
postoperative day #2. On postoperative day #2, the patient
was transferred to the floor. The patient was seen by the
Department of Physical Therapy, who felt that he should be
ready for discharge home upon being medically ready. On
postoperative day #3, the patient's Foley catheter and wires
were removed. The patient was seen by the Physical Therapy
Department who felt that he was at a level 4 and would most
likely be at level 5 by postoperative day #4. The patient
was discharged to home on postoperative day #4 in good
condition on the following medications:
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg p.o.b.i.d.
2. Lasix 20 mg p.o.b.i.d. times 7 days.
3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o.b.i.d. times 7 days/
4. Colace 100 mg p.o.b.i.d.
5. Aspirin 325 mg p.o.q.d.
6. Prilosec 20 mg p.o.q.d.
7. Tri-Chlor 54 mg p.o.q.d.
8. Levoxyl 125 mg mcg p.o.q.d.
9. Ibuprofen 400 mg p.o.q.6h.p.r.n.
10. Dilaudid 2 mg to 4 mg p.o.q.4h.p.r.n.
11. Plavix 75 mg p.o.q.d.
12. Imdur 60 mg p.o.q.d.
13, Proscar 5 mg p.o.q.d.
14. Niaspan 1000 mg p.o.q.d.
DISCHARGE DIAGNOSIS: Status post off-pump redo CABG times
one.
FOLLOW-UP CARE: The patient was to followup with Dr. [**Last Name (STitle) 1537**] in
four weeks and with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in
three to four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2145-2-26**] 12:09
T: [**2145-2-26**] 13:21
JOB#: [**Job Number **]
|
[
"600.0",
"V45.81",
"244.9",
"782.0",
"414.01",
"414.02",
"V45.82",
"411.1",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.11",
"99.20",
"88.53",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
4682, 5197
|
5219, 5759
|
2997, 4659
|
2156, 2979
|
1336, 2133
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,886
| 109,178
|
50994
|
Discharge summary
|
report
|
Admission Date: [**2158-3-1**] Discharge Date: [**2158-3-7**]
Date of Birth: [**2082-10-9**] Sex: M
Service: C-MED
CHIEF COMPLAINT: Left elbow pain.
HISTORY OF PRESENT ILLNESS: This is a 72-year-old male with
a long history of coronary artery disease (status post
coronary artery bypass graft in [**2138**], multiple
catheterizations and interventions), hypertension,
hyperlipidemia, past tobacco history, family history of
coronary artery disease, who reports a long history of angina
manifested as left elbow pain. However, prior to this week,
angina occurred twice a week on average with episodes lasting
only a few minutes reaching about [**2-11**] in intensity. Then,
two days prior to this admission the patient began noticing
increasing elbow pain that waxed and waned over the next few
days but never completely subsided. The pain was limited to
the left elbow, reached as high as [**4-13**] to [**5-14**], and was not
accompanied by shortness of breath, chest pain, palpitations,
nausea, vomiting or diaphoresis. He took sublingual
nitroglycerin without relief, only later realizing that his
nitroglycerin had long ago expired. When pain persisted, he
presented to the doctor today and was subsequently referred
to the emergency department.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post 4-vessel coronary
artery bypass graft in [**2148**] (saphenous vein graft to D1, left
anterior descending artery, first obtuse marginal, posterior
descending artery); status post percutaneous transluminal
coronary angioplasty in [**2152-4-3**] after an acute myocardial
infarction with stenting of the saphenous vein graft to the
first obtuse marginal (95% occlusion); [**2152-11-3**]
catheterization with 40% lesion in the saphenous vein graft
to the right coronary artery and a 90% lesion in the
saphenous vein graft to first obtuse marginal which was
stented times two; [**2154-11-4**] catheterization and
percutaneous transluminal coronary angioplasty with stenting
of saphenous vein graft to right coronary artery; [**2155-11-4**] catheterization with percutaneous transluminal coronary
angioplasty and stenting of the left circumflex.
2. Hypertension.
3. Hyperlipidemia.
4. Abdominal aortic aneurysm (4 cm in diameter; has been
stable; followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]).
5. Prostate cancer.
6. Renal cell carcinoma, status post nephrectomy in [**2156-2-2**]
7. Chronic renal insufficiency.
8. Colitis.
9. Degenerative joint disease, especially of the right hip
and lower spine.
10. Bilateral inguinal hernia repair.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Isordil 20 mg p.o. t.i.d.
3. Norvasc 10 mg p.o. q.d.
4. Lopressor 100 mg p.o. b.i.d.
5. Accupril 40 mg p.o. q.d.
6. Cardura 4 mg p.o. b.i.d.
7. Lipitor 40 mg p.o. q.d.
8. Sublingual nitroglycerin 0.3 mg p.r.n.
SOCIAL HISTORY: The patient is married and lives with his
son. The patient has lived in a nursing home since [**2156-11-3**]. He worked in a furniture warehouse. He denies
alcohol use. He does have greater than a 90-pack-year
smoking history, but he quit in [**2138**].
FAMILY HISTORY: His sister died of heart disease at age 65.
Father died of heart disease at age 78. Family history also
positive for diabetes.
PHYSICAL EXAMINATION: Heart rate 92, blood pressure 136/80,
97% oxygen saturation nasal cannula. In general, the patient
was pleasant, comfortable, in no apparent distress. HEENT
revealed arcus senilis bilaterally anicteric. Pupils were
equal, round and reactive to light. Extraocular movements
were intact. Moist mucous membranes. No oral lesions. Neck
was supple. No lymphadenopathy. No bruits. No jugular
venous distention. Lungs were clear to auscultation
bilaterally. Heart had a regular rate and rhythm, normal S1
and S2. No murmurs, rubs or gallops. Abdomen had positive
bowel sounds, soft, obese, nontender. Extremities with 1+
bilateral lower extremity pretibial edema, 2+ posterior
tibialis pulses bilaterally, 1+ dorsalis pedis pulses
bilaterally, 2+ femoral pulses bilaterally. No bruits.
Rectal was OB negative per emergency department.
LABORATORY: CBC with a white blood cell count of 6,
hematocrit 40.2, platelets 190. Chem-7 revealed sodium
of 140, potassium 4.8, chloride 105, bicarbonate 23, BUN 27,
creatinine 1.7, glucose 95. Coagulations revealed an
INR of 1, PTT 26.1. Creatine kinase 125, MB 10, MB index 8,
troponin 2.5. Peak creatine kinase 209. Peak MB 26 with an
MB index of 12. Troponin I of 12.4.
Electrocardiogram revealed normal sinus rhythm at 92 beats
per minute, right bundle-branch block, borderline
first-degree AV block, axis 93 degrees, 1-mm ST elevations in
V4 through V6 (new compared with electrocardiogram from
[**2156-6-24**]).
[**2158-3-2**], catheterization revealed a right-dominant
system and 3-vessel disease. Left main was normal. Left
anterior descending artery totally occluded proximally.
Right coronary artery totally occluded proximally. Left
circumflex proximal 60% stenosis. Regarding the patient's
grafts: Saphenous vein graft to left anterior descending
artery with no stenosis, saphenous vein graft to posterior
descending artery with 90% proximal, 50% in-stent stenosis,
saphenous vein graft to left circumflex was patent with
native obtuse marginal with 80% lesion.
Ventriculography revealed an ejection fraction of 52%.
The patient underwent successful percutaneous transluminal
coronary angioplasty of saphenous vein graft to posterior
descending artery with direct stenting of the proximal
lesion. In addition, percutaneous transluminal coronary
angioplasty was done on the in-stent restenosis of the
saphenous vein graft to posterior descending artery with less
than 20% residual stenosis and TIMI-III flow.
Chest x-ray showed no evidence of cardiopulmonary process.
[**3-3**] ultrasound on right groin revealed a 2-cm to 2.5-cm
round pseudoaneurysm at the common femoral artery. A repeat
ultrasound on [**2158-3-6**], with Duplex color Doppler
revealed no evidence of pseudoaneurysm, hematoma, or AV
fistula.
Echocardiogram revealed left atrial moderate dilatation,
interatrial septum (consistent with right atrial pressure),
mild left ventricular hypertrophy, ejection fraction of
question 35%, hypokinetic anterolateral wall and akinetic
inferoposterior wall with mild 1 to 2+ mitral regurgitation.
HOSPITAL COURSE: This is a 75-year-old male with a history
of hypertension, hyperlipidemia, coronary artery disease,
status post coronary artery bypass graft and multiple
interventions, and smoking who presented with five hours of
resting angina partially relieved by nitroglycerin.
Electrocardiogram with ST elevations in V4 through V6 and
enzymes that ruled in for an acute myocardial infarction.
The patient was admitted to Eleven Riseman and started on IV
nitroglycerin, continued on beta blocker, heparin, and
aspirin. He was placed on Integrilin and taken to cardiac
catheterization on [**3-2**].
Catheterization revealed 3-vessel disease with totally
occluded right coronary artery and left anterior descending
artery, 90% proximal stenosis and 50% in-stent stenosis of
the saphenous vein graft to posterior descending artery
graft, native obtuse marginal 80% lesion, 60% proximal left
circumflex lesion. His saphenous vein graft to left anterior
descending artery graft revealed no stenosis, and the
saphenous vein graft to left circumflex graft was patent.
The patient had percutaneous transluminal coronary
angioplasty and stents placed to his 90% proximal saphenous
vein graft to posterior descending artery graft leading to 0%
residual stenosis. The patient also had percutaneous
transluminal coronary angioplasty to dilate the in-stent
stenosis of the saphenous vein graft to posterior descending
artery which lead to less than 20% residual stenosis and
TIMI-III flow. Catheterization also revealed mild
ventricular systolic and diastolic dysfunction.
The patient's post catheterization course was complicated by
a right femoral pseudoaneurysm measuring 2 cm to 2.5 cm.
This occurred over the weekend, and the patient was scheduled
to have thrombin injection on Monday; however, a repeat
ultrasound on Monday (two days after appearance of the bruit)
revealed no evidence of pseudoaneurysm. On the following day
the patient saw physical therapy and was discharged home.
Of note, the patient's cardiac medications were maximized
during his hospitalization. His Lopressor originally 50 mg
b.i.d. was increased to as much as 100 mg and then gradually
decreased back down to 50 mg because of bradycardia to the
40s with sinus pauses of 2 seconds. Because the patient was
still hypertensive with mild ventricular systolic
dysfunction, captopril was started and increased to 75 mg
p.o. t.i.d. Further adjustments should be made as an
outpatient.
On the day of discharge, the patient complained of greenish
left eye discharge with crusting. Eye was mildly injected.
He will be sent home with antibiotic drops to treat
conjunctivitis.
DISCHARGE DIAGNOSES:
1. Acute myocardial infarction.
2. 3-vessel coronary artery disease.
3. Successful percutaneous transluminal coronary angioplasty
and stent of proximal saphenous vein graft to posterior
descending artery lesion. In addition, successful
percutaneous transluminal coronary angioplasty of in-stent
stenosis within the saphenous vein graft to posterior
descending artery.
4. Right groin pseudoaneurysm, self resolved.
5. Left eye conjunctivitis.
6. Hypertension.
Rest of diagnoses as per past medical history.
MEDICATIONS ON DISCHARGE:
1. Polytrim 1 drop three times a day times seven days to
left eye.
2. Plavix 75 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Lipitor 40 mg p.o. q.d.
5. Captopril 75 mg p.o. t.i.d.
6. Lopressor 50 mg p.o. b.i.d.
7. Cardura 4 mg p.o. q.d.
8. Sublingual nitroglycerin 0.3 mg p.r.n.
FOLLOWUP:
1. The patient was to follow up with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 105949**] (Cardiology) in two to four weeks.
2. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) **](Vascular
Surgery); the patient was to call for followup.
3. Follow up with Dr. [**First Name8 (NamePattern2) 46**] [**Last Name (NamePattern1) 2450**]; the patient was to call
for followup.
CONDITION AT DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 13956**]
MEDQUIST36
D: [**2158-3-7**] 13:14
T: [**2158-3-7**] 13:53
JOB#: [**Job Number 48573**]
|
[
"372.30",
"401.9",
"410.71",
"414.01",
"V45.81",
"V45.82",
"414.02",
"272.0",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"36.06",
"37.22",
"88.56",
"88.53",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
3239, 3368
|
9151, 9667
|
9693, 10489
|
2696, 2946
|
6493, 9130
|
3391, 6475
|
10504, 10771
|
150, 168
|
197, 1276
|
1299, 2670
|
2963, 3222
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,777
| 105,007
|
31500
|
Discharge summary
|
report
|
Admission Date: [**2113-10-12**] Discharge Date: [**2113-10-18**]
Date of Birth: [**2039-11-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
throat tightness with exertion
Major Surgical or Invasive Procedure:
[**2113-10-12**] cabg x3 (LIMA to DIAG, SVG to OM, SVG to distal LAD)
History of Present Illness:
73 yo male with anginal symptoms and abnormal nuclear stress
test. Referred for cardiac cath.
Past Medical History:
NIDDM
neuropathy
HTN
elev. lipids
PVD with left iliac/bil. SFA and tibial dz)
prostate Ca (s/p resection [**2090**])
anxiety
prior appendectomy
Social History:
retired from hotel business
quit smoking 10 years ago
[**2-4**] glasses wine/day
Family History:
non-contrib.
Physical Exam:
5'[**16**]" 205#
NAd
HR 66 RR 20 right 183/74 left 173/79
skin/HEENT unremarkable
neck supple with full ROM and no carotid bruits appreciated
CTAB
RRR no murmur
soft, NT, ND, + BS
extrems, warm, well-perfused, no edema or varicosities noted
neuro grossly intact
2+ bil. fems/ radials
dopplerable right DP/PT
1+ right PT, 1+ left DP
Pertinent Results:
[**2113-10-16**] 06:45AM BLOOD WBC-7.3 RBC-3.12* Hgb-10.3* Hct-29.9*
MCV-96 MCH-32.9* MCHC-34.4 RDW-12.9 Plt Ct-169#
[**2113-10-16**] 06:45AM BLOOD Plt Ct-169#
[**2113-10-16**] 06:45AM BLOOD Glucose-234* UreaN-16 Creat-0.9 Na-138
K-4.2 Cl-101 HCO3-33* AnGap-8
[**2113-10-16**] 06:45AM BLOOD Calcium-9.2 Phos-2.4* Mg-2.2
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 74125**], [**Known firstname 49107**] [**Hospital1 18**] [**Numeric Identifier 74126**] (Complete)
Done [**2113-10-12**] at 10:34:34 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2039-11-4**]
Age (years): 73 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Congenital heart disease. Left
ventricular function. Mitral valve disease.
ICD-9 Codes: 746.9, 440.0, 396.9
Test Information
Date/Time: [**2113-10-12**] at 10:34 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW05-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.22 >= 0.29
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Sinus Level: 2.4 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum. PFO is present. Normal/small IVC diameter
(<=1.5cm) with respiratory collapse (estimated RAP 0-5mmHg).
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
LV wall thickness. Normal LV cavity size. Mild regional LV
systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic 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 TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. A patent foramen ovale is present. The
estimated right atrial pressure is 0-5mmHg. Left ventricular
wall thicknesses and cavity size are normal. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal and mid inferior wall hypokinesis and
thinning.. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no pericardial effusion.
POST CPB:
Improved LV focal systolic function. EF = 50-55%
No other change
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
RADIOLOGY Final Report
CHEST (PA & LAT) [**2113-10-16**] 10:36 AM
CHEST (PA & LAT)
Reason: eval ptx s/p ct d/c
[**Hospital 93**] MEDICAL CONDITION:
73 year old man s/p CABG
REASON FOR THIS EXAMINATION:
eval ptx s/p ct d/c
CHEST PA AND LATERAL.
COMPARISON: [**2113-10-12**], chest portable line placement.
HISTORY: Pneumothorax and status post CABG.
FINDINGS: There has been interval removal of ET tube, Swan-Ganz
catheter, NG tube, and chest tubes. There is no pneumothorax. A
small area of left lower lobe atelectasis is identified, and
slightly smaller in appearance since prior exam. There are no
focal consolidations or effusions identified.
IMPRESSION: Area of left lower lobe atelectasis, slightly
improved. No evidence of pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2113-10-17**] 9:23 AM
??????
Brief Hospital Course:
Admitted [**10-12**] and underwent CABG x3 with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition on titrated
neosynephrine and propofol drips. Extubated later that day and
transferred to the floor on POD #1 to begin increasing his
activity level. Gently diuresed toward his preoperative weight.
Chest tubes and pacing wires removed without incident. Beta
blockade slowly titrated, and he was restarted on his home
diabtes medications. He continued to do well and he was ready
for discharge [**Last Name (un) **] eon POD #6.
Medications on Admission:
atenolol 25 mg daily
zocor 40 mg daily
plavix 75 mg daily
ASA 81 mg daily
diamicron MR 60 mg daily
actos 15 mg daily
Vit. B12 200 mg daily
selenium one tab daily
aerobic oxygen 20-30 gtss daily
aflush free niacin 500 mg daily
Vit. ? E 400 IU daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. 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*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
9. Niacin Flush Free 100-400 mg Capsule Sig: One (1) Capsule PO
once a day.
10. diamicron MR 60 mg Sig: One (1) once a day.
11. Selenium 25 mcg Tablet Sig: One (1) Tablet PO once a day.
12. Vitamin B-12 100 mcg Tablet Sig: Two (2) Tablet PO once a
day.
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
1 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
CAD s/p cabg x3
NIDDM
neuropathy
HTN
elev. lipids
PVD
prostate Ca
anxiety
PSH: prostate resection [**2090**]
appendectomy
Discharge Condition:
good
Discharge Instructions:
SHOWER DAILY and pat incisions dry
no lotions, creams , or powders on any incision
nodriving for one month
no lifting greater than 10 pounds for 10 weeks
call surgeon for fever greater than 101, redness, or drainage
Followup Instructions:
see Dr. [**First Name (STitle) **] in [**1-3**] weeks
see Dr. [**Last Name (STitle) **] in [**2-4**] weeks [**Telephone/Fax (1) 170**]
Completed by:[**2113-10-18**]
|
[
"401.9",
"745.5",
"440.21",
"443.9",
"272.0",
"429.2",
"300.00",
"355.9",
"V15.82",
"V10.46",
"440.0",
"414.01",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9236, 9255
|
6792, 7344
|
354, 428
|
9424, 9431
|
1219, 4504
|
9696, 9865
|
832, 846
|
7643, 9213
|
5878, 5903
|
9276, 9403
|
7370, 7620
|
9455, 9673
|
4553, 5532
|
861, 1200
|
284, 316
|
5932, 6769
|
456, 551
|
573, 718
|
734, 816
|
5542, 5841
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,600
| 151,143
|
37971
|
Discharge summary
|
report
|
Admission Date: [**2183-10-27**] Discharge Date: [**2183-11-4**]
Date of Birth: [**2125-6-12**] Sex: M
Service: OME
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 20728**] is a 58-year-old
male with metastatic renal cell carcinoma, admitted today to
begin cycle 1, week 2, high-dose IL-2 therapy.
His oncologic history began in [**2181-12-28**], when he
presented to the ER with difficulty urinating and pain, felt
to be from nephrolithiasis, with imaging at that time
demonstrating left kidney mass without metastatic disease. On
[**2182-1-24**], he underwent a laparoscopic left sided
radical nephrectomy with removal of the ipsilateral adrenal
gland as well. Pathology revealed a 5.5 cm, clear cell renal
cell carcinoma, firm and grade 3. Surgical margins were
negative without lymphovascular invasion. Given a stage 1
disease he was followed with serial imaging. On [**2182-8-16**],
CT scan reportedly showed no evidence of recurrent disease.
Followup CT scan on [**2183-8-12**], showed new pulmonary nodules,
a soft tissue mass in the left renal fossa, as well as an
enlarged retroperitoneal, necrotic lymph node. PET CT done on
[**2183-8-21**], showed avidity in the hilar and mediastinal lymph
nodes. Brain MRI was negative. On [**2183-8-25**], he underwent a
CT-guided biopsy of a paraaortic lymph node, which confirmed
the diagnosis of metastatic renal cell carcinoma. He began
cycle 1, week 1, high-dose IL-2 therapy on [**2183-10-13**]. During
the week he received 11 of 14 doses, with course complicated
by toxic encephalopathy and shock. He is now recovered is
ready for week 2 of therapy.
PAST MEDICAL HISTORY: Hyperlipidemia, GERD, status post
tonsillectomy and adenoidectomy, obstructive sleep apnea,
history of erectile dysfunction, anxiety, and metastatic
renal cell carcinoma as above.
ALLERGIES: To codeine.
MEDICATIONS: Omeprazole 20 mg p.o. daily, Celexa 20 mg p.o.
daily, simvastatin 40 mg daily, and Tylenol p.r.n.
PHYSICAL EXAMINATION: GENERAL: Well-appearing male, no
acute distress. Performance status 1. VITAL SIGNS: 95.7, 76,
20, 114/62, O2 sat 96% on room air. HEENT: Normocephalic,
atraumatic. Sclerae anicteric. Moist oral mucosa without
lesions. NECK: Supple. LYMPH NODES: No cervical,
supraclavicular or bilateral, axillary lymphadenopathy.
HEART: Regular rate and rhythm, S1, S2. CHEST: Clear
bilaterally. ABDOMEN: Rounded, soft, nontender, no HSM or
masses. EXTREMITIES: No lower extremity edema. SKIN: Dry
with resolving erythematous rash. NEUROLOGIC EXAM: Alert and
oriented x3.
ADMISSION LABS: White [**Year (4 digits) **] count 13.8, hemoglobin 12.5,
hematocrit 38, platelet count 382,000, INR 1, glucose 95, BUN
31, creatinine 1.7, sodium 37, potassium 5.1, chloride 102,
CO2 25, ALT 15, AST 17, CK 33, total bili 0.4, albumin 3.6,
calcium 8.9, phosphorus 3.5, magnesium 2.2.
HOSPITAL COURSE: Mr. [**Known lastname 20728**] was admitted and was sent to
Interventional Radiology for central line placement. His
admission weight was 117 kg, and we dosed his IL-2 using
adjusted ideal body weight. He received IL-2, 600,000
international units per kilogram, equaling 53.4 million units
IV every 8 hours x14 potential doses. During this week he
received 5 of 14 doses, with doses held due to shock and
acute renal failure.
On hospital day #2 he developed hypotension without response
to 3 fluid boluses. He was placed on dopamine [**Known lastname **] pressure
support but became tachycardic. He was then switched to Neo-
Synephrine with improvement in his heart rate and [**Known lastname **]
pressure. Shock was attributed to capillary leak syndrome
from IL-2 therapy. Continuous [**Known lastname **] pressure, bedside, and
central telemetry monitoring were instituted. No cardiac
arrhythmias were noted. IL-2 therapy was held given his
prolonged need for vasopressors. He essentially was able to
receive 1 dose of IL-2 thereafter each time, requiring
reinstitution of vasopressor support. On treatment day #4 he
was started on dopamine, given evidence of acute renal
failure. He had creatinine at that time of 5.1 with severe
oliguria bordering on anuria. His IL-2 was placed on hold and
renal dose dopamine was initiated. He had mild metabolic
acidosis noted that at that time, improved with bicarbonate
replacement intravenously. On treatment day #5 his urine
output had improved, with a creatinine of 6.4, attributed to
IL-2-induced acute renal failure. His bicarbonate was closely
monitored and repleted below 20. Electrolytes were monitored
and repleted per protocol. He developed hyperkalemia early in
his course, treated with Kayexalate successfully without any
EKG changes noted. Strict I's and O's, serum creatinine and
bicarbonate were monitored b.i.d. Intravenous fluids were
maintained given acute renal failure and associated shock.
Other side effects early in the week included nausea improved
with antiemetic therapy; development of an erythematous skin
rash; fatigue; and diarrhea improved with antidiarrheals.
On treatment day #6, Mr. [**Known lastname 20728**] was noted to be apneic after
having removed his CPAP machine. Non-rebreather was placed
with course breath sounds noted bilaterally. [**Known lastname **] pressure
systolically was 60. He was initiated on IV fluids and
vasopressors at that time. He was transferred emergently to
the ICU with ABG revealing hypercarbic respiratory failure.
He was intubated successfully by Anesthesia placed on
ventilatory support. His [**Known lastname **] pressure stabilized on
pressors. He was weaned from the ventilator after
approximately 36 hours. His renal function showed slow
improvement. Mentally he was alert and oriented x3, and was
transferred back to the floor 2 days after being transferred
to the ICU. He made a rapid recovery from that point forward,
and was able to ambulate well with his wife. [**Name (NI) **] pressure
was stable, O2 sats were in the high 90s on room air. He was
having some residual diarrhea, improved with Lomotil, but was
discharged home on [**2183-11-4**].
During this week he had no transaminitis or
hyperbilirubinemia. He was anemic without need for packed red
[**Year (4 digits) **] cell transfusion. He had no thrombocytopenia or
coagulopathy noted. On [**2183-11-4**], his creatinine
kinase level was elevated at 256, with a normal MB and
troponin level, felt to be inconsistent with myocarditis. He
was deemed ready for discharge on [**2183-11-4**].
CONDITION ON DISCHARGE: Stable, ambulatory, with mental
status alert and oriented x3.
DISCHARGE STATUS: To home with his wife.
DISCHARGE DIAGNOSES: Metastatic renal cell carcinoma, status
post cycle 1, week 2, high-dose IL-2 therapy complicated by
height hypercarbic respiratory failure, shock, and acute
renal failure
DISCHARGE MEDICATIONS: Lasix 20 mg p.o. daily x5 days or
until you reach pretreatment weight, Tylenol 1-2 tablets
q.i.d. p.r.n. fever or pain, Compazine 5 mg q.i.d. p.r.n.
nausea/vomiting, Keflex 500 mg p.o. b.i.d. x5 days, Lomotil 1-
2 tablets q.i.d. p.r.n. diarrhea, Eucerin cream topically,
Sarna lotion topically, Prilosec 20 mg p.o. daily, Celexa 20
mg p.o. daily, Atarax 50 mg q.i.d. p.r.n. pruritus.
FOLLOWUP PLANS: Mr. [**Known lastname 20728**] will return to clinic in 4 weeks
after CT scans to assess disease response.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 18853**]
MEDQUIST36
D: [**2183-11-18**] 11:25:06
T: [**2183-11-19**] 16:19:54
Job#: [**Job Number 84843**]
cc:[**Numeric Identifier 84844**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 62676**], M.D.
Happy and Healthy Family Medicine
[**Apartment Address(1) **]
[**Hospital1 3597**]
[**Numeric Identifier 10774**]
|
[
"799.1",
"196.1",
"E939.4",
"300.00",
"272.4",
"458.29",
"584.9",
"293.0",
"276.1",
"V58.12",
"189.0",
"276.4",
"196.2",
"288.60",
"530.81",
"401.9",
"607.84",
"518.81",
"592.0",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"00.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6609, 6781
|
6805, 7810
|
2884, 6456
|
1996, 2522
|
166, 1631
|
2581, 2866
|
2540, 2564
|
1654, 1973
|
6481, 6587
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,592
| 130,570
|
45324
|
Discharge summary
|
report
|
Admission Date: [**2155-5-14**] Discharge Date: [**2155-5-20**]
Date of Birth: [**2081-10-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Transferred from [**Hospital1 **] for hyptension.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 year old woman with MMP s/p recent hospitalization [**Date range (1) **]
for persistent fevers who is transferred from [**Hospital **] Rehab for
SBP into 60s [**2155-5-14**]. She has been there since [**4-25**] after admit
for [**Female First Name (un) **] and [**Female First Name (un) **] line infection and pseudomonas in sputum s/p
14 day course caspo/linezolid/[**Last Name (un) 2830**] (to finish [**5-2**] but reportedly
only got [**Last Name (un) 2830**]/linezolid through [**5-7**]). She was noted to have a
hct drop 6/18 to 23 (may have been transfussed 2uPRBC's-not
clear from d/c summary) but hct 29.3 [**1-13**]. Additionally was
hypothermic with elevated WBC, hypernatremia to 157, melanotic
stools. She became hypotensive to SBP 80 [**5-13**] so reportedly
received 2 uPRBC's (though no change in hct) and unknown
quantity of IVF. UOP noted to be only 25cc/hour. C. diff
reportedly negative. [**5-14**]: BP 64/40 [**5-14**] with improvement to
97/70 with 25 gm albumin. Was started on aztreonam 1gm q12 [**5-12**]
(given h/o ESBL resistent organisms/pseudomonas in the past),
vanco 1 gm q24 [**5-14**]. Lab data from [**Hospital1 **] shows hct
30.0->23.5->29.3(? s/p 2 uPRBC's though not clear from d/c
summary)->29.6(s/p 2uPRBC's). Sodium 154, creatinine 0.6, WBC
17.7 (69% PMN, 0 bands, 20% lymph). Blood cultures 6/18 grew 1
bottle coag neg staph, 1 bottle GPC's in clusters. She was
transferred here for further management. CXR reportedly
concerning for LLL process. She was given D5W @ 100cc/hr and
started free water boluses via peg [**5-13**] 300cc q6.
Past Medical History:
Past Medical History:
-Recent hospitalization [**Date range (1) **] for line infection: [**Female First Name (un) 564**] and
[**Female First Name (un) **] grown at Rehab. Treated with caspofungin, linezolid, and
meropenem for 14 day course (through [**2155-5-2**]), PICC placed [**4-24**],
TEE negative.
CAD: stent to LAD 97, s/p CABG for 2VD with prosthetic MVR, and
closure of foramen ovale on [**2155-2-21**], complicated by mediastinal
hemorrhage, prolonged shock, renal failure, neurologic
impairment
-Cardiomyopathy, EF 40% on echo [**2155-4-8**]
-Anoxic encephalopathy: trach/peg on [**2155-3-12**]: consult report
from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32661**] ([**Hospital1 2025**]) from [**2155-3-28**] states prognosis for a
meaningful full recovery at this point is likely zero.
-Respiratory failure: attempted to wean from vent on last admit
but unable: vent at current settings AC 500 x 12/PEEP 5/ FiO2
40%; grew pseudomonas in sputum s/p 14 day course of meropenum
-Renal failure [**12-27**] ATN, noted on last admit to make 1L urine/day
but again required HD after discharge at rehab (tues/thurs/sat)
-A-fib
-Hypertension
-Hypercholesterolemia
-Insulin dependent diabetes
-Spinal stenosis
-COPD
Social History:
no ETOH, previous 20 pack year smoking history, quit 20 years
ago, previously lived w/ daughter, [**Name (NI) 13788**] who is HCP, since
[**1-29**] either at [**Hospital1 **] or [**Hospital1 **]
Family History:
Unknown.
Physical Exam:
VS: T 94.8 Ax HR 82 BP 102/77 RR 13 Sat 100%
AC: 550/12/40/5
Gen: NAD
HEENT: OP clear, MM slightly dry, mouth open, eyes open, sclera
injected
Neck: trach tube in place, no significant surrounding discharge,
JVP to jaw at 15 degrees, no LAD
Respiratory: Decreased breath sounds at bases with transmitted
upper airway sounds but no distinct wheezes/rales/rhonchi
CV: RRR no murmurs, rubs, gallops; S1 S2 present, radial pulses
1+ bilaterally, DP/PT non-palpable bilaterally (though
dopplerable)
Abdomen: midline, left lower quadrant well-healed scars, PEG
tube in place, BS present, NT, ND
Extremities: 4+ PE all 4 extremties, multiple decubitus ulcers
on left arm, left leg, right leg (with ? pustular discharge and
necrotic toes R)
Back: Sacral decubitus ulcers
Neuro: Eyes open with disconjugate gaze, no corneal blink reflex
though occaisional fasiculations, no oculocephalic reflex,
pupils 3mm bilaerally, unresponsive, no gag, no response to
painful stimuli x4 extremities and sternal rub, spontaneous left
arm movement noted, + spontaneous respirations.
Pertinent Results:
Admission labs:
ABG: pH 7.43 pCO2 38 pO2 121 HCO3 26
TSH:12
Creat:40
Na:41
UA: Color Yellow Appear Clear SpecGr 1.020 pH 5.0 Urobil Neg
Bili Neg Leuk Sm Bld Lg Nitr Pos Prot 30 Glu Neg Ket Neg
RBC 17 WBC 49 Bact Mod Yeast Many Epi 0
156 127 41
------------<99
4.4 24 0.5
estGFR: >75
Ca: 7.8 Mg: 2.3 P: 3.2
ALT: 29 AP: 131 Tbili: 0.1 Alb: 2.0 AST: 26 [**Doctor First Name **]: 83 Lip: 34
Triglyc: 172
Cortsol: 10.6
9.7
16.2>---<201
30.5
N:89 Band:4 L:1 M:5 E:1 Bas:0
Hypochr: 2+ Anisocy: 1+ Poiklo: 1+ Macrocy: 2+ Polychr: 1+
Target: OCCASIONAL Tear-Dr: OCCASIONAL How-Jol: 1+ Plt-Est:
Normal
PT: 12.7 PTT: 33.2 INR: 1.1
CXR: Bilateral efffusions/pulmonary edema/atelectasis, midline
present on R, ? ETT high at 7.8cm.
ECG: NSR (82), axis, intervals NL, low voltage, QW III (old),
TWI III, aVF; V5 uninterpretable. No ST changes.
TEE [**2155-4-22**]: Normal functioning mitral annuloplasty ring with
very mild mitral regurgitation. No vegetations identified.
Complex (non-mobile) aortic atherosclerosis. Small secundum type
atrial septal defect. Regional left ventricular systolic
dysfunction c/w CAD.
EEG [**2155-2-27**]: This is an abnormal portable routine EEG due to the
very low voltage, slow and unvarying background, suggestive of
severe
encephalopathy, possibly due to diffuse cortical damamge.
Occasionally focal slowing was seen in the right temporal region
suggestive of subcortical dysfunction.
Cultures:
[**5-14**] Urine YEAST. >100,000 ORGANISMS/ML..
[**5-15**] Urine: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**5-16**] Stool CDiff negative
[**5-16**] Blood cultures pending
[**5-17**] Sputum: serratia and pseudomonas
Brief Hospital Course:
A/P: 73 yo woman with CAD s/p CABG/MVR complicated by
mediastinal hemorrhage, and anoxic brain injury in persistent
vegetative state with h/o GIB, hypotension, GPC's in blood,
decreased urine output, hypernatremia, hypothyroidism.
# Hypotension:
The patient was hypotensive upon admission. Given a blood
culture positive for GPC in clusters she was started on
vancomycin. In addition she had grown pseudomonas and serratia
per OSH culture data and was started on zosyn. We treated the
underlying infections and aggressively hydrated the patient with
IV fluids. In addition we identified a candidal UTI and treated
empirically for [**Female First Name (un) **] sepsis with IV fluconazole.
The patient required vasopressin temporarily but was
successfully weaned and was able to maintain a blood pressure
with systolics in the 90-100's.
.
# Anoxic brain injury/Plan of care: Per neurologists, the
patient has no meaningful hope of significant neurologic
recovery from her anoxic brain injury. We consulted social work
and our ethics servie and discussed the objectives of care with
the patient's family and health care proxy. The family's
decision was made to make the patient DNR, to not escalate care,
and to avoid procedures that would cause pain.
.
# Respiratory failure: Thought to be secondary anoxic brain
injury exacerbated by new-onset PNA. The patient was kept on
mechanical ventilatory support throughout her stay and was not
successful in attempts to wean.
# H/O GIB: The patient had guiac positive stool but given her
degree of morbidity it was deemed that an appropriate GI bleed
workup would not be appropriate at that time. She was
maintained on a [**Hospital1 **] PPI and transfused as necessary.
.
# Hypothyroidism: The patient was found to have elevated TSH to
12 with low FT4 and T3 which was thought to be contributing to
hypotension, hypothermia. We started her on levothyroxine.
.
# Hypernatremia: Likely [**12-27**] to dehydration. The patient had a
free water deficit of 3.2L and was given multiple free water and
d5w boluses which successfully normalized her sodium. Labs ruled
out central DI as a possiblity.
.
# Diabetes melitus: The patient was given insulin throughout her
stay to maintain a glucose below 150.
.
# H/O Renal failure requiring HD: The patient was started on
epogen and her urine output was monitored closely. She
responded well to fluid boluses and did not require hemodialysis
during this stay.
.
# CAD: We held her ASA as she had GI bleeding.
.
# Sacral Decubitis Ulcers: The patient was placed on a kinair
bed and received a wound care consult. She had wound care by
protocol throughout her stay for several decubitus ulcers,
including on to the coccyx and others on her buttocks. The
family declined any possibility of surgery for a diverting
colostomy to improve her wound care.
Medications on Admission:
alteplase 2 mg to PICC [**2155-5-14**]
albumin 25gm [**2155-5-14**]
vancomycin 1gm q24 [**2155-5-14**]
aztreonam 1gm iv q12 [**5-12**]
ipratropium/albuterol inhaler 4 puffs qid
artificial tears OU q2
lispro insulin QID per sliding scale
vitamin C 500mg qd
docusate 100mg [**Hospital1 **]
pantoprazole 40mg via peg qd
zinc 220mg po qd
epo 3,000 u MWF
polyvinyl alcohol opthalmic 2 gtt OU q2 prn
fluticasone 220mcg q12
perative 60ml/hr tube feeds via peg with 300cc free water q6
hours
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Tablet, Delayed Release (E.C.)(s)
2. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: [**11-26**] PO BID (2 times a
day).
4. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Month/Day (2) **]: One (1)
Appl Ophthalmic PRN (as needed).
5. Zinc Sulfate 220 (50) mg Capsule [**Month/Day (2) **]: One (1) Capsule PO
DAILY (Daily).
6. Ascorbic Acid 90 mg/mL Drops [**Month/Day (2) **]: Five (5) PO DAILY (Daily).
7. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6) Puff
Inhalation Q6H (every 6 hours).
8. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6)
Puff Inhalation QID (4 times a day).
9. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Month/Day (2) **]: Two
(2) inhalation Inhalation [**Hospital1 **] ().
10. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation Q2H (every 2 hours) as needed for secretions.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
12. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
injection Injection TID (3 times a day).
13. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: One
(1) flush Intravenous DAILY (Daily) as needed.
15. Piperacillin-Tazobactam Na 4.5 gm IV Q8H
Day 1: [**5-16**]
16. 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
17. Fluconazole 200 mg IV Q24H
Day 1 [**2155-5-17**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
sepsis
anoxic brain injury
pseudomonas and serratia pneumonia
hypernatremia
Discharge Condition:
stable
Discharge Instructions:
Please administer the medications as prescribed.
Of note, the patient's family has made her DNR and asks for no
escalation of care and no procedures that would cause
discomfort.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2155-6-25**]
1:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2155-5-20**]
|
[
"496",
"276.51",
"V44.0",
"995.92",
"707.07",
"112.5",
"780.03",
"276.0",
"585.9",
"707.03",
"112.2",
"V45.81",
"482.1",
"250.00",
"518.83",
"272.0",
"425.4",
"V43.3",
"403.90",
"785.52",
"707.05",
"427.31",
"244.9",
"V44.1",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11574, 11645
|
6289, 9136
|
366, 372
|
11765, 11773
|
4583, 4583
|
12000, 12306
|
3477, 3487
|
9670, 11551
|
11666, 11744
|
9162, 9647
|
11797, 11977
|
3502, 4564
|
277, 328
|
400, 1979
|
4599, 6266
|
2023, 3248
|
3264, 3461
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,393
| 187,412
|
32251
|
Discharge summary
|
report
|
Admission Date: [**2101-1-4**] Discharge Date: [**2101-1-20**]
Date of Birth: [**2021-3-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Transferred from SICU w/ hypoxia
Major Surgical or Invasive Procedure:
[**Last Name (un) 1372**]-gastric tube
thoracentesis
History of Present Illness:
79 yo male with PMH of HTN, critical AS, AFib, remote
pancreatitis, and aortic aneurysm who presented to [**Hospital3 635**]
hospital on [**2100-12-26**] with weakness and RUQ pain. He was found to
be anemic, tachycardic, and had an INR of 5.5. He was given
blood, fluids, FFP and had a CT scan at the OSH which showed
stranding of the tail and mid body of the pancreas with
overlying hematoma. A visceral angiogram performed showed no
active bleeding or vascular abnormality to explain the bleeding.
The patient was then transferred to [**Hospital1 18**] for further
management.
On transfer ([**2101-1-4**]), the patient was afebrile, tachycardic to
116, abdomen nontender, and AxO x 1. The patient was started on
clears which he tolerated well.
Upon transfer to medicine, the patient was made NPO again due to
abdominal pain and distension. He was felt to be clinically
stable and did not require surgical intervention. He was on a
diltiazem gtt initially for his Afib in the SICU, but was
converted to a PO regimen prior to transfer with decent rate
control. The patient states that he continues to have abdominal
discomfort, but he is hungry. He is a poor historian due to his
dementia.
Since his admission he has been receiving rate control with
dilt. He has required nasal cannula (2-4L) during his stay. He
was found to have 5/5 blood cultures positive for coag neg staph
and has been treated with vancomycin. He had a TTE that was
negative for endocarditis but did confirm that he had critical
AS. He has run I/O approximately even the past 24 hours.
Yesterday he was intermittently dropping his O2sats to upper 80s
which would resolve quickly with nebs. His O2 requirement was 4L
NC. This morning ~6:30am he was receiving his morning dose of
dilt and was soon thereafter to be more short of breath (~within
30minutes). No cough or choking was witnessed.
His remained hypoxic requiring NRB. His vitals prior to transfer
were
97F 120/84 112 25 97%NRB. He states that his breathing was
difficult. He denies chest pain or cough. He denies abd pain.
Of note he had a PICC that was placed at the OSH that has since
been removed after the blood cultures were resulted as positive.
He is also day 3 of levofloxacin therapy for a potential
aspiration pneumonia.
Past Medical History:
HTN
Critical AS (0.7cm2)
Atrial Fibrillation
prior EtoH
dementia
h/o syncope
Asthma
remote pancreatitis
aortic aneurysm
chronic subdural hematoma
Social History:
No smoking, occasional alcohol (?h/o heavy use), no drug use
Family History:
Non-contributory
Physical Exam:
VS: Temp: afebrile BP: 104/79 HR: 100 RR: 24 O2sat 100%
GEN: pleasant. ill appearing
HEENT: arcus senilus. PERRL, EOMI, anicteric, MMM,
NECK: jvd to jaw. ,
RESP: coarse breath expiratory sounds bilat left > right
CV: irregular, tachy. S1/S2 masked from breath sounds. late
peaking syst murmur at RUSB
ABD: distended, tympanic. sluggish bowel sounds
EXT: no c/c/e, cool, trace PT pulses
SKIN: no rashes/no jaundice
NEURO: AAOx1. Cn II-XII intact.
Pertinent Results:
147 102 48
============< 115
3.2 39 1.0
Ca: 9.5 Mg: 2.0 P: 3.1
ALT: 13 AP: 103 Tbili: 3.7 Alb: 3.2
AST: 19 LDH: 346 Dbili: TProt:
[**Doctor First Name **]: 144 Lip: 69
Iron: 18
calTIBC: 280
Ferritn: 349
TRF: 215
Triglyc: 46
11.9 > 35 < 311
N:83.1 L:7.5 M:5.4 E:3.7 Bas:0.3
PT: 15.3 PTT: 27.1 INR: 1.3
Micro:
[**2101-1-4**] [**5-5**] BCx - coag neg staph
[**2101-1-5**] [**3-5**] BCx - coag neg staph
EKG: afib @114 leftward axis. LVH with repolarization changes.
slow Rwave progression. no change from prior
Imaging:
[**2101-1-5**] CT abd/pelvis - .
1Severe pancreatitis associated with a hemorrhagic pseudocyst
within the gastric wall, without evidence of vascular
complication. A component of necrosis cannot be excluded.
2. Bilateral pleural effusions and ascites, a component of which
is
loculated.
3. Aneurysms of the ascending thoracic and infrarenal abdominal
aorta.
4. Extensive coronary artery and aortic valvular calcifications.
5. Small focus of consolidation within the right upper lobe.
Early pneumonia cannot be excluded and attention is recommended
on followup studies.
[**2101-1-7**] TTE - The left atrium is markedly dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF 60-70%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is moderately dilated.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: No valvular vegetations seen. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Severe calcific aortic
stenosis. Mild mitral regurgitation. Moderate pulmonary
hypertension. Dilated thoracic aorta
CXR:
[**2101-1-7**] -
1. Mild CHF, essentially unchanged since the prior study.
2. Mildly dilated loops of small bowel. Clinical correlation is
advised.
3. A persistent left retrocardiac opacity.
[**2101-1-8**] - (unofficial) underpenetrated film. worsening bilat
edema with [**Hospital1 **]-basilar atelectasis. marked enlarged stomach
bubble
Brief Hospital Course:
79 yo male with h/o HTN, critical AS, dementia who presents with
hemorrhagic pancreatitis, found to have coag neg staph
bacteremia (treated with vancomycin), elevated bilirubin, atrial
fibrillation, acute renal failure and ileus transferred to MICU
for respiratory distress and worsening hypoxia. Imaging
revealed b/l pleural effusions. B/L thoracenteses revealed
exudative effusion on the left and serosanguinous fluid on the
right. His respiratory status declined, felt likely due to
complication of pancreatitis and volume overload, while in
setting of critical AS.
On [**2101-1-20**], the family decided that the patient would not want
a prolonged illness and a decision was made to make the patient
DNR/DNI and comfort measures only. The patient was made
comfortable and expired at 1:57pm on [**2101-1-20**]. The family
declined autopsy.
Medications on Admission:
TRANSFER MEDS FROM SICU:
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Insulin SC Sliding Scale
Diltiazem 90 mg PO QID
Ipratropium Bromide Neb 1 NEB IH Q6H
FoLIC Acid 1 mg PO DAILY
Levofloxacin 500 mg PO Q24H
Furosemide 20 mg IV ONCE
Pantoprazole 40 mg PO Q24H
Heparin 5000 UNIT SC TID
Thiamine 100 mg PO DAILY
Xopenex *NF* 0.63 mg/3 mL Inhalation TID
.
Meds at home:
Lisinopril 10 mg Daily
Mag Oxide 400 mg PO TId
Atenolol 25 mg qAM
Trazadone ? aHs
Folic Acid 1 mg Daily
Vitamin B1 100 mg Daily
ASA 81 mg Daily
Omeprazole 20 mg Daily
Neutraphos 1 pk TId
Warfarin 5 mg 3x/week
Lasix 40 mg Daily
Inhallers for wheezing
Discharge Medications:
none, expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis:
Respiratory Failure
Hemorrhagic Pancreatitis
Pancreatic Pseudocyst
Bacteremia
Secondary Diagnosis:
Hypertension
Dementia
Diabetes
Discharge Condition:
stable; tolerating POs
Discharge Instructions:
Expired [**2101-1-20**]
Followup Instructions:
Expired [**2101-1-20**]
Completed by:[**2102-7-5**]
|
[
"441.2",
"303.91",
"263.9",
"294.8",
"493.20",
"428.33",
"782.4",
"577.0",
"305.1",
"432.1",
"786.6",
"507.0",
"518.81",
"568.81",
"790.7",
"799.02",
"584.9",
"428.0",
"416.8",
"401.9",
"041.11",
"577.2",
"427.31",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7647, 7656
|
6092, 6943
|
345, 399
|
7849, 7874
|
3461, 6069
|
7946, 7999
|
2961, 2979
|
7609, 7624
|
7677, 7677
|
6969, 7586
|
7898, 7923
|
2994, 3442
|
273, 307
|
427, 2697
|
7795, 7828
|
7696, 7774
|
2719, 2867
|
2883, 2945
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,543
| 187,978
|
39704
|
Discharge summary
|
report
|
Admission Date: [**2171-10-15**] Discharge Date: [**2171-10-20**]
Date of Birth: [**2102-6-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**10-16**] Coronary artery bypass grafting x4; left internal mammary
artery grafted to the left anterior descending; reversed
saphenous vein graft to the ramus intermedius, diagonal branch,
and posterior left ventricular branch.
History of Present Illness:
Mr. [**Known lastname 87496**] is a 69 year old man who has complained 6 months of
left upper chest tightness while golfing. He [**Known lastname 1834**] a
cardiac catheterization which revealed multi-vessel disease and
he was referred for cardiac surgery.
Past Medical History:
PVD, HTN, hyperlipidemia, LT common iliac stent ~18months ago
Social History:
Mr. [**Known lastname 87496**] lives with his wife. [**Name (NI) **] is a retired personnel
manager
Family History:
non-contributory
Physical Exam:
Pulse: Resp:14 O2 sat:
B/P Right:130/74 Left: 134/74
Height:67" Weight:76.7kg
General:WDWN in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur n
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:1-2/6 Left: [**1-16**]
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 87497**] (Complete)
Done [**2171-10-16**] at 12:54:58 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: [**2102-6-21**]
Age (years): 69 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 424.2
Test Information
Date/Time: [**2171-10-16**] at 12:54 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2010AW4-: Machine: AW5
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *2.8 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**1-12**] T): 2.4 cm2
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.00
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20
cm/s) LAA ejection velocity. All four pulmonary veins identified
and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Simple atheroma in ascending aorta. Focal calcifications in
ascending aorta. Simple atheroma in aortic arch. Normal
descending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Physiologic MR (within
normal limits).
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
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. Suboptimal image
quality. The patient appears to be in sinus rhythm. Results were
Conclusions
PRE BYPASS The left atrium is moderately dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The base of thye posterior leaflet is moderately
thickened and calcified. Physiologic mitral regurgitation is
seen (within normal limits). The tricuspid valve leaflets are
mildly thickened. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is being a paced. There is normal
biventricular systolic function. Valvular function is unchanged.
The thoracic aorta appears intact after decannulation. No
significant changes from the pre-bypass study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2171-10-16**] 15:53
Brief Hospital Course:
On [**10-16**] Mr. [**Known lastname 87496**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting.
Please see the operative note for details. He tolerated the
procedure well and was transferred in critical but stable
condition to the cardiovascular surgical intensive care unit.
He extubated and weaned from neosynepherine. His chest tubes
were removed and he was transferred to the surgical step down
floor. His epicardial wires were removed. Mr. [**Known lastname 87496**] was seen
by the physical therapy in consultation. By post-operative day
four he was ready for discharge to home. All follow-up
appointments were advised.
Medications on Admission:
Lipitor 80mg daily, Carvedilol 12.5mg [**Hospital1 **], ASA 325mg daily,
Micardis/HCT 40/12.5mg daily, ISMN ER 30mg daily, Vit D
2000units daily
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*2*
6. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospital VNA
Discharge Diagnosis:
chest pain
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 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:
Please call to schedule the following appointments
Surgeon: Dr. [**Last Name (STitle) **] in 3 weeks. ([**Telephone/Fax (1) 11763**]
Cardiologist: Dr. [**Last Name (STitle) 87498**] [**Name (STitle) 87499**] in [**4-15**] weeks.
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 87500**] in [**4-15**] weeks. ([**Telephone/Fax (1) 87501**]
**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:[**2171-10-20**]
|
[
"443.9",
"401.9",
"458.29",
"285.9",
"272.4",
"413.9",
"V15.82",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8015, 8074
|
6339, 6987
|
334, 566
|
8129, 8340
|
1752, 6316
|
9263, 9826
|
1073, 1091
|
7183, 7992
|
8095, 8108
|
7013, 7160
|
8364, 9240
|
1106, 1733
|
284, 296
|
594, 853
|
875, 939
|
955, 1057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,052
| 149,934
|
27375
|
Discharge summary
|
report
|
Admission Date: [**2190-6-8**] Discharge Date: [**2190-6-22**]
Date of Birth: [**2126-11-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Transfer from [**Hospital1 2436**] rehabillitation for abdominal
distension, concern for C. Difficile megacolon
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 63 year old female with DM2, COPD, HTN, and multiple
abdominal surgeries who had previously been a patient at [**Hospital **] where she was found to have a question of
ischemic colitis at the splenic flexure on a colonoscopy done on
[**2190-5-27**]. An angiogram reportedly showed [**Last Name (un) **] blood vessels.
Towards the end of her stay at this hospital, she began
experiencing watery stools and was treated with Flagyl and her
symptoms resolved. She was then sent to [**Hospital 582**] rehab, where
she developed recurrent diarrhea and a fever to 101. She was
found to have C. Difficile colitis. This was treated with
Flagyl and PO/PR Vancomycin with no improvement in symptoms.
She was found to have abdominal distension so an NG tube was
placed on [**2190-6-7**].
Past Medical History:
COPD, HTN, DM2, s/p CCY, s/p appy, hernia repairs, C-sections,
TAH
Social History:
former smoker
Family History:
NC
Physical Exam:
VS- 95.2, 108, 96/52, 20, 95% (2L), FS 216
Gen- mild discomfort, NAD
HEENT: PERRL, EOMI
Neck: supple
CV: RRR, S1S2
Abd: soft, obese, distended, diffuse tenderness to palpation
worse at the LLQ, no rebound or guarding
Neuro: AxOx3
Pertinent Results:
[**2190-6-8**] 05:17PM BLOOD WBC-26.0* RBC-3.60* Hgb-9.8* Hct-30.5*
MCV-85 MCH-27.2 MCHC-32.0 RDW-16.4* Plt Ct-708*
[**2190-6-11**] 04:15AM BLOOD WBC-19.9* RBC-3.21* Hgb-8.8* Hct-27.2*
MCV-85 MCH-27.3 MCHC-32.3 RDW-16.7* Plt Ct-639*
[**2190-6-14**] 06:27AM BLOOD WBC-19.4* RBC-3.58* Hgb-9.4* Hct-30.1*
MCV-84 MCH-26.4* MCHC-31.4 RDW-17.4* Plt Ct-583*
[**2190-6-18**] 10:00AM BLOOD WBC-13.3* RBC-3.61* Hgb-10.1* Hct-30.7*
MCV-85 MCH-28.0 MCHC-32.9 RDW-18.4* Plt Ct-522*
[**2190-6-20**] 05:05AM BLOOD WBC-11.4* RBC-3.39* Hgb-9.3* Hct-28.9*
MCV-85 MCH-27.3 MCHC-32.0 RDW-19.6* Plt Ct-484*
[**2190-6-8**] 05:17PM BLOOD ALT-5 AST-6 LD(LDH)-124 AlkPhos-93
Amylase-10 TotBili-0.3
[**2190-6-8**] 05:17PM BLOOD Lipase-6
[**2190-6-8**] 05:17PM BLOOD Glucose-195* UreaN-27* Creat-1.9* Na-130*
K-4.2 Cl-100 HCO3-21* AnGap-13
Brief Hospital Course:
This patient was admitted to [**Hospital1 18**] on [**2190-6-8**] for symptoms
concerning to C. Difficile colitis megacolon. A KUB showed
massively dilated colon measuring up to 11 cm which given the
history of C. difficile colitis is concerning for toxic
megacolon. A CT scan showed diffuse wall thickening seen
throughout the colon consistent with pancolitis, consistent with
patient's known history of C. diff colitis. There is no evidence
of pneumatosis, air in any mesenteric veins, portal venous air,
or free air in the abdomen to suggest ischemic bowel. Her WBC
was 26 but she was afevrile. She was admitted to the ICU and
surgery was consulted. She recieved aggressive fluid
resuscitation, IV Flagyl, and PO/PR Vancomycin. A CVL was
placed to aid with ICU care. She was deemed unsafe for an
operation at this point. She recieved serial abdominal
examinations. On HD 3, TPN was started. Her recal tube was
discontinued and she was transferred to the floor. She was on
maintenance IV fluids. Her WBC was 19. Physical therapy saw
her and [**Hospital 22374**] rehab. On HD 6 she was started on sips. On
HD 7 she tolerated clears. On HD 9 she was started on
cholestyramine for diarrhea. She was started on Linezolid for a
VRE UTI. On HD 13 she tolerated a regular diet. On HD 14 her
WBC was 11. Her TPN was stopped. On HD 15 she was discharged
to rehab. By the advice of the ID servce, she was off of all
antibiotics except PO Vancomycin, which she is to take for 7
days. Flagyl and Linezolid were stopped. A urine culture from
[**6-19**] grew out Pseudomonas, but a UA from [**6-21**] was negative so ID
did not recommend any treatment.
Medications on Admission:
protonix, lovenox, protonix, bupropion, nortryptine, PO
vancomycin, flagyl
Discharge Medications:
1. Vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 7 days.
2. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
4. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Cardizem CD 300 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO qdaily ().
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
11. Insulin Regular Human Subcutaneous
12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Capsule Sig: One
(1) Tablet PO Q4-6H (every 4 to 6 hours) as needed.
14. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
15. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day) as needed for diarrhea.
16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) 7658**]
Discharge Diagnosis:
C. Difficile colitis
Discharge Condition:
stable
Discharge Instructions:
Please call or come to the ED with any fevers > 101, nausea,
vomiting, worsening diarrhea, worsening abdominal pain, or any
other worrisome issues that may arise. Please continue to take
your PO Vancomycin for 7 days. Please continue to work with PT
to increase your strength.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up in 2
weeks at ([**Telephone/Fax (1) 6449**]
Completed by:[**2190-6-22**]
|
[
"557.0",
"401.9",
"250.00",
"008.45",
"496",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
5726, 5803
|
2494, 4161
|
426, 432
|
5868, 5877
|
1657, 2471
|
6204, 6359
|
1388, 1392
|
4286, 5703
|
5824, 5847
|
4187, 4263
|
5901, 6181
|
1407, 1638
|
275, 388
|
460, 1251
|
1273, 1341
|
1357, 1372
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,316
| 158,592
|
43401
|
Discharge summary
|
report
|
Admission Date: [**2164-1-5**] Discharge Date: [**2164-1-20**]
Date of Birth: [**2114-12-7**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
respiratory distress s/p bilateral knee replacements
Major Surgical or Invasive Procedure:
Bilateral total knee replacements
History of Present Illness:
49 yo M w/ PMH of OSA s/p b/l knee replacement today.
Preoperatively, he got 250 micrograms of fentanyl and 2 mg
versed before 8 AM. An epidural catheter was placed that
delivered bupivicaine and 1.6 mg of hydromorphone. He was
extubated post procedure but became apneic so an oral airway was
placed. He had been very difficult to intubate, so a nasal
airway was also placed. He was wheezing so 0.5 ml racemic
epinephrine was administered twice.
Upon transfer to the ICU, he was on CPAP with nasal trumpet and
completely obtunded. Of note, his ABG prior to transfer showed
7.18/83/180 and lytes were significant for K of 5.6. Upon
arrival, no urine output was noted and a second creatinine
reflected failure as it rose from 1.6 to 2.3. He was transferred
on fluids containing potassium.
On HD#2 noted to be in respiratory distress with RR in
40s/stridor, hypercarbic, and hypoxic was intubated
fiberoptically. Noted to have low grade temp and was started on
ceftriaxone/clinda/vanc for presumptive PNA. Patient remained
hemodynamically stable, with improving renal function and serum
bicarbonate rising. Self extubated 3 days later.
Past Medical History:
Depression
Hypertension
OSA, not compliant with CPAP in the past
diabetes II, on oral medications
dyslipidemia
kidney surgery as a child
Social History:
He has not smoked for 10 years. Drinks 3-4 [**First Name4 (NamePattern1) 4884**] [**Last Name (NamePattern1) 93407**] on one
night per week. Drinks up to 5 beers at a time. problem. [**Name (NI) **]
lives with his wife, has no children at home. He works in an
after school program.
Family History:
Mother died of complications of DM. Several brothers and sisters
with DM. Also significant for hypertension.
Physical Exam:
Gen: sleepy but easily arousable
HEENT: perrla, eomi
Cor: regular
Pulm: wheezes bilaterally anteriorly
Abd: obese, soft, NT, quiet BS, mildly distended, large well
healed surgical incisions on flanks bilaterally
Ext: bilateral knees wrapped with ACE bandages. Left leg in CPM
machine. He has ice machine on both knees. Right toes cool, left
toes warm. Radial pulses 2+ bilaterally, moving all 4
extremities
Pertinent Results:
BLOOD CX: NO GROWTH
URINE CX: NO GROWTH
SPUTUM CX:
GRAM STAIN (Final [**2164-1-7**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2164-1-9**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
FUNGAL CULTURE (Final [**2164-1-20**]): NO FUNGUS ISOLATED.
[**2164-1-5**] 09:41PM GLUCOSE-176* UREA N-37* CREAT-2.5* SODIUM-135
POTASSIUM-6.2* CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2164-1-5**] 09:41PM CALCIUM-7.5* PHOSPHATE-7.0*# MAGNESIUM-2.0
[**2164-1-5**] 09:41PM HCT-29.0*
[**2164-1-5**] 08:49PM TYPE-ART TEMP-36.6 O2-70 PO2-88 PCO2-69*
PH-7.22* TOTAL CO2-30 BASE XS--1 INTUBATED-NOT INTUBA
[**2164-1-5**] 06:08PM TYPE-ART PO2-88 PCO2-88* PH-7.15* TOTAL
CO2-32* BASE XS--1 INTUBATED-NOT INTUBA
[**2164-1-5**] 06:04PM TYPE-ART PO2-51* PCO2-105* PH-7.10* TOTAL
CO2-34* BASE XS--1 INTUBATED-NOT INTUBA
[**2164-1-5**] 05:59PM GLUCOSE-262* UREA N-35* CREAT-2.3* SODIUM-133
POTASSIUM-7.1* CHLORIDE-98 TOTAL CO2-25 ANION GAP-17
[**2164-1-5**] 05:59PM ALT(SGPT)-26 AST(SGOT)-29 CK(CPK)-524* ALK
PHOS-74 TOT BILI-0.3
[**2164-1-5**] 05:59PM CK-MB-8 cTropnT-0.02*
[**2164-1-5**] 05:59PM CALCIUM-8.2* PHOSPHATE-8.6*# MAGNESIUM-2.3
[**2164-1-5**] 05:59PM WBC-19.3* RBC-4.63 HGB-12.3* HCT-37.7*
MCV-81* MCH-26.5* MCHC-32.6 RDW-14.1
[**2164-1-5**] 05:59PM NEUTS-74.7* BANDS-6.1* LYMPHS-9.1* MONOS-9.1
EOS-0 BASOS-0 METAS-1.0*
[**2164-1-5**] 05:59PM PLT SMR-NORMAL PLT COUNT-208
CHEST, AP UPRIGHT VIEWS: Comparison is made to [**2158-8-16**].
The lung volumes are low. There are bibasilar opacities, more
prominent on the right than the left. These may relate to
postsurgical atelectases, but pneumonia cannot be excluded.
There is no definite effusion or pneumothorax. IMPRESSION:
Bibasilar opacities, possibly atelectases, but pneumonia cannot
be excluded.
Sinus rhythm. Compared to the previous tracing of [**2164-1-6**] no
significant
diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 156 86 358/409.71 62 45 72
[**1-12**]:
White Blood Cells 11.7* K/uL 4.0 - 11.0
Red Blood Cells 3.07* m/uL 4.6 - 6.2
Hemoglobin 8.5* g/dL 14.0 - 18.0
Hematocrit 24.9* % 40 - 52
MCV 81* fL 82 - 98
MCH 27.7 pg 27 - 32
MCHC 34.1 % 31 - 35
RDW 15.0 % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 363 K/uL 150 - 440
.
Glucose 167* mg/dL 70 - 105
Urea Nitrogen 17 mg/dL 6 - 20
Creatinine 1.1 mg/dL 0.5 - 1.2
Sodium 136 mEq/L 133 - 145
Potassium 3.4 mEq/L 3.3 - 5.1
Chloride 96 mEq/L 96 - 108
Bicarbonate 35* mEq/L 22 - 32
Anion Gap 8 mEq/L 8 - 20
CHEMISTRY
Calcium, Total 8.0* mg/dL 8.4 - 10.2
Phosphate 3.0 mg/dL 2.7 - 4.5
Magnesium 2.4 mg/dL 1.6 - 2.6
CXR [**1-11**]:
Opacification in both lower lungs is little changed since
[**1-9**], improved since [**1-6**]. Whether this is
atelectasis or pneumonia is radiographically indeterminant. The
upper lungs are clear. The heart is normal in size, and there is
no pulmonary edema, appreciable pleural effusion or indication
of pneumothorax.
NON-CONTRAST CHEST CT: Minimal ground glass and linear opacities
at the dependent portions of the lung bases is consistent with
atelectasis. There is a small left and trace right pleural
effusion. The lungs are otherwise clear and the pleural surfaces
are smooth. The airways are patent to the subsegmental level.
There is no mediastinal, hilar, or axillary lymphadenopathy. The
heart size is normal with no pericardial effusion. A central
venous line traverses the right atrium, through the tricuspid
valve, with the tip terminating in the right ventricle.
In the imaged portion of the upper abdomen, the adrenal glands
are normal. The remaining imaged portion of the upper abdomen is
unremarkable on this unenhanced study, which is not specifically
tailored for evaluating the abdominal organs. No osseous
findings suspicious for malignacy are noted.
IMPRESSION:
1. Mild bibasilar atelectasis and small pleural effusions. No
evidence of recurrent pneumonia.
2. Right subclavian central venous catheter tip terminating in
the right ventricle. Line should be retracted to avoid
irritation of the ventricular wall.
CXR [**2164-1-20**]: PICC in place (at cavoatrial junction)
MRI HEAD: As reported, there is abnormal signal intensity in the
medial aspect of each globus pallidus, worse on the right than
the left. There is FLAIR hyperintensity and abnormal
enhancement. The lesions are inconspicuous on the pre-contrast
T1-weighted images. Normal globus pallidus mineralization is
seen on the susceptibilty images. On the diffusion-weighted
images, the regions are heterogeneous. They are also
heterogeneous on the ADC mapping images but no clear area of
restricted diffusion is seen. The distribution is suggestive of
hypoxemic type injury. Carbon monoxide produces identical
pattern. The brain parenchyma is otherwise normal. The
ventricles and sulci are normal in size.
IMPRESSION: There is abnormal FLAIR hyperintensity and
enhancement in the medial aspect of each globus pallidus, worse
on the right than the left, suggesting hypoxemic injuries.
MRI PITUITARY: FINDINGS: The study is degraded by motion
artifact. However, the pituitary gland appears normal without
masses or abnormal enhancement.
There is persistent enhancement of the globus pallidus
bilaterally. There is some apparent increased T1 signal within
the globus calluses bilaterally, which is more conspicuous than
the [**2164-1-17**] MRI. Although this could be small amount
of hemorrhage, this could also be technical. If clinically
warranted, a CT could be performed.
The remainder of the visualized brain is stable in appearance.
IMPRESSION: No evidence of pituitary mass.
BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler
images of the common femoral vein, superficial femoral vein, and
popliteal vein were performed. There is a duplicated superficial
venous system on the left. There is limited visualization of the
distal superficial femoral veins bilaterally due to patient's
large body habitus. However, there are no intramural thrombi
identified. Normal flow, augmentation, compressibility, and
waveforms are demonstrated.
IMPRESSION: No evidence of DVT in either lower extremity.
BILATERL KNEE XRAY: Bilateral tricompartmental total knee
replacements are seen. There is a suggestion of bilateral knee
effusions. Soft tissue swelling is noted diffusely about the
knee. No hardware-related complication is seen. No fracture or
dislocation is noted. Skin clips are seen anteriorly
bilaterally.
IMPRESSION:
1. Bilateral tricompartmental total knee replacements without
evidence of hardware-related complication.
2. Diffuse soft tissue swelling and bilateral small joint
effusions. The possibility of joint infection must be excluded
clinically.
Brief Hospital Course:
Assessment: 49 M with hypercarbic respiratory failure s/p
bilateral total knee replacement
.
Plan:
.
# Hypercarbic hypoxic respiratory failure: Likely secondary to
OSA combined with narcotics now s/p NIMV and ventilation.
Repeat ABG on the floor in setting of daytime somnolence without
evidence of persistent hypercarbia. Case discussed with sleep
attending on call, Dr. [**Last Name (STitle) **], who recommended auto-BIPAP
given review of past sleep study and report of poor CPAP
tolerance. Patient will be started on auto-BIPAP at rehab, as
machine is not available here at [**Hospital1 18**]. He is scheduled for an
outpatient sleep study and follow-up in sleep clinic with Dr.
[**First Name (STitle) **]. No documented desats overnight on the floor but history
of desats to 60% on previous sleep study.
.
# Nosocomial pneumonia:
Patient defervesced and respiratory status improved on
antibiotics. He will complete a total of 10 days of IV
vancomycin and zosyn. Multiple blood cultures have been
negative.
.
# Hypoxic brain injury: Patient noted to be excessively
somnolent during the day, while in bed. He is much more awake
and alert while sitting up in a chair. Head MRI remarkable for
likely hypoxic brain injury. Neurology was consulted and agree
with diagnosis. They recommended starting L-carnitine,
creatine, vitamin E, and coenzyme Q10 to minimize risk of
post-hypoxic encephalopathy. Given myoclonic jerks, EEG done
and shows background slowing (consistent with encephalopathy)
but no epileptiform activity. ABG without evidence of
hypercarbia. TSH, folate, B12 were all normal. Sedating meds
were avoided. Patient initiated on CPAP to avoid
desaturation/hypercarbia overnight. He will follow-up with Dr.
[**First Name (STitle) 6817**] of neurology for this issue.
.
# Status post bilateral total knee replacements: Wounds healing
well. Staples removed [**2164-1-20**]. Patient is scheduled for
follow-up in ortho clinic on [**2164-1-31**]. He is to continue on
lovenox until then. He continues to use CPM and is working with
physical therapy daily. He was reevaluated prior to discharge
by attending orthopedist, Dr. [**First Name (STitle) **] in the setting of low grade
temperature and rising wbc for question of joint infection.
Bilateral knee xrays show soft tissue swelling and small
bilateral knee effusions, thought to be consistent with postop
changes. Dr. [**First Name (STitle) **] agrees there is no indication for joint
aspiration. Bilateral LENIs were done due to asymmetrical,
significant lower extremity edema but were negative for DVT.
.
# Polyuria: Suspect this is due to a postATN diuresis.
Endocrine was consulted given concern for possible central DI
but water deprivation test not consistent with this diagnosis.
Please monitor ins and outs and give IVF as needed. Of note,
patient is taking good po.
.
# Diabetes II: Patient's home glipizide was increased from 5 to
10 mg po qd. In addition, he has been maintained on an insulin
sliding scale. Please start glargine prn if sugars remain
elevated above 200 for improved control.
.
# Hypertension: Patient's home valsartan was increased for
improved blood pressure control.
.
# Hyercholesterolemia: Patient's lipitor was held in the setting
of elevated LFTs, thought to be due to rhabdomyolysis. LFTs are
steadily improving. Patient will follow-up with his PCP to
restart this medication. ASA restarted prior to discharge.
.
# Rhabdomyolysis/acute renal failure: Peak CK 18,166. CK now
down to 200. Patient has been making good urine and creatinine
has normalized to 1.1.
.
# Transaminitis: No Alk phos/Bili elevation to suggest
obstruction. Trended down. Likely secondary to rhabdo. Lipitor
restarted prior to discharge.
.
# Depression: Mood stable. Patient continued on his home
celexa.
.
# FEN: DM diet
.
# prophylaxis: lovenox and bowel regimen
.
# FULL CODE
.
# Dispo: Patient discharged to [**Hospital3 **] [**0-0-**]
Medications on Admission:
Lipitor 20mg qD
Diovan 160mg qD
Citalopram 40mg qD
Glipizide 5mg qD
ASA 81mg qD
Discharge Medications:
1. Vitamin E 400 unit Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. Levocarnitine 330 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
3. Coenzyme Q10 300 mg Capsule Sig: One (1) Capsule PO four
times a day.
4. Creatine Powder Sig: Five (5) grams PO twice a day.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day:
for total of 200 mg po qd.
12. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection four times a day: per sliding scale.
14. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 grams
Intravenous Q8H (every 8 hours) for 4 days.
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
Q 8H (Every 8 Hours) for 3 days.
16. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Bilateral knee osteoarthritis
Hypercarbic respiratory failure
nosocomial pneumonia
hypoxic brain injury
severe obstructive sleep apnea
type 2 diabetes, poorly controlled
hypertension
rhabdomyolysis
acute renal failure
Discharge Condition:
Fair
Discharge Instructions:
Keep the incision/dressing clean and dry. You may apply a dry
sterile dressing as needed for drainage or comfort.
If you are experiencing any increased redness, swelling, pain,
or have a temperature >101.5, please call your doctor or go to
the emergency room for evaluation.
You may bear partial weight on both legs.
Resume all of your home medication and take all medication as
prescribed by your doctor.
Continue your Lovenox injections as prescribed for
anticoagulation.
You have a scheduled follow up appointment with [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 17811**], NP
on [**2164-1-24**].
Monitor for change in mental status (sleepy in bed but stays
awake in seated position).
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC MSN Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2164-1-31**] 2:15 (ORTHOPEDICS)
Provider: [**First Name11 (Name Pattern1) 1507**] [**Last Name (NamePattern4) 44653**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2164-2-8**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2164-2-8**] 2:00 (NEUROLOGY)
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone: [**Telephone/Fax (1) 612**] Date/Time:[**2164-2-10**]
9:20 (SLEEP DISORDERS)
Please follow-up for your sleep study on Tuesday, [**1-24**],[**2163**] at 8:45 PM. Location: [**Hospital1 18**], [**Location (un) 620**] Emergency Room
(report to [**Apartment Address(1) 93408**]). Phone: [**Telephone/Fax (1) 74633**]
Please call to schedule follow-up with your primary care doctor
(Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 8499**]) to be seen within 2 weeks. Phone:
[**Telephone/Fax (1) 7976**]
|
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icd9cm
|
[
[
[]
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] |
[
"93.90",
"99.04",
"96.6",
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icd9pcs
|
[
[
[]
]
] |
14866, 14936
|
9387, 13337
|
327, 363
|
15198, 15205
|
2558, 9364
|
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|
2004, 2114
|
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|
13363, 13444
|
15229, 15944
|
2129, 2539
|
235, 289
|
391, 1529
|
1551, 1689
|
1705, 1988
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,913
| 105,885
|
46011
|
Discharge summary
|
report
|
Admission Date: [**2192-2-17**] Discharge Date: [**2192-3-6**]
Date of Birth: [**2122-6-18**] Sex: M
Service: MEDICINE ICU
HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old
gentleman with an extensive tobacco history complaining of
fever to 102, productive cough and progressive shortness of
breath for two to three days. The patient also commented on
associated malaise and diarrhea for two episodes. The
patient denied sick contacts, chest pain, did report
receiving the flu vaccine this year and has no history of
prior hospitalizations for chronic obstructive pulmonary
disease flares, pneumonias or any other pulmonary
complications. The patient denies recent travel, lower
extremity trauma, calf pain or any other risk factors for
pulmonary embolus. Review of systems was otherwise negative.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Fast heart rate.
3. Increased cholesterol.
4. Benign prostatic hypertrophy.
5. Status post appendectomy.
6. Emphysema without steroid or inhaler use.
ALLERGIES: Penicillin, which produces a rash.
MEDICATIONS;
1. Toprol 100.
2. Lipitor 10 q.d.
3. Cardura 2 q.d.
SOCIAL HISTORY: Significant for greater then 100 pack years
tobacco history. Occasional ethanol use.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 101.8. Heart
rate 95. Blood pressure 175/76. Respiratory rate 23.
Satting 88% on room air. 97% on 2 liters. In general, alert
and oriented times three, mild distress, shortness of breath
with speech. HEENT pupils are equal, round and reactive to
light. Bilateral injected sclera. Flat JVP. Lungs with
diffuse rhonchi, expiratory wheeze and delayed expiration.
Cardiovascular regular rate and rhythm. S1 and S2 with
distant heart sounds. Abdomen was soft, obese, nontender,
nondistended with normoactive bowel sounds. Extremities were
without clubbing, cyanosis or edema and were warm, dry and
pink.
PERTINENT DIAGNOSTIC STUDIES ON ADMISSION: Normal CBC with
normal differential with white blood cell count. Normal
electrolytes. Blood cultures that were sent remain negative.
Chest x-ray with emphysematous changes without evidence of
acute cardiopulmonary disease. CT angiogram with diffuse
emphysematous changes without evidence of infiltrate,
effusion or pulmonary embolus. Initial electrocardiogram
normal sinus rhythm without evidence of acute ischemic
changes.
HOSPITAL COURSE: 1. Chronic obstructive pulmonary disease
exacerbation: The patient was initially admitted to the
General Medical Service for a presumed chronic obstructive
pulmonary disease exacerbation in the setting of a upper
respiratory infection with negative DFAs for influenza A and
B. Subsequently the patient was transferred to the Intensive
Care Unit and intubated for hypercapnic respiratory failure
and was continually treated with Levofloxacin, steroids and
nebulized Albuterol and Atrovent for this chronic obstructive
pulmonary disease exacerbation with full ventilatory support.
Several days into the Intensive Care Unit course bile
cultures for influenza came back positive. The patient
completed a course of Levofloxacin and was briefly extubated
for two to three days with recurrent respiratory failure,
reintubated and eventually underwent tracheostomy. On the
day of discharge the patient's chest x-ray remained clear.
The patient was afebrile and tolerating recurrent spontaneous
breathing trials on trach mask with intermittent requirement
of pressure support ventilation. Sputum samples sent from
the day of discharge revealed gram positive cocci without
evidence of infiltrate on chest x-ray, evidence of a fever,
stable white blood cell count and improved respiratory
status.
2. Cardiovascular: The patient developed positive
intubation hypotension and intermittently required pressures
for support of his blood pressure throughout his Intensive
Care Unit course. The patient also developed rapid atrial
fibrillation during his Emergency Department course that was
initially treated with Diltiazem. The patient was placed on
Diltiazem drip and required intermittent boluses of Diltiazem
throughout his Intensive Care Unit course. After extubation
the patient was switched to po Metoprolol of which he was
maintained as an outpatient for his known history of
paroxysmal atrial fibrillation and supraventricular
tachycardia. At the time of discharge the patient had been
without pressers for several days and had his heart rate well
controlled on b.i.d. Metoprolol. The patient's outpatient
cardiologist Dr. [**Last Name (STitle) 1147**] was involved in the care of this
patient on a day to day basis and frequently added input to
the care of his supraventricular tachycardia.
3. Gastrointestinal bleed: After intubation and placement
of a nasogastric tube the patient was noted to have evidence
of an upper gastrointestinal bleed. The Gastroenterology
Service was consulted and performed an endoscopy and
discovered events of trauma from the nasogastric tube that
was thought to be the cause of this self limited upper
gastrointestinal bleed while on anticoagulation for the
paroxysmal atrial fibrillation. The patient was without
evidence of gastrointestinal bleed throughout the remainder
of his hospitalization.
4. Hematuria: During the patient's Intensive Care Unit
course the patient developed gross hematuria in the setting
of continuous indwelling Foley catheters. This hematuria was
associated with a brief drop in the patient's hematocrit,
which required 2 units of packed red blood cells for
transfusion. After continuous bladder irrigation the
hematuria resolved and the patient was without such findings
throughout the remainder of his hospital course.
5. Fluid, electrolytes and nutrition: The patient was
maintained on tube feeds throughout his Intensive Care Unit
stay and received a percutaneous feeding tube placement and
was tolerating tube feeds at goal at the time of discharge.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To rehab.
DISCHARGE DIAGNOSES:
1. Respiratory failure.
2. Chronic obstructive pulmonary disease exacerbation.
3. Influenza.
4. Paroxysmal supraventricular tachycardia.
5. Atrial fibrillation.
6. Hematuria.
7. Emphysema.
DISCHARGE MEDICATIONS:
1. Metoprolol.
2. Colace.
3. Bisacodyl.
4. Nicotine patch.
5. Doxazosin.
6. Albuterol.
7. Atrovent
8. Fluticasone
FOLLOW UP PLANS: The patient is to contact Dr. [**Last Name (STitle) 1147**] for
follow up within one to two weeks of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**]
Dictated By:[**Name8 (MD) 28700**]
MEDQUIST36
D: [**2192-3-6**] 12:24
T: [**2192-3-6**] 12:31
JOB#: [**Job Number 97945**]
|
[
"491.21",
"292.0",
"518.84",
"428.0",
"E937.0",
"599.7",
"427.31",
"487.0",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"31.1",
"99.04",
"38.91",
"96.56",
"43.11",
"45.13",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6022, 6219
|
6242, 6764
|
2403, 5939
|
173, 832
|
1956, 2385
|
854, 1148
|
1165, 1273
|
5964, 6001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,403
| 104,337
|
28242+57587
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-11-4**] Discharge Date: [**2181-11-24**]
Date of Birth: [**2123-12-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 15373**]
Chief Complaint:
57 year old man with history of malignant melanoma, left
parietal infarct, multiple intracranial lesions most likely
consistent with metastasis, and ischemic right foot.
Major Surgical or Invasive Procedure:
1. Status post lumbar puncture
2. Right femoral popliteal bypass
History of Present Illness:
Mr. [**Name14 (STitle) 66264**] is a 57 year old man with a history of melanoma
status post excision in [**2181-7-14**], lung nodule on CXR 2-3 months
ago, as well as history of deep vein thrombosis, peripheral
vascular disease and hypothyroidism who transferred to [**Hospital1 18**] on
[**11-4**] for workup of a cold, blue right foot.
.
Over the past 2 weeks, his family has noted intermittent
episodes of confusion and agitation. The first episode occured
about two weeks ago when he was driving his car erratically. The
passenger reported that he was speaking nonsensically and
mumbling so that she could not understand him. When his wife
arrived to the scene, she says that he "looked funny" but was
unable to further characterize his appearance. She also noted
that the patient had difficulty walking "as if he were drunk."
She took him home and he slept for a few hours. On awakening, he
"was fine". He has no recollection of this event. Later in the
week, he had several more, similar episodes characterized by
nonsensical speech, confusion, and amnesia. On Saturday [**11-4**],
he went for an MRI of his right foot and leg. His wife reports
that his foot had been bothering him for the past year. After
the MRI, he again seemed confused and tired. He went to bed when
he came home and slept for much of the day. When he woke up, his
speech again "did not make sense". His wife said that he kept
repeating that he "needed help". He also complained of a mild
headache and vomited several times. His wife called an ambulance
and he was brought to a local ED where he was found to have a
cold, blue foot.
Past Medical History:
1. Malignant Melanoma-on back s/p excision [**7-19**] - 2 x 1.4cm
lesion, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 68586**] [**Last Name (NamePattern1) 1105**], w/greatest thickness of .5mm. Four
axillary LNs were sampled and found to be negative.
2. Lung nodule on Chest CT 3 months ago at [**Hospital 487**] Hospital
3. Deep vein thrombosis [**2179**]
4. Peripheral vascular disease
5. Hypothyroidism
6. No history of stroke or seizure
7. ?GERD-admitted on Protonix
Social History:
No history of tobacco or alcohol. Works as facilities manager
and lives with wife and children.
Family History:
Father died of "rare blood disease" at 39. History of diabetes
in his mother. [**Name (NI) **] other known history of cancer.
Physical Exam:
Exam:
T-99.5 BP-142/77 HR-81-89 RR-[**11-28**] O2Sat-96%
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
CV: RRR, Nl S1 and S2
Lung: Clear to auscultation bilaterally
Abd: +BS soft, nontender
Ext: right foot cold and mottled, no palpable pulse.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, teary
throughout exam. Unable to relay a coherent history. Oriented to
person, place (Knows that this is [**Hospital3 **], but thinks he is
in [**Location (un) **], MA), month and year. Inttentive, says DOW
forwards, but unable to say them backwards. Speech is fluent
with mildly impaired comrehension (unable to "point to source of
illumination" though can follow simpler appendicular commands),
repetition is intact; naming impaired for low frequency objects,
but was able to name all items on the stroke card. No
dysarthria. [**Location (un) **] and writing profoundly impaired: He is able
to write illegibly in capital letters, but no discernable words
formed. Registers [**3-16**], recalls 0/3 in 5 minutes. He has right
left
confusion. No finger anomia. Unable to do simple calculations.
Evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Extinguishes DSS in right visual field. Extraocular
movements intact bilaterally, no nystagmus. Sensation intact
V1-V3. Facial movement symmetric. Hearing intact to finger rub
bilaterally. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. Right drift.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 * * * *
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
*limited by pain but at least [**3-18**]
Sensation: Intact to light touch, pinprick, + extinction to DSS
on right. JPS and vibration difficult to assess given
inattention.
Reflexes: +2 and symmetric throughout. Toes downgoing on left,
unable to asses on right due to pain.
Coordination: Finger-nose-finger normal, RAMs normal.
Gait/Romberg: Unable to assess due to ischemic foot.
Pertinent Results:
[**2181-11-3**] 09:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2181-11-4**] 05:50AM BLOOD %HbA1c-6.4* [Hgb]-DONE [A1c]-DONE
[**2181-11-4**] 05:50AM BLOOD Triglyc-78 HDL-35 CHOL/HD-4.3 LDLcalc-99
[**2181-11-4**] 05:50AM BLOOD TSH-1.2
[**2181-11-4**] 05:50AM BLOOD Free T4-1.2
.
EEG:[**2181-11-4**] This is an abnormal EEG of stage II sleep due to
the
infrequent bursts of generalized delta frequency slowing. This
abnormality suggests a deep midline subcortical dysfunction.
.
CT brain: 10/22/061. Enhancing 7 mm lesion in the left parietal
lobe, concerning for metastatic focus given history of melanoma.
2. Surrounding edema within the left parietal lobe may be
secondary to this metastatic focus. Given its large distribution
relative to metastatic lesion and loss of [**Doctor Last Name 352**]-white matter
differentiation and sulcal effacement, infarction should also be
considered. An MRI would be of further utility in evaluating for
additional nonvisualized metastatic lesions as well as
infarction.
3. Mild shift of midline rightward approximately 2 mm. No
evidence of gross herniation.
.
MRI [**2181-11-4**]:
1. Subacute infarction in the left posterior MCA/PCA - MCA
watershed zone distribution. 2. Three more rounded areas of
enhancement in the left hemisphere, likely representing
metastatic disease.
.
MRI [**2181-11-23**]: Left MCA stroke with underlying history of
melanoma. T1-weighted axial and sagittal images are performed
through the brain following intravenous gadolinium
administration. Comparison is made to the prior exam from
[**2181-11-4**]. The examination is significantly degraded due
to patient motion and patient shaking during the exam.
There is a wedge-shaped area of increased T1 signal which
partially enhances following intravenous gadolinium
administration involving the left posterior parietal lobe along
the watershed distribution. This corresponds to the previously
seen area of infarction from the previous exam of [**2181-10-14**].
No other abnormal enhancements are seen within the brain
parenchyma. The ventricular system is symmetrical without
hydrocephalus. The examination does not exclude the presence of
metastatic disease. A repeat examination would be recommended
preferably with sedation for further evaluation of the brain
parenchyma. There is a small enhancing lesion involving the left
caudate nucleus which was present on the previous exam. The left
posterior parietal lesion is not visualized on the current exam.
Overall, the exam remains degraded by motion artifact and repeat
study with gadolinium administration using MP-RAGE protocol
would be recommended for further evaluation.
.
ECG: [**2181-11-15**] Sinus rhythm. Possible prior inferior infarct.
Since previous tracing, no significant change.
.
Carotid Ultrasound: No evidence of internal carotid artery
stenosis on either side.
Brief Hospital Course:
Hospital course by system:
1. Neurology: When transferred here on [**11-4**], Mr. [**Known lastname 68587**]
remained confused. Imaging studies demonstrated a subacute
infarction in the left posterior MCA/PCA territory along with
multiple lesions suggestive of metastatic disease, question
melanoma. Outside pathology confirmed incidence of malignant
melanoma ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1105**]) on his back from that was removed with
negative lymph nodes in [**7-19**]. A Neuro-oncology consult was
obtained and workup for potential source of metastatic appearing
brain lesions was performed. On [**11-6**], a CT torso was negative;
notably, it did not show evidence of the pulmonary nodules seen
previously at [**Hospital3 **]. On [**11-7**], a bone scan was
negative for osseious disease. Cytology from cerebrospinal fluid
failed to demonstrate malignant cells in the CSF. Social work
was involved to support the family through the admission. The
family were able to meet with Neuro-Oncologist [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 4253**] to
discuss options for diagnosis of the brain lesions and
therapeutic options. A brain biopsy was recommended. A WAND
study of the brain was conducted on [**2181-11-22**], and due to changes
in the parietal lesion, which was more wedge-shaped and
consistent with infarct, the decision was made to reimage the
brain via MRI with and without contrast and MR spectroscopy with
plan to discharge Mr. [**Known lastname 68587**] to rehab and have him follow-up
with the [**Known lastname **] and Neurosurgical teams. His case will be
discussed in the multidisciplinary Brain [**Hospital 341**] Clinic and follow
up brains will be figured out at that time.
.
In regards to his initial presentation, seizures were considered
a possible explanation for his behavioral changes. EEG was
abnormal but without epileptiform activity. Patient was started
on Keppra but developed depressed mood. Keppra was ceased and
dilantin commenced. Dilantin was ceased on [**2181-11-19**] due to
supratherapeutic levels and suspected drug rash owing to
associated blanching erythematous maculopapular rash and fever.
Trileptal was commenced for seizure prophylaxis and foot pain.
He will titrate up to a dose of 900 mg po bid.
.
In regards to his left parietal lobe stroke, a stroke work up
was undertaken. ECG showed changes suggestive of old infarct.
Cardiac enzymes were negative. Patient was started on Aspirin.
Cardiac echo was unremarkable. Stroke work up showed normal
lipids on statin treatment. The statin was continued. Duplex
ultrasound of carotids found no significant disease. HbA1c was
6.4.
.
2. Vascular: Patient presented with ischemic right foot. Right
lower extremity angiogram was performed. This showed occlusion
of the distal SFA with reconstitution of an anterior tibial
artery at its origin with run off to the foot via this vessel.
There was some stenosis or occlusion of the mid anterior tibial
with reconstitution distally and flow into the foot via patent
dorsalis pedis artery (Please see results). The decision was
made to take the patient to the operating room for a lower
extremity revascularization. Prior to surgery Mr. [**Known lastname 68587**] was
placed on heparin GTT.
.
As Mr. [**Known lastname 68587**] continued to experience significant pain, a pain
consult was obtained and his pain regiment was improved,
although it remained difficult to control due to ischemia. He
was cleared by cardiology, and a right femoral-popliteal bypass
was performed on [**11-13**]. The operation went well. He was
transferred to the vascular service on the day of surgery and
returned to the neurology service on [**2181-11-17**]. The wound is
healing well. Mr [**Known lastname 68587**] has some post operative pain likely
neuropathic in origin due to vascular damage to nerves. This was
treated with Trileptal. PT was involved to mobilize. His
staples will be removed as an outpatient in the vascular surgery
clinic; please call to schedule an appointment in one week.
.
3. GI: Patient was continued on protonix.
.
4. Respiratory: Mr [**Known lastname 68587**] required oxygen via nasal cannulae
to 2L intermittently throughout the admission. There was no
deterioration throughout.
.
5. Infectitious disease: Post operative fevers occurred on
[**2181-11-17**] and [**2181-11-19**]. Urine, blood cultures and CXR were
unremarkable. CXR, urine cx, and blood cx from [**2181-11-20**] were also
unremarkable.
.
6. Endocrine: Thyroid function was normal. Thyroxine continued.
.
7. Derm: The patient developed an erythematous morbilliform rash
during the last week of his admission. It was felt that this was
most likely due to Dilantin hypersensitivity. Dilantin was
discontinued.
Medications on Admission:
1. Oxycontin 20 mg [**Hospital1 **] prn
2. Protonix 40mg QD
3. Lipitor 20mg QD
4. Levoxyl 25mg QD
5. [**Doctor Last Name 18928**] 30mg daily
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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Insulin Regular Human 100 unit/mL Solution Sig: variable
units Injection ASDIR (AS DIRECTED): per adult sliding scale.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One Hundred
(100) mg Injection TID (3 times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal
TID (3 times a day) as needed.
9. Oxcarbazepine 300 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Increase to 3 tablets (900 mg po bid) on Wednesday
[**11-28**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
1. Left MCA parietal lobe stroke, question underlying mass
lesions
2. Peripheral vascular disease status post ischemic right leg
status post femoral popliteal bypass
3. Melanoma removal from back [**7-19**]
4. Question seizures
5. Hypothyroidism
Discharge Condition:
Fair. Still with residual parietal lobe infarction signs with
difficulty attending to the right side of the world,
dyscalculia, difficulty [**Location (un) 1131**] and writing, right left
confusion, and finger agnosia.
Discharge Instructions:
Please take all medications as prescribed.
Please keep all follow up appointments.
Please return to the closest Emergency Room if you have any
headaches, visual changes, speech or language disturbances,
focal numbness, weakness, incoordination.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 68588**] at [**Telephone/Fax (1) 68589**] to schedule
follow up.
The Brain [**Hospital 341**] Clinic will contact you regarding follow up with
[**Name (NI) **] and NeuroSurgery. Their number is [**Telephone/Fax (1) 1844**].
Patient needs follow up in the [**Hospital **] Clinic with Dr. [**Last Name (STitle) **].
Please call for an appointment; needs to be seen in 1 week to
have staples removed. Call [**Telephone/Fax (1) 2395**] for appointment
Name: [**Known lastname 11770**],[**Known firstname 3549**] Unit No: [**Numeric Identifier 11771**]
Admission Date: [**2181-11-4**] Discharge Date: [**2181-11-24**]
Date of Birth: [**2123-12-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2987**]
Addendum:
Preliminary read of the patient's repeat MRI/MR Spectroscopy was
that his left parietal lesion was most consistent with
infarction.
He should continue on ASA 325 mg po qd. This was held prior to
possible to brain biopsy but should be restarted prior to
transfer to rehab.
Discharge Medications:
Patient should also be on ASA 325 mg po qd. This was held in
preparation for possible brain biopsy and should be restarted on
transfer to rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2997**] MD [**MD Number(1) 2998**]
Completed by:[**2181-11-24**]
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"88.42",
"03.31",
"39.29",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
16204, 16405
|
8092, 8092
|
489, 556
|
14301, 14522
|
5183, 8069
|
14817, 16012
|
2840, 2968
|
16035, 16181
|
14032, 14280
|
12896, 13039
|
14546, 14794
|
8119, 12870
|
2983, 3235
|
280, 451
|
584, 2197
|
4161, 5164
|
3274, 4145
|
3259, 3259
|
2219, 2710
|
2726, 2824
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,606
| 156,085
|
46963+58962
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-3-30**] Discharge Date: [**2181-4-1**]
Date of Birth: [**2122-2-7**] Sex: F
Service: MICU ORANG
ANTICIPATED DATE OF DISCHARGE IS [**2181-3-31**].
HISTORY OF PRESENT ILLNESS: This is a 57 year old female
with a history of a prior upper gastrointestinal bleed who
presented to the Emergency Room on the night of admission
with a syncopal event. She had been in her original state of
health up until 07:00 p.m. that evening when she started to
feel lightheadedness and dizzy. She sat down in a chair to
rest and upon standing she immediately had syncope. The
syncope was witnessed by her husband. She had a second
syncopal event when she was escorted by her husband into the
bathroom a few minutes later, and at that point she was
brought to the Emergency Room for evaluation.
As mentioned her review of systems was negative previous to
this episode. She denied fevers, nausea, vomiting. Her last
bowel movement had been that morning and it was normal formed
stool. She also denied any abdominal pain, hemoptysis,
diarrhea, melena or bright red blood per rectum.
While in the Emergency Room, it was noted that she had
melanotic stool on rectal examination and she went on to have
two melanotic bowel movements. A nasogastric lavage was done
with 400 cc of fluid which revealed coffee ground material
which did not clear. The patient was also noted to have
heart rate up into the 110s and a blood pressure that went as
low as 90/50. Throughout the whole time, she was alert and
oriented, mentating correctly and making good urine output.
An EKG was checked which showed T wave inversions of leads V1
through V3, which was different from her baseline. Cardiac
enzymes were sent from the Emergency Room and one aspirin was
given prior to the recognition of possible gastrointestinal
bleed.
PAST MEDICAL HISTORY:
1. Upper gastrointestinal bleed in [**2177**], status post laser
treatment. The site of bleeding was found to be peptic ulcer
disease. She was on proton pump inhibitors for a few months
afterwards but had discontinued this.
2. Ovarian cancer status post total abdominal hysterectomy
and bilateral salpingo-oophorectomy resected in [**2178**]. No
recurrence.
ALLERGIES: This patient has no known drug allergies.
MEDICATIONS:
1. Vitamin C.
2. Vitamin E.
3. Fish Oil.
SOCIAL HISTORY: She does not smoke tobacco. She is a
social drinker, one or two drinks per week. She works as an
accountant. She lives at home with her husband.
PHYSICAL EXAMINATION: Vital signs of 98.4 F.; heart rate of
85; blood pressure 98/44; respiratory rate of 16; saturation
of 100% on room air. This is a pleasant woman in no apparent
distress, alert and oriented times three. She was nontoxic
appearing. She had reactive pupils, full extraocular
movements and moist mucous membranes with anicteric sclerae.
She had a supple neck. She had a III/VI systolic ejection
murmur loudest at the apex of her heart. She states that
this is an old murmur. Her lungs were clear to auscultation
bilaterally. Her abdomen was slightly distended but
nontender with normoactive bowel sounds. She had no edema of
the extremities. Her neurological examination was grossly
intact.
LABORATORY: Data showed she had a white blood cell count of
13.5 and initial hematocrit of 28.7 and platelets of 266.
Sodium of 144, potassium of 4.1, chloride 109, bicarbonate
29, BUN and creatinine 41 and 0.5, glucose of 122.
Her initial cardiac enzymes were negative.
The course in the Emergency Department included two liters of
fluid, a Gastrointestinal consultation, an EKG as mentioned
which showed T wave inversions of V1 through V3, intravenous
Protonix and nasogastric tube placement with lavage.
She was admitted to the Medical Intensive Care Unit in good
condition with the plan for an upper endoscopy in the
morning.
SUMMARY OF HOSPITAL COURSE:
1. GASTROINTESTINAL BLEED: An upper endoscopy performed by
GI the following morning showed melanotic stool throughout
the stomach but no active sites of bleeding; however, it was
difficult to evaluate given the amount of material in the
stomach. The duodenum was clear. The patient was given a
total of three liters of intravenous fluid. Her hematocrit
was rechecked and found to be 22. She was transfused two
units of packed red blood cells. Protonix 40 intravenously
was continued and H.pylori was sent as well as serial
hematocrits.
At the time of this dictation, an upper endoscopy is
scheduled after lavage and clearance of the melanotic
material of the stomach to better visualize the area.
The patient received 10 mg of subcutaneous Vitamin K given an
INR of 1.2.
2. BLOOD LOSS ANEMIA: Secondary to gastrointestinal bleed.
She was transfused two units.
3. SYNCOPE: This is likely secondary to anemia from
gastrointestinal bleed and hypovolemia.
4. CARDIOVASCULAR: This patient had T wave inversions on
EKG. She had one set of cardiac enzymes which were negative.
She also was asymptomatic throughout. Serial EKG will be
checked prior to discharge.
5. OVARIAN CANCER: This was not an active issue during the
[**Hospital 228**] hospital stay.
At the time of dictation, the patient is pending a few
studies prior to discharge, however, it is anticipated that
she will be discharged in good condition to home.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Syncope.
3. Blood loss anemia.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. She was counseled to avoid alcohol until further
follow-up with her primary care physician.
2. Follow-up includes seeing her primary care physician
within the next week.
This dictation will be addended prior to the patient's
discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36
D: [**2181-3-30**] 11:30
T: [**2181-3-31**] 22:55
JOB#: [**Job Number 99601**]
Name: [**Known lastname **], [**Known firstname **] L Unit No: [**Numeric Identifier 15952**]
Admission Date: [**2181-3-30**] Discharge Date: [**2181-4-1**]
Date of Birth: [**2122-2-7**] Sex: F
Service: MEDICINE
THIS IS A DISCHARGE SUMMARY ADDENDUM TO A PRIOR DISCHARGE
SUMMARY.
The patient was transferred to the Medical Service from the
Intensive Care Unit on [**2181-3-31**]. She was
transferred so that she could be observed overnight in case
she should bleed or drop her hematocrit. The patient
remained stable overnight with no significant change in her
hematocrit and no bleeding. Therefore, she was discharged on
[**2181-4-1**].
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Blood loss anemia.
3. Syncope.
FOLLOW-UP: The patient is to follow-up with her primary care
physician in one week. She is to follow-up with the
Gastroenterology Service.
MAJOR SURGICAL INVASIVE PROCEDURE: Transfusion of three
units of packed red blood cells and endoscopy.
DISCHARGE MEDICATIONS: Protonix 40 mg, 1 po q.d.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-209
Dictated By:[**Dictator Info 15953**]
MEDQUIST36
D: [**2181-4-1**] 07:44
T: [**2181-4-1**] 12:41
JOB#: [**Job Number 15954**]
|
[
"794.31",
"285.1",
"V10.43",
"458.0",
"785.0",
"276.5",
"531.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"96.34",
"45.13",
"99.04",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
7127, 7381
|
6736, 7054
|
7078, 7105
|
5504, 6715
|
3893, 5332
|
2533, 3865
|
218, 1843
|
1865, 2342
|
2360, 2509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,101
| 102,247
|
1129
|
Discharge summary
|
report
|
Admission Date: [**2182-4-29**] Discharge Date: [**2182-5-1**]
Date of Birth: [**2118-11-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
SOB/Chest pain
Major Surgical or Invasive Procedure:
Central Venous Line placement
History of Present Illness:
History of Present Illness: 63M with cigar smoking history and
radiographically apparent diffuse metastatic disease (likely
highly aggressive Stage IV Lung CA) who came to the ED, was
intubated, and admitted to the unit for severe acidosis and
respiratory support. Patient was in his USOH until about 1 month
ago when he started experiencing SOB, weight loss (8lbs in 2
weeks), cough, gouty attacks in his toes, and right sided chest
pain. He was initially evaluated in clinic [**4-11**] with a CXR and
subsequent CT chest showing Left perihilar mass, mediastinal
LAD, right pulmonary nodules, and what appear to be diffuse
liver mets. He was seen by IP as an outpatient and had a
thoracentesis [**4-23**] with cytology still pending.
Over the last 2 days, his status has taken a turn for the worse.
Per wife, he has become jaundiced with increasing shortness of
breath. This morning he was apparently doing okay, by lunch time
he was only able to speak [**1-21**] words at a time due to shortness
of breath and by this evening he was unable to talk. His wife,
[**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 7243**], called the IP office regarding his
symptoms and was referred to the ED for further management.
.
In the ED, initial VS were: 30-40 rr, 70s O2. diaphoretic.
borderline hypotensive SBP 90s
-EKG with LBBB - unsure if new - meets sgarbosas criteria
-CK: 243 MB: 8 Trop-T: <0.01
-CTA Torso negative for PE but demonstrating the left perihilar
mass, with liver mets
-CT Head non-con negative
-Labs: WBC of 58.9 with 90% neutrophils, INR 3.3
-Chem 7: K 6.8, Bicarb 7, Bun/Cr 102/2.5
-Lactate 14.1 -> 14.9
-pH 6.84/58/411 -> 7.09/38/148
-ALT: 586 AP: 2875 Tbili: 11.4 Alb: 3.2 AST: 1300 LDH: 5685
-Phos 10.7, Mg 4.3, Ca 9.4, Uric acid 21.1
-UA: Many Bacteria, 8 whites, 1 epi
-Serum Tox: Negative
.
Given:
-3 amps of bicarb
-calcium, insulin, dextrose
-albuterol nebs
-now on bicarb drip - 150 per hour
-5L NS
-zosyn and vancomycin for concern of cholangitis
-Renal contact[**Name (NI) **] regarding concern for tumor lysis syndrome
-Intubated, vents - 500, rate 15 --> rate increased 27
-Not started on pressors, no CVL placed, MAP around 65 -->
slowly downtrending
two 18s and 20g
2 u FFP ordered
on metformin
Wife - full code
Admitted to MICU for further management
.
On arrival to the MICU, patient's VS: 97.0, 110, 103/61, 27,
100% FiO2 50%. Intubated and sedated and unable to give further
history.
.
Past Medical History:
History:
-Gout
-Allergic Rhinitis
-Obesity
Social History:
Social History: Lives with his significant other. [**Name (NI) 1403**] in the
Medical Collection Business. Hasn't had any exposures to
asbestos or other metals. Smokes [**11-4**] cigars a year, has done
that for
the past 30 years, Drinks 12-15 drinks a week (beer), no known
drug use
Family History:
Family History: Grandfather has chronic bronchitis
Physical Exam:
ADMISSION PHYSICAL EXAM:
97.0, 110, 103/61, 27, 100% FiO2 50%
General: Sedated, intubated
HEENT: Icteric sclerae
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anteriorly
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE PHYSICAL EXAM: Expired
Pertinent Results:
ADMISSION LABS:
.
[**2182-4-29**] 06:45PM BLOOD WBC-58.9*# RBC-5.45 Hgb-15.4 Hct-50.6
MCV-93 MCH-28.3 MCHC-30.5* RDW-13.9 Plt Ct-81*#
[**2182-4-29**] 06:45PM BLOOD Neuts-80* Bands-9* Lymphs-2* Monos-3
Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-3*
[**2182-4-29**] 06:45PM BLOOD Hypochr-3+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+
[**2182-4-29**] 11:15PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Burr-2+
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**]
Fragmen-OCCASIONAL
[**2182-4-29**] 06:45PM BLOOD PT-33.6* PTT-47.9* INR(PT)-3.3*
[**2182-4-29**] 06:45PM BLOOD Plt Smr-LOW Plt Ct-81*#
[**2182-4-29**] 06:45PM BLOOD Fibrino-179*
[**2182-4-29**] 11:15PM BLOOD Fibrino-84*#
[**2182-4-29**] 11:15PM BLOOD FDP-80-160*
[**2182-4-29**] 06:45PM BLOOD Glucose-62* UreaN-102* Creat-2.5*# Na-137
K-6.8* Cl-91* HCO3-7* AnGap-46*
[**2182-4-29**] 11:15PM BLOOD Glucose-154* UreaN-81* Creat-1.8* Na-141
K-4.9 Cl-113* HCO3-11* AnGap-22*
[**2182-4-29**] 06:45PM BLOOD ALT-586* AST-1300* LD(LDH)-5685*
CK(CPK)-243 AlkPhos-2875* TotBili-11.4*
[**2182-4-29**] 11:15PM BLOOD ALT-513* AST-1584* LD(LDH)-5100*
CK(CPK)-172 AlkPhos-1551* TotBili-6.8*
[**2182-4-29**] 06:45PM BLOOD Lipase-26
[**2182-4-29**] 06:45PM BLOOD Albumin-3.2* Calcium-9.4 Phos-10.7*
Mg-4.3* UricAcd-21.1*
[**2182-4-29**] 11:15PM BLOOD Calcium-6.6* Phos-8.6*# Mg-2.8*
[**2182-4-29**] 11:15PM BLOOD CEA-131*
[**2182-4-29**] 06:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2182-4-29**] 08:32PM BLOOD Type-ART pO2-411* pCO2-58* pH-6.84*
calTCO2-11* Base XS--26 Intubat-INTUBATED
[**2182-4-29**] 06:51PM BLOOD K-6.6*
[**2182-4-29**] 08:32PM BLOOD Glucose-113* Lactate-14.3* Na-134 K-5.6*
Cl-105
[**2182-4-29**] 08:32PM BLOOD Hgb-11.7* calcHCT-35
[**2182-4-29**] 11:31PM BLOOD freeCa-0.79*
[**2182-4-29**] 07:30PM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2182-4-29**] 07:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-MOD Urobiln-NEG pH-5.0 Leuks-NEG
[**2182-4-29**] 07:30PM URINE RBC-5* WBC-8* Bacteri-MANY Yeast-NONE
Epi-1
[**2182-4-29**] 07:30PM URINE CastHy-48*
[**2182-4-29**] 07:30PM URINE Gr Hold-HOLD
[**2182-4-29**] 07:30PM URINE Hours-RANDOM
.
Final Labs:
.
[**2182-5-1**] 04:00AM BLOOD WBC-32.4* RBC-3.56* Hgb-10.0* Hct-31.0*
MCV-87 MCH-28.1 MCHC-32.4 RDW-14.6 Plt Ct-64*
[**2182-5-1**] 04:00AM BLOOD Neuts-61 Bands-5 Lymphs-19 Monos-5 Eos-9*
Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-12*
[**2182-5-1**] 04:00AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**]
[**2182-5-1**] 12:50PM BLOOD PT-55.4* PTT-55.7* INR(PT)-5.5*
[**2182-5-1**] 08:22AM BLOOD FDP-40-80*
[**2182-5-1**] 12:50PM BLOOD Glucose-206* UreaN-100* Creat-4.8* Na-139
K-6.5* Cl-89* HCO3-26 AnGap-31*
[**2182-5-1**] 12:50PM BLOOD ALT-1419* AST-6173* LD(LDH)-[**Numeric Identifier 7244**]*
AlkPhos-2185* TotBili-12.1*
[**2182-5-1**] 04:00AM BLOOD Lipase-702*
[**2182-5-1**] 12:50PM BLOOD Albumin-1.7* Calcium-8.0* Phos-8.1*
Mg-2.9* UricAcd-4.3
[**2182-5-1**] 12:55PM BLOOD Type-ART Temp-37.7 Rates-/20 Tidal V-500
PEEP-10 FiO2-100 pO2-109* pCO2-41 pH-7.47* calTCO2-31* Base XS-5
AADO2-553 REQ O2-93 -ASSIST/CON Intubat-INTUBATED
[**2182-5-1**] 12:55PM BLOOD Lactate-11.3*
.
MICRO/PATH:
Blood Culture x 2 sets [**2182-4-29**]: NGTD
Urine Culture [**2182-4-29**]: NO GROWTH
MRSA SCREEN [**2182-4-29**]: Pending
.
IMAGING/STUDIES:
.
CT Head Non-Con [**2182-4-29**]:
IMPRESSION: No acute intracranial process. No space occupying
lesion
identified. If clinical concern for intracranial mass is high,
MRI is more
sensitive for detecting metatatic disease; non-contrast CT has
limited
sensitivity but there is no evidence for mass effect or edema.
.
CT Torso with IV Contrast [**2182-4-29**]:
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Short term interval progression of the large left hilar mass
with
progression of mediastinal, right hilar and left axillary
lymphadenopathy. The pulmonary arteries are attenuated as
described above by hilar lymphadenopathy. Small left pleural
effusion has decreased in size. Right pulmonary nodules are
overall increased slightly in size despite the short interval.
3. Bilateral lung parenchymal opacities likely represent
atelectasis and post obstructive pneumonitis. Infection cannot
be excluded, though not necessarily present.
4. Increased size and heterogeneity of the liver since
[**2182-4-18**], compatible with diffuse metastatic disease including
rapid increase. Porta hepatic lymph nodes are enlarged and
increased in size. No other metastatic disease in the abdomen or
pelvis.
5. Diverticulosis without diverticulitis.
Brief Hospital Course:
Assessment and Plan: 63M with cigar smoking history and new
diagnosis of Stage IV adenocarcinoma of the lung who was
intubated admitted for respiratory distress found to have renal
failure, fulminant hepatic failure, DIC, and TLS.
.
# Stage IV Adenocarcinoma of the Lung: Patient had recent hx of
weight loss, SOB, voice hoarseness and a CT with left perihilar
mass with compression of adjacent pulmonary artery and bronchi,
bilateral lung nodules with LAD and what appears to be diffuse
liver metastases. On admission, no tissue diagnosis was
available but pleural fluid cytology from outpatient
thoracentesis returned as adenocarcinoma. His course was fairly
atypical given the general nature of this malignancy as he, over
a period of a week developed significant symptoms of chest pain
and SOB which progressed to multiorgan failure and expiration
despite aggressive intensive care.
.
# Respiratory Failure: Patient was intubated for respiratory
distress, tachypnea, and hypoxia likely related to his acidosis
compressive perihilar mass in the ED. He underwent a CTA chest
which was negative for pulmonary embolism or significant pleural
effusion. His ventilator settings were aggressively titrated for
management of his acidosis but as his condition continued to
deteriorate the focus of his care was transitioned to comfort
with weaning of his ventilator settings. He passed shortly
thereafter in no apparent distress.
.
# Acute Renal Failure, Hyperkalemia: Patient had a Cr of 2.5 on
admission up from unknown prior baseline and initial K of 6.8 in
the ED with prominent peaked t-waves on EKG as well as an
arterial pH of 6.84. His hyperkalemia was felt to be the result
of acidsosis causing extracellular shifts, renal failure causing
decreased excretion, and tumor lysis syndrome causing increased
production. His acidosis and hyperkalemia were initially
controllable with high dose continuous bicarbonate drip as well
as frequent administration of IV insulin and dextrose. On
meeting with his family, it was determined that if he were able
to make his own decisions he would likely not be in favor of
being put on dialysis for an irreversible condition. As his
condition deteriorated he became less responsive to medical
management of his hyperkalemia.
.
# Severe Lactic Acidosis: On admission his arterial pH was 6.84,
GAP of 38, and lacate of 14.9. His lactic acidosis was thought
to be multifactorial related to likely fairly sudden-onset renal
failure and fulminant hepatic failure with highly aggressive
malignancy and tumor lysis. He was maintained on aggressive
management his acidosis as described above but his condition
continued to worsen.
.
# Tumor Lysis Syndrome: On admission he had a Cr 2.5, Uric acid
21.1, K 6.8, Phos 10.7, Calcium 9.4, LDH 5600+. He had been
having issues with gouty attacks which were new for him and
likely the initial stages of his TLS. TLS is very atypical for a
solid malignancy so concern was raised for possible lymphoma
although review of his blood smear and final report on his
pleural fluid as positive for adenocarcinoma removed this
suspicion. He was treated aggressively as above in addition to
recieving a dose of rasburicase.
.
# Concern for Sepsis, Source Unknown: Patient was admitted with
a white count to 59K with 10% bands, tachycardia, tachypnea, and
borderline pressures in the ED that were fluid responsive.
Positive UA with negative urine cultures, pending blood
cultures, and possible obstructive liver enzyme profile
(although could be [**Last Name (un) 7245**] malignancy related). He was treated
with vanc/zosyn empirically during his hospitalization.
.
# Fulminant Liver Failure/DIC: Patient was admitted with Tbili
11.4, INR 3.3, ALT 500+, AST 1300, Alk phos 2800. Also with low
fibrinogen and thrombocytopenia. This was thought to be related
to bulk disruption of his hepatic parenchyma by massive tumor
infiltration and overall multiorgan failure from rapidly
progressive malignancy.
.
Despite the greatest efforts of the [**Hospital 228**] medical team and
staff, Mr. [**Known lastname **] had progressive multiorgan dysfunction without
options for oncological treatment from his terminal lung cancer.
He passed away in no apparent distress in the presence of his
loving significant other and sister.
Medications on Admission:
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s) by
mouth every four (4) - six (6) hours as needed for pain
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2182-5-2**]
|
[
"286.6",
"278.00",
"162.9",
"511.81",
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"785.52",
"196.1",
"274.9",
"995.92",
"V49.86",
"477.9",
"584.5",
"276.4",
"277.88",
"401.9",
"038.9",
"305.1",
"197.7",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.71",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13079, 13088
|
8600, 12880
|
318, 349
|
13135, 13140
|
3777, 3777
|
13192, 13354
|
3208, 3245
|
13051, 13056
|
13109, 13114
|
12906, 13028
|
13164, 13169
|
3285, 3724
|
264, 280
|
405, 2806
|
3793, 8577
|
2828, 2873
|
2905, 3176
|
3749, 3758
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,387
| 183,747
|
24562
|
Discharge summary
|
report
|
Admission Date: [**2104-3-3**] Discharge Date: [**2104-3-8**]
Date of Birth: [**2051-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Referred from [**First Name3 (LF) **] lab after routine [**First Name3 (LF) 113**] showed pericardial
effusion with echocardiographic tamponade.
Major Surgical or Invasive Procedure:
Left thoracotomy, partial pericardial resection,
evacuation of pericardial effusion and left pleural effusion.
History of Present Illness:
52 year-old man with h/o metastatic esphogeal adenocarcinoma,
known pericardial effusion s/p pericardiocentesis with balloon
pericardotomy on [**2104-1-31**] who came to the [**Date Range 113**] lab today for
routine [**Date Range 113**] and was found to have tamponade physiology by TTE
(RV collapse on subcostals). He was brought to the holding area
for possible pericardiocentesis; however, after evaluation by
cardiac surgery, decision was made to bring patient for
pericardial window procedure in the OR tomorrow.
.
The patient reports CP which he has had since placement of his
esophageal stent. This is a constant pain, which he says is
secondary to his esophageal stent placement. He tells me that
his fentanyl patch and prn dilaudid help to relieve this pain.
He reports SOB which he states has been present for 2 weeks, but
now improving. He denies dizziness, blurry vision, cough,
fever, chills. Some nausea and fatigue associated with his
chemotherapy.
Past Medical History:
1) Metastatic Adenocarcinoma of Esophagus:
--> s/p 5 cycles cisplatin and 5-FU (completed in [**9-/2102**]); h/o
XRT, followed by consolidation chemotherapy alone and CyberKnife
radiation therapy to left pelvic metastasis in [**10-29**].
--> Course c/b RUE DVT related to line. [**7-/2103**], he began to
experience difficulty swallowing and subsequent evaluation
revealed local recurrence. Started irinotecan and cisplatin
--> Developed PE [**2103-11-18**], on Lovenox.
--> Periesophageal fluid collection: Found on CT [**2104-1-28**]; this
fluid
collection was conecerning for abscess vs necrotic lymph node.
Fluid collections were to small to drain (1.6cm x 1.5cm). He
was treated with Zosyn and then 3 weeks of Augmentin. Follow up
CT chest on [**2104-2-19**] showed resolution of fluid collection.
2) Hyperlipidemia
3) A fib: diagnosed on admission [**1-30**]
4) Anxiety
Social History:
Married, 18 and 15 year old sons. [**Name (NI) 4084**] smoked. "social
drinker" no EtOH over the last 2 weeks.
Family History:
Mother had ovarian cancer at age 54, father MI age 48. Multiple
family members on mother's side with "cancers."
Physical Exam:
VS: 110/52 - 108 - 18 - 100%RA
PULSUS: 30-40 mmHg
Gen: middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa. Dry MM, OP clear, no exudate.
Neck: Supple; JVP at level of the mandible.
CV: RR, normal S1/S2. No m/r. No S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. Left port
well appearing w/o erythema. CTAB, no crackles, wheezes or
rhonchi.
Abd: Soft, NT, ND. No HSM or tenderness. +palpable mass in RLQ
(patient states that this is secondary to lovenox).
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: 1+ DP/PT pulses
Pertinent Results:
REPORTS:
.
2D-ECHOCARDIOGRAM performed on [**2104-3-3**] demonstrated:
The left atrium is moderately dilated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%). The right ventricular
cavity is unusually small. Right ventricular systolic function
is borderline normal. The aortic valve leaflets (3) are mildly
thickened. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a large pericardial effusion.
There is right ventricular diastolic compression, consistent
with impaired fillling/tamponade physiology. There is
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling. There is stranding/echodense material in
the pericardial space.
.
[**2104-3-4**]:
Pericardial fluid:
NEGATIVE FOR MALIGNANT CELLS.
.
[**2104-3-7**] TTE:
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 grossly
normal. Right ventricular
chamber size and free wall motion are normal. There is abnormal
septal motion suggestive of pericardial constriction. There is a
small pericardial effusion. The pericardium may be thickened.
There is significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling. Otherwise, there is no echocardiographic
evidence of tamponade. Compared with the prior study (images
reviewed) of [**2104-3-3**], the pericardial effusion is now much
smaller.Septal bounce is now noted. A pleural effusion is
present in both studies.
.
LABS:
.
[**2104-3-8**] 06:48AM BLOOD WBC-6.3 RBC-3.20* Hgb-10.1* Hct-31.3*
MCV-98 MCH-31.6 MCHC-32.3 RDW-20.0* Plt Ct-167
[**2104-3-7**] 05:58AM BLOOD WBC-6.0 RBC-2.90* Hgb-9.2* Hct-28.3*
MCV-98 MCH-31.8 MCHC-32.6 RDW-20.4* Plt Ct-149*
[**2104-3-6**] 05:45AM BLOOD WBC-6.5 RBC-3.06* Hgb-9.9* Hct-29.7*
MCV-97 MCH-32.2* MCHC-33.2 RDW-20.4* Plt Ct-133*
[**2104-3-5**] 09:20PM BLOOD WBC-6.9 RBC-3.14* Hgb-10.1* Hct-30.5*
MCV-97 MCH-32.0 MCHC-33.0 RDW-20.7* Plt Ct-135*
[**2104-3-5**] 02:30AM BLOOD WBC-6.4 RBC-3.17* Hgb-10.3* Hct-30.7*
MCV-97 MCH-32.6* MCHC-33.6 RDW-21.5* Plt Ct-126*
[**2104-3-4**] 05:53PM BLOOD Hct-34.8*
[**2104-3-4**] 09:15AM BLOOD WBC-5.3 RBC-3.35*# Hgb-11.2*# Hct-32.2*#
MCV-96 MCH-33.3* MCHC-34.7 RDW-21.5* Plt Ct-132*
[**2104-3-3**] 04:00PM BLOOD WBC-4.6 RBC-2.50* Hgb-8.4* Hct-25.2*
MCV-101* MCH-33.6* MCHC-33.3 RDW-20.4* Plt Ct-118*
[**2104-3-8**] 06:48AM BLOOD Plt Ct-167
[**2104-3-8**] 06:48AM BLOOD PT-13.5* PTT-30.5 INR(PT)-1.2*
[**2104-3-7**] 05:58AM BLOOD Plt Ct-149*
[**2104-3-7**] 05:58AM BLOOD PT-14.7* PTT-31.4 INR(PT)-1.3*
[**2104-3-6**] 05:45AM BLOOD Plt Ct-133*
[**2104-3-6**] 05:45AM BLOOD PT-14.2* PTT-26.3 INR(PT)-1.3*
[**2104-3-5**] 09:20PM BLOOD Plt Ct-135*
[**2104-3-5**] 02:30AM BLOOD Plt Ct-126*
[**2104-3-4**] 09:15AM BLOOD Plt Ct-132*
[**2104-3-4**] 09:15AM BLOOD PT-14.1* PTT-26.2 INR(PT)-1.2*
[**2104-3-3**] 04:00PM BLOOD Plt Ct-118*
[**2104-3-3**] 04:00PM BLOOD PT-15.1* PTT-32.2 INR(PT)-1.4*
[**2104-3-3**] 04:00PM BLOOD Fibrino-570*#
[**2104-3-8**] 06:48AM BLOOD Glucose-93 UreaN-9 Creat-0.7 Na-140 K-3.6
Cl-104 HCO3-27 AnGap-13
[**2104-3-7**] 05:58AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-29 AnGap-10
[**2104-3-6**] 05:45AM BLOOD Glucose-106* UreaN-9 Creat-0.7 Na-137
K-3.9 Cl-102 HCO3-26 AnGap-13
[**2104-3-5**] 02:30AM BLOOD Glucose-113* UreaN-14 Creat-0.8 Na-134
K-4.3 Cl-102 HCO3-26 AnGap-10
[**2104-3-4**] 09:15AM BLOOD UreaN-14 Creat-0.9 Cl-105 HCO3-22
[**2104-3-3**] 04:00PM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-135
K-4.0 Cl-102 HCO3-25 AnGap-12
[**2104-3-3**] 04:00PM BLOOD ALT-23 AST-22 LD(LDH)-141 AlkPhos-79
Amylase-54 TotBili-0.5
[**2104-3-3**] 04:00PM BLOOD Lipase-32
[**2104-3-8**] 06:48AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
[**2104-3-7**] 05:58AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.9
[**2104-3-6**] 05:45AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.6
[**2104-3-3**] 04:00PM BLOOD Albumin-3.3* Calcium-8.1* Phos-3.8 Mg-1.7
[**2104-3-3**] 04:00PM BLOOD Hapto-227*
[**2104-3-4**] 06:00PM BLOOD Type-[**Last Name (un) **] pH-7.31*
[**2104-3-4**] 09:22AM BLOOD Type-ART pO2-90 pCO2-44 pH-7.34*
calTCO2-25 Base XS--2
[**2104-3-4**] 07:41AM BLOOD Type-ART pO2-368* pCO2-54* pH-7.29*
calTCO2-27 Base XS--1
[**2104-3-4**] 06:00PM BLOOD K-4.6
[**2104-3-4**] 09:22AM BLOOD Glucose-118* Na-136 K-3.9
[**2104-3-4**] 07:41AM BLOOD Glucose-100 Na-137 K-4.4
[**2104-3-4**] 06:00PM BLOOD freeCa-1.17
[**2104-3-4**] 09:22AM BLOOD freeCa-1.11*
[**2104-3-4**] 07:41AM BLOOD freeCa-1.16
Brief Hospital Course:
52 yo man with h/o metastatic esphogeal adenocarcinoma, known
pericardial effusion s/p pericardiocentesis with balloon
pericardotomy on [**2104-1-31**], found to have tamponade physiology by
TTE, s/p pericardial window on [**3-4**].
***
# PERICARDIAL EFFUSION: Pt had known pericadial effusion s/p
recent tap w/ percutaneous pericardotomy. Cytology negative for
malignant cells, but low yield test for this cause. Followed w/
serial echos as outpatient, with echocardiographic evidence of
tamponade on admission. He was brought to holding area for
pericardiocentesis on admission, but decision was made for
patient to have pericardial window performed in OR. Initially
had clinical tamponade with pulsus of 30-40mmHg, but was
hemodynamicall stable. Pt underwent pericardial window on [**3-4**]
(Left thoracotomy, partial pericardial resection, evacuation of
pericardial effusion and left pleural effusion), with removal of
500cc bloody fluid and placement of L chest tube. L chest tube
was d/c'd on [**3-6**].
- pt was found again to have elevated pulsus of 40mm Hg, however
[**Month/Year (2) 113**] did not show signs of tamponade
- pericardial fluid and pericardial biopsy were negative for
malignant cells
- pt was tachycardic throughout the admission. His beta blocker
was held initially due to tamponade, however this was restarted
after the pericardial window procedure. His blood pressure
remained stable throughout the admission.
- held lovenox prior to procedure, then restarted. Hct remained
stable.
- pt to f/u with CT surgery 2 weeks after discharge
.
# H/O PE: patient w/ h/o PE. On outpatient lovenox.
- held lovenox prior to pericardial window procedure, and pt was
maintained on heparin. Pt was briefly off anticoagulation before
and after the procedure, but his Lovenox was quickly restarted
and his hct remained stable. He was discharged on his home dose
of lovenox.
.
# METASTATIC ESOPHAGEAL CANCER: managed by Dr. [**Last Name (STitle) 3274**] as an
outpatient.
- during the admission, pt's pain was controlled with a fentanyl
PCA, fentanyl patch, and dilaudid PO prn. Pt was then weaned off
of the PCA as his fentanyl patch dose was increased.
.
# H/O AFIB: remained in sinus during the admission.
- metoprolol held initially, then restarted and uptitrated back
to home dose. Pt was discharged on his home dose of Toprol XL.
.
# FEN: cardiac diet with supplements
.
# ACCESS: L port
.
# CODE: Full Code
Medications on Admission:
- Senna 8.6 mg PO BID as needed
- Docusate 100 mg PO BID as needed
- Pantoprazole 40 mg PO Q24H
- Fentanyl 75 mcg/hr Patch 72HR Transdermal
- Lorazepam 0.5-1 mg PO Q4-6H as needed for nausea, anxiety.
- Toprol XL 200 mg PO once a day
- Hydromorphone 2 mg 1-2 Tablets PO Q4H as needed
- Enoxaparin 100 mg/mL Q12H
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
4. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
6. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg
Subcutaneous Q12H (every 12 hours).
Disp:*30 days* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
pericardial effusion with cardiac tamponade
secondary diagnoses:
esophageal CA
DVT
PE
Discharge Condition:
Stable. Pain well controlled.
Discharge Instructions:
As you know, you had fluid and pressure around your heart when
you came in, which was improved by creating what is called a
"pericardial window." This relieved the pressure.
You will have to see Dr. [**Last Name (STitle) **] in 2 weeks to have the staples
removed from your chest. Until then, you cannot shower or get
the area wet. You will do dressing changes as discussed with
the nurse prior to discharge.
Please seek medical attention immediately if you experience
chest pain, shortness of breath, nausea, vomiting, dizziness, or
any other concerning symptoms.
Please take all medications as prescribed. We have not made any
changes to your regimen.
Please attend all follow-up appointments.
Followup Instructions:
You should follow-up with Dr.[**Name (NI) 3502**] office in 2 weeks to have
your clips removed. The phone number for his office is
[**Telephone/Fax (1) **]. You also have an appointment with Dr. [**Last Name (STitle) **]
scheduled for [**4-14**] at 11:30 AM.
Dr. [**Last Name (STitle) 171**] (cardiology) would like to see you in follow up as
well. Please call [**Telephone/Fax (1) 1989**] to schedule an appointment for
sometime in [**Month (only) **].
You have the following additional appointments scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 25360**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2104-3-11**] 2:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2104-3-11**] 3:00
Completed by:[**2104-3-9**]
|
[
"427.31",
"E849.8",
"150.8",
"423.9",
"V12.51",
"E933.1",
"272.0",
"285.29",
"198.5",
"785.0",
"300.00",
"287.4",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"37.0",
"37.12",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11948, 11954
|
8157, 10583
|
457, 570
|
12104, 12136
|
3439, 8134
|
12888, 13732
|
2617, 2732
|
10945, 11925
|
11975, 11975
|
10609, 10922
|
12160, 12865
|
2747, 3420
|
12060, 12083
|
272, 419
|
598, 1570
|
11994, 12039
|
1592, 2472
|
2488, 2601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,725
| 175,396
|
43215
|
Discharge summary
|
report
|
Admission Date: [**2154-1-27**] Discharge Date: [**2154-1-31**]
Date of Birth: [**2110-4-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
altered mental status, sob, decreased urine output, chest
burning
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43 year-old woman with multiple medical problems, including CAD
s/p MI [**2141**], CHF with diastolic dysfunction, TIDM c/b
gastroparesis, [**Year (4 digits) **]/scleroderma, restrictive lung disease,
Gerd, s/p retinal hemorrhage [**1-26**], presents today with
decreased urine output, shortness of breath, mental status
changes, and chest burning. She also reports a month long
history of diarrhea that resolved 4 days ago. She reports
decreased appetite, po intake, and now with no bowel movement
for 4 days. Two days prior to presentation she developed
worsening dyspnea at rest associated with nonradiating chest
burning sensation, and increasing abdominal and lower extremity
swelling. She also noted onset of a rash in the bilateral lower
extremities that is not painful or itching. She was recently
started on standing Reglan as treatment for gastroparesis one
week prior to presentation. Additionally in the past week
prednisone was tapered off. She also had noted a hemorrhage in
her right eye one day PTA.
In the ED, hypotensive at 90/50. Treated with 3L NS, CTX dose
and 100mg hydrocortisone and transferred to [**Hospital Unit Name 153**].
Past Medical History:
CAD s/p MI and LAD/RCA stents [**2141**]
CHF w/ EF 57% 9/02
DM1 (IDDM) w/ triopathy
Scleroderma
[**Year (4 digits) **] syndrome (Lupus overlap)
Restrictive lung dz
H/o flash pulmonary edema
+ antiphospholipid antibody syndrome on coumadin
S/p PE [**1-/2142**]
GERD
Hiatal hernia
gastroparesis
Hypothyroidism
CRI
Migraines
Gout
s/p appy and ccy
Social History:
Lives w/ husband and daughter, prior [**6-11**] pk yr tob hx, quit 10
yr ago. Does not work. Denies EtOH.
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] [**Telephone/Fax (1) 20792**]
Cardiologist: [**First Name8 (NamePattern2) 5987**] [**Last Name (NamePattern1) 13114**] [**Telephone/Fax (1) 25520**]
Endocrinologist: [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 26643**]
Pulmonary: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 23427**] [**Telephone/Fax (1) 93113**]
Nephrologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10083**] [**Telephone/Fax (1) 3637**]
Ophthalmologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 28100**]
Rheumatologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2226**]
Gastroenterologist: [**Telephone/Fax (1) 21732**]
Family History:
Mom w/ scleroderma/[**Telephone/Fax (1) **], multiple myeloma
Physical Exam:
T 97.6 HR 98 BP 99/43 RR 16 92%4Lnc
Gen: lying in bed, comfortable, speaking in full sentences, NAD
HEENT: PERRL, anicteric, conjunctiva pink, MMM
Neck: supple, no LAD
CV: RRR with distant heart sounds, no mrg, 1+DP pulses B
Resp: bibasilar crackles
Abd: obese, soft, NT, mildly distended, no masses, no fluid
wave
Ext: erythematous with 2+ pitting edema bilaterally
Skin: erythema anterior aspect of B legs, no telangiectasias,
no raynoud's
Neuro: A&Ox3, CNII-XII intact, strenth [**6-6**] throughout,
decreased sensation to fine touch B distal LE, +asterixis
Pertinent Results:
[**2154-1-27**] 01:00PM URINE HOURS-RANDOM UREA N-318 CREAT-197
SODIUM-31
[**2154-1-27**] 01:00PM URINE OSMOLAL-316
[**2154-1-27**] 01:00PM PT-23.2* PTT-45.6* INR(PT)-3.4
[**2154-1-27**] 01:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2154-1-27**] 01:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2154-1-27**] 01:00PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**4-6**]
[**2154-1-27**] 01:00PM URINE AMORPH-FEW
[**2154-1-27**] 01:00PM URINE EOS-NEGATIVE
[**2154-1-27**] 11:41AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2154-1-27**] 11:41AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2154-1-27**] 11:41AM URINE RBC->50 WBC-[**7-12**]* BACTERIA-FEW
YEAST-NONE EPI-21-50
[**2154-1-27**] 11:18AM LACTATE-2.3*
[**2154-1-27**] 11:17AM GLUCOSE-111* UREA N-110* CREAT-6.5*#
SODIUM-134 POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-30* ANION GAP-15
[**2154-1-27**] 11:17AM ALT(SGPT)-22 AST(SGOT)-17 CK(CPK)-56 ALK
PHOS-91 AMYLASE-42 TOT BILI-0.5
[**2154-1-27**] 11:17AM cTropnT-0.04*
[**2154-1-27**] 11:17AM CK-MB-NotDone
[**2154-1-27**] 11:17AM ALBUMIN-3.7 CALCIUM-9.3 PHOSPHATE-3.2
MAGNESIUM-3.1*
[**2154-1-27**] 11:17AM WBC-10.2 RBC-2.80* HGB-8.7* HCT-26.0* MCV-93
MCH-31.0 MCHC-33.4 RDW-15.2
[**2154-1-27**] 11:17AM NEUTS-84.5* LYMPHS-11.7* MONOS-3.6 EOS-0.1
BASOS-0.2
[**2154-1-27**] 11:17AM PLT COUNT-282
.
CXR: no acute cardiopulmonary process
ECG: 85bpm, nsr, nml intervals, nml axis, no st/t changes
[**2154-1-28**] RENAL ULTRASOUND: The right kidney measures 11.0 cm.
The left kidney measures 11.2 cm. There is no evidence of
hydronephrosis, masses or stones. A Foley catheter is identified
within a decompressed bladder
Brief Hospital Course:
43 year-old woman with h/o CAD s/p MI [**2141**], CHF with diastolic
dysfunction, TIDM c/b gastroparesis, [**Year (4 digits) **]/scleroderma,
restrictive lung disease, Gerd, s/p retinal hemorrhage [**2154-1-26**],
presents today with decreased urine output, increased LE edema,
shortness of breath, mental status changes, and chest burning.
Laboratory analysis suggestive of ARF on CRI. During
hospitalization the following problems were addressed:
1. ARF: Patient with CRI, baseline creatinine around 2.2, but
very labile, presented with creatinine 6.5. Renal ultrasound
showed no hydronephrosis. FENA 0.8% suggestive of prerenal
azotemia. Renal consulted, spun urine with no sediment noted.
Etiology thought to be prerenal secondary to hypovolemia with
diarrhea. Initial presentation concerning for uremia given
fluid overload, rash, asterixis on exam, but creatinine improved
to 4.8 by day #2 and patient did not want hemodialysis and her
electrolytes were stable. All nephrotoxic medications held; [**Last Name (un) **]
held. Initially treated with ivf's, went into diastolic heart
failure, and treated with lasix. She thereafter continued to
autodiurese.
2. Hypotension: likely due to hypovolemia, intravascular
depletion as pressure responded well to IVFs. Baseline SBP
100s, presented with SBP 90. No evidence of infection or other
source of sepsis. [**Month (only) 116**] have benefitted from [**Last Name (un) 104**] stim test given
recent steroid course, but steroids dosed in ED. No further
steroids given and blood pressure remained within normal range.
Antihypertensives were initially held. Beta-blocker resumed as
blood pressure came up and as she has diastolic failure.
3. Mental status changes: ddx: uremia as described above vs
hypoglycemia as pt reports baseline bl sugar 180s and symptoms
develop with bl sugar 80, presented to ED with bl glucose 108.
Mental status now improved back to baseline.
4. ? PNA vs viral syndrome: In [**Hospital Unit Name 153**], patient treated with CTX
-> then switched to levoaquin monotherapy, and had rapid
improvement with stabilization of pressures and marked diuresis
and start of resolution of ARF on CRI. She was put on a 7 day
course of levaquin.
5. Coagulopathy: patient on coumadin for h/o antiphospholipid
antibody syndrome. Anticoagulation held as pt supratherapeutic
with INR 3.7 on presentation; may be d/t antibiotic use causing
decreased metabolism of coumadin vs nutritional losses. Pateint
received 10mg SQ vitamin K and INR came down to 1.7. She was
put on heparin and switched to lovenox as a bridge and coumadin
was restarted at home dose of 3mg QHS.
6. CAD: pt presented with chest pain not c/w previous
ischemia, no ECG changes, normal cardiac enzymes. B-blocker and
[**Last Name (un) **] were initially held with hypotension; continued on lipitor.
Pt is not on ASA at baseline.
7. CHF: pt with h/o diastolic dysfunction, nml EF (>55%) on
echo [**2151**] and more recently by report from pt's cardiologist.
No evidence of pulmonary edema on initial CXR, but with pulm
edema on day #2 after IVF load. Treated on day #2 with lasix
with good response. No longer short of breath, and beta-blocker
resumed.
8. type I DM: On home insulin pump. Patient is followed at
[**Last Name (un) **].
9. Gastroparesis: complication of DM; reglan held as it is a
new medication and patient with MS changes and ARF in patient
with h/o urinary retention. Once renal function improved,
reglan restarted.
10. Sciatica: d/t disc herniation; s/p steroid course and
taper, treated in house with oxycodone prn for pain control per
home regimen
11. Hypothyroidism: continued on home synthroid
12. Diarrhea: seems to be resolved now; may be have been
antibiotic associated; was likely the etiology of her metabolic
alkalosis as diarrheal dehydration causing contraction alkalosis
13. Gout: holding allopurinol [**3-5**] nephrotoxicity
14. R retinal hemorrhage: followed by ophthalmology, and
thought to be a preretinal hemmorhage with no contraindication
to anticoagulation. She also has known proliferative diabetic
retinopathy s/p PRP OU, which has resulted in decreased
peripheral visual fields. Outpatient followup recommended.
Medications on Admission:
Warfarin Sodium 3 mg PO HS
Atorvastatin 80 mg PO QD
Losartan Potassium 50 mg PO once a day
Nifedipine ER 30 mg Sustained Release PO once a day.
Betaxolol HCl 20 mg PO once a day.
Verapamil HCl 120 mg Sustained Release PO once a day.
Levothyroxine Sodium 150 mcg PO QD
Desipramine 75mg PO QD
Allopurinol 200 mg PO QD
Hydrochlorothiazide 50 mg PO QD
Calcitriol 0.25 mcg PO QD
Furosemide 80 mg 2-4 times a day
Omeprazole 20 mg PO twice a day
Gabapentin 300 mg PO BID
iron supplement
Zolpidem Tartrate 5-10 mg PO HS PRN
Tigan 250 mg once a day PRN migraine.
Midrin prn
Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H PRN.
oxycodone prn
Metoclopramide 5 mg PO QIDACHS
Provigil 100mg prn
Multivitamin once a day
Cipro for bacterial overgrowth d/c'd one week ago
Flagyl 500mg PO TID for bacterial overgrowth d/c'd 1 week ago
Prednisone taper d/c'd 4-5 days ago
Hyoscyamine 0.125-0.250 mg QID PRN RUQ pain
Discharge Medications:
1. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
4. Warfarin Sodium 2 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
7. Betaxolol HCl 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Verapamil HCl 120 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Desipramine HCl 75 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
11. Hyoscyamine Sulfate 0.125 mg Tablet Sig: 1-2 Tablets PO [**3-7**]
times daily.
12. Neurontin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. Insulin Pump Eng/French R1000 Misc Miscell.
15. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
16. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous once
a day: take this while your INR is less than 2.5.
Disp:*7 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnoses
1. Acute Renal Failure with uremia
2. Hypotension
3. Congestive heart failure
4. Mental status changes
5. R retinal hemorrhage
6. Pneumonia
7. Diarrhea
Secondary diagnoses:
8. type I DM
9. Gastroparesis
10.Chronic renal insufficiency
11. Hypothyroidism
12. Sciatica
13.Gout
14. antiphospholipid antibody syndrome
14. scleroderma/[**Company **] syndrome
Discharge Condition:
stable and improved without difficulty and with improving
creatinine. Last creatinine was 2.9.
Discharge Instructions:
Please call your doctor if you experience fever greater than
100.5, shaking chills, shortness of breath, chest pain, severe
nausea, vomiting or abdominal pain, inability to urinate, or
worsening diarrhea.
Have your creatinine and INR checked on Monday.
Weigh yourself at least three times daily. Do not take lasix or
hydrochlorothiazide for now. You can start lasix once a day if
you gain more than two pounds in a day.
You can resume all your other outpatient medications.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 3707**], your PCP, [**Name10 (NameIs) 176**] one week of
discharge to have your creatinine and INR checked.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2154-4-23**] 2:00
|
[
"585",
"250.41",
"250.61",
"337.1",
"428.30",
"536.3",
"486",
"710.1",
"428.0",
"584.9",
"276.5",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11983, 12032
|
5424, 9654
|
337, 344
|
12448, 12545
|
3555, 5401
|
13071, 13391
|
2884, 2947
|
10623, 11960
|
12053, 12224
|
9680, 10600
|
12569, 13048
|
2962, 3536
|
12245, 12427
|
232, 299
|
372, 1536
|
1558, 1904
|
1920, 2868
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,233
| 123,323
|
6527
|
Discharge summary
|
report
|
Admission Date: [**2132-1-4**] Discharge Date: [**2132-1-24**]
Date of Birth: [**2063-6-17**] Sex: M
Service: SURGERY
Allergies:
Compazine / Phenergan / Percocet
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Esophageal adenocarcinoma
Major Surgical or Invasive Procedure:
[**2132-1-4**] Minimally invasive esophagogastrectomy
[**2132-1-10**] Right thoracoscopy with evacuation of right hemothorax.
History of Present Illness:
Mr. [**Known lastname 24529**] is a 68 year-old male with recently diagnosed locally
advanced esophageal adenocarcinoma receiving neoadjuvant
chemoradiation s/p 5-FU/cisplatin cycle #1 on [**2131-10-8**], also
with a history of DM type 2, HTN and COPD, who presents for
laparoscopic esophagectomy.
Past Medical History:
1. Recently diagnosed locally advanced esophageal adenocarcinoma
diagnosed in [**8-/2131**], status post cycle 1 of 5FU and Cisplatin
[**10-8**], receiving concomitant XRT prior to surgical resection. No
distant metastases.
2. COPD
3. History of recurrent gallstone pancreatitis with resultant
chronic pancreatitis, status post cholecystectomy.
4. DM type 2
5. GERD
6. Hypercholesterolemia
7. Status post port placement and J-tube placmement on [**9-21**].
Social History:
He lives at home with his wife and children. Ex-smoker, quit
years ago. Occasional EtOH. Speaks Cantonese.
Family History:
Non-contributory.
Physical Exam:
T 98.0 P 103 BP 112/69 R 20 SaO2 95%
Gen - no acute distress
Heent - no scleral icterus, extraocular muscles intact, mucous
membranes moist
Lungs - clear
Heart - regular rate and rhythm
Abd - soft, nontender, nondistended, bowel sounds audible
Extrem - no lower extremity edema, warm, well perfused
Pertinent Results:
[**2132-1-4**] 04:02PM BLOOD WBC-15.0*# RBC-2.59* Hgb-8.8* Hct-25.6*
MCV-99* MCH-34.0* MCHC-34.4 RDW-20.3* Plt Ct-200
[**2132-1-4**] 04:02PM BLOOD PT-12.9 INR(PT)-1.1
[**2132-1-4**] 04:02PM BLOOD Glucose-156* UreaN-25* Creat-0.8 Na-135
K-4.5 Cl-106 HCO3-23 AnGap-11
[**2132-1-4**] 04:02PM BLOOD Calcium-7.9* Phos-4.3 Mg-1.5*
[**2132-1-17**] 8:49 am SWAB Source: neck.
**FINAL REPORT [**2132-1-21**]**
GRAM STAIN (Final [**2132-1-17**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Final [**2132-1-20**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2132-1-21**]): NO ANAEROBES ISOLATED
[**2132-1-17**] 9:26 am URINE
**FINAL REPORT [**2132-1-19**]**
URINE CULTURE (Final [**2132-1-19**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
The patient was admitted and had a minimally invasive
esophagogastrectomy which he tolerated well and was transferred
to the unit in stable condition. On post-op day 2, the patient
became hypotensive with MAP 55-60, had an increased oxygen
requirement, and was tachycardic with heart rate 120-150s. The
patient was intubated without incident for his increased oxygen
requirement and received blood transfusions for a Hct of 21.8.
His chest tube and neck drain had bloody drainage, but became
more serous in the following day. The patient was started on a
Levophed drip and was able to be weaned from it. The bleeding
into his drains appeared to stop. However, the patient remained
tachycardic despite adequate resuscitation. A chest x-ray
obtained at that time showed bilateral pleural effusions. An
esophagoscopy showed pink and well perfused mucosa ruling out
graft ischemia/necrosis as the cause for the patient's
tachycardia and increased oxygen requirement. The plan at this
point was for conservative management. Zosyn was started for
empiric antibiotic therapy. Attempts were made to wean the
sedation were thwarted by the patient's agitation. In addition,
the patient did not tolerate vent weanings well. Tube feeds
were started to provide nutrition.
On post-op day 4, a CT scan was obtained which showed a moderate
to large sized right pleural effusion. Interventional radiology
was consulted to tap this effusion and they were able to tap
800cc of bloody drainage. The patient had to be restarted on a
Levophed drip for hypotension. With failure to wean the patient
from the vent, the decision was made to take the patient to the
OR for a right thoracoscopy with evacuation of right hemothorax
on [**2132-1-10**]. The patient tolerated this surgery well and the
right lung was seen to expand fully in the OR after evacuation
of the hemothorax. The following day, the patient was able to
be extubated from the vent and was able to be weaned from
Levophed. Despite extubation, the patient continued to be
agitated requiring haldol at times. He also developed suicidal
ideations and Psychiatry was consulted. A one to one sitter was
provided and the patient was started on zyprexa to which he had
a good response.
The patient remained stable and was transferred to the floor on
[**2132-1-16**]. On [**1-17**], the patient spiked a fever of 101.7 and was
found to have a klebsiella urinary tract infection and was
treated with Ancef. The patient also develop some erythema at
his neck drain site. A neck CT scan showed an abscess at the
superficial margin of the sternocleidomastoid muscle. The drain
was d/c'd, the wound was opened up, pus was drained, and packed
with nugauze. The patient's erythema resolved and the drainage
stopped.
Physical therapy was consulted to assist the patient with
ambulation and he was able to ambulated without assistance. The
patient continued to require supplemental oxygen to keep his
SaO2 up and was discharged with home supplemental oxygen
therapy. Serial chest x-rays showed stable basilar atelectasis
and consolidations with no evidence of increasing pleural
effusion. Nebulizer treatments were provided to the patient
which helped with his oxygenation. After the patient was
extubated, he had had persistent coughing which worsened
whenever he swallowed liquids. There was concern for aspiration
and a video swallow exam was obtained which indeed did show
moderate oropharyngeal dysphagia with aspiration of thin liquids
when he swallowed with his head upright. He was able to achieve
a functional swallow for soft solids and thin liquids when he
swallowed with his chin to his chest. At discharge, he was
following these aspiration precautions well and will follow up
with the outpatient swallowing therapy here. The patient was
discharged with tube feeds to maintain his nutrition.
Medications on Admission:
PERCOCET 5MG-325MG PO
COMPAZINE
NYSTATIN 100,000 unit/gram Topical
FENTANYL 50 mcg/hour Transdermal
DEXAMETHASONE 4 mg Oral 2 Tablet(s) by mouth twice a day
GLUCERNA Oral
PROMOTE WITH FIBER Oral
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution [**Month/Year (2) **]: One (1) nebule
Inhalation every six (6) hours.
Disp:*60 nebule* Refills:*2*
2. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) nebule
Inhalation every six (6) hours.
Disp:*60 nebule* Refills:*2*
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Month/Year (2) **]:
One (1) Cap Inhalation DAILY (Daily).
4. Fluticasone 110 mcg/Actuation Aerosol [**Month/Year (2) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid [**Hospital1 **]: Five
(5) mL PO twice a day.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
7. Lipram-PN20 56,000-20,000- 44,000 unit Capsule, Delayed
Release(E.C.) [**Last Name (STitle) **]: Four (4) Capsule, Delayed Release(E.C.) PO
TID w/ meals ().
8. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. Senna-C 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO qAM as needed
for constipation.
10. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Fentanyl 50 mcg/hr Patch 72HR [**Last Name (STitle) **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
12. Hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every [**5-3**]
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
13. Actos 45 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO qAM.
14. Home oxygen
Please administer home oxygen at 4 L continuous via nasal
cannula.
15. Olanzapine 2.5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Tube feeds
Probalance 3/4 strength. Feed continuously at rate of 80 cc/hr.
Check residuals q4hr. Hold feeding for residual >= 100 ml.
17. Home nebulizer machine
Please provide home nebulizer machine.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Esophageal adenocarcinoma
Right hemothorax
Wound infection
Respiratory failure
Discharge Condition:
Stable
Discharge Instructions:
Call your doctor or seek immediate medical attention if you
experience fever, chills, lightheadedness, dizziness, chest
pain, shortness of breath, palpitations, severe abdominal pain,
nausea/vomiting, or increased drainage, redness, or bleeding
from surgical wounds.
You may have a regular diet of soft solids and thin liquids.
You must sit upright at 90 degrees and tuck your chin when
swallowing.
You may resume all your home medications.
No driving while taking pain medications.
No tub baths or swimming.
You may use dry dressing to cover surgical wounds.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**1-29**] weeks. Call
[**Telephone/Fax (1) 2981**] for appointment.
Please follow up with Dr. [**Last Name (STitle) 952**] from the Thoracic Surgery
service. Call [**Telephone/Fax (1) 170**] to schedule an appointment.
|
[
"682.2",
"250.00",
"272.0",
"786.2",
"518.5",
"530.81",
"285.1",
"041.3",
"577.1",
"998.11",
"496",
"599.0",
"401.9",
"998.59",
"293.0",
"511.8",
"V15.3",
"041.11",
"151.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"86.04",
"43.99",
"42.23",
"96.6",
"40.3",
"99.04",
"96.04",
"34.09",
"89.64",
"34.91",
"99.07",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10585, 10640
|
4336, 8203
|
317, 445
|
10762, 10771
|
1752, 4313
|
11380, 11661
|
1395, 1414
|
8448, 10562
|
10661, 10741
|
8229, 8425
|
10795, 11357
|
1429, 1733
|
252, 279
|
473, 773
|
795, 1253
|
1269, 1379
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,049
| 118,250
|
5401
|
Discharge summary
|
report
|
Admission Date: [**2150-7-10**] Discharge Date: [**2150-7-21**]
Date of Birth: [**2086-8-27**] Sex: F
Service: BLUE SURGERY
HISTORY OF PRESENT ILLNESS: This is a 63-year-old woman who
presented with a prior medical history including end-stage
renal disease, quadriplegia, osteoporosis, depression,
congestive heart failure and diabetes, who presented to the
[**Hospital6 256**] on [**7-10**] with symptoms
of constipation, decreased appetite, decreased bowel
movements and flatus.
PHYSICAL EXAM: She was distended, tender in the abdomen, and
an abdominal x-ray revealed a large bowel obstruction. In
addition, her physical exam was notable for decreased motion
of the extremities which was consistent with her prior
history of being quadriplegic.
HOSPITAL COURSE: The patient was consented and underwent
sigmoidoscopy and colonoscopy to reveal a sigmoid volvulus.
At that time, Dr. [**Last Name (STitle) 957**] discussed the matter with the
patient's family, and consent was obtained for an exploratory
laparotomy. The patient underwent general anesthesia and
underwent an exploratory laparotomy, during which an adhesive
band about the sigmoid colon was noted. This band caused a
segment of ischemia within the sigmoid colon and was
resected, creating a loop sigmoid colostomy.
Postoperatively, the patient remained intubated and was
transferred to the Trauma Surgical ICU where she remained
intubated and under close observation for three days. On the
fourth postoperative day, [**7-14**], the patient was
transferred to the floors, and the remainder of her hospital
course entailed advancing her diet with tube feeding, total
parenteral nutrition, and advancing PO oral intake.
Moreover, the patient, during her entire hospital course,
underwent dialysis three times a week as per her normal
scheduled, Tuesday, Thursday and Friday, and was followed, in
addition to the surgical team, by the renal team, the
neurosurgery team, and the psychiatry team for her various
co-morbidities.
On discharge, the patient is now tolerating an oral diet and
receiving adequate sustenance for her nutritional needs.
DISCHARGE STATUS: Good.
DISCHARGE DIAGNOSES: 1) Intestinal obstruction, status post
loop sigmoid colostomy.
Co-morbidities include:
2) Quadriplegia, 3) Renal failure, 4) ........... 5)
Osteoporosis, 6) Status post Billroth II procedure, 7)
Coronary artery disease, 8) Status post right shoulder
removal, 9) Atherosclerotic heart disease, 10) Cirrhosis of
the liver, 11) Alcoholic pancreatitis, 12) Depression, 13)
Hypovolemia requiring fluid resuscitation, 14) Chronic blood
loss anemia requiring transfusion, 15) Status post
cholecystectomy, 16) Status post laminectomy, 17) Status post
total abdominal hysterectomy and bilateral
salpingo-oophorectomy, 18) Appendectomy, 19) Urinary tract
infection, 20) Depression, 21) Sacral decubitus ulcers.
DISCHARGE MEDICINES: 1) ampicillin 500 mg po qd, 2) ascorbic
acid 250 mg po bid, 3) pancrease 1 capsule po tid with meals,
4) zinc sulfate 220 mg po bid, 5) percocet 1 tablet po q 4-6
h prn pain, 6) clonazepam 0.5 po tid, 7) Nephrocaps 1 capsule
po qd, 8) thiamine 100 mg po qd, 9) subcutaneous heparin
injections 5,000 U [**Hospital1 **], 10) bisacodyl 10 mg po qd, 11)
Protonix 40 mg po qd, 12) zolpidem tartrate 5 mg po qd before
bedtime, 13) metoprolol 25 mg po bid, 14) oxycodone SR 20 mg
po bid, 15) cyclobenzaprine 5 mg po tid, 16) fluoxetine 20 mg
po qd, 17) mineral oil 15 ml po bid, 18) albuterol 1-2 puffs
via an inhaler q 6 h prn, 19) aspirin 325 mg qd, 20)
lorazepam 0.5 mg IV q 6 h prn, 21) fentanyl patch 100 mg q 72
h.
The patient is being discharged to [**Location (un) 1036**] which is her
home at this time, phone# ([**Telephone/Fax (1) 21932**]. Her follow-up
appointment with Dr. [**Last Name (STitle) 957**] is in one week. Please refer to
the discharge papers for the exact time and date of the
schedule.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern1) 21933**]
MEDQUIST36
D: [**2150-7-21**] 12:03
T: [**2150-7-21**] 11:38
JOB#: [**Job Number 21934**]
|
[
"599.0",
"263.9",
"707.0",
"403.91",
"280.0",
"560.81",
"428.0",
"571.2",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"45.23",
"46.03",
"99.15",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
2185, 4165
|
791, 2163
|
520, 773
|
174, 504
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,953
| 138,296
|
27462
|
Discharge summary
|
report
|
Admission Date: [**2153-7-18**] Discharge Date: [**2153-7-26**]
Date of Birth: [**2098-6-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ativan
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
55M w/ stage 3b Right lung Cancer s/p chemotherapy and radiation
therapy for surgical treatment/tumor excision
Major Surgical or Invasive Procedure:
s/p Rt pneumonectomy with omental flap.[**2153-7-18**]
History of Present Illness:
55-
year-old gentleman with a long history of smoking who
presented with hemoptysis requiring intervention by
bronchoscopic and radiologic therapies. He was found to have
a large right hilar mass extending from the upper lobe into
the lower lobe and middle lobe, a bulky mediastinal
adenopathy and extension of the tumor up against the
esophagus. He underwent therapy with definitive chemotherapy
and chemotherapy and then was restaged. On restaging, he was
found to have a traumatic response, and therefore, his case
was discussed at the thoracic oncology multidisciplinary
center for possible salvage surgical resection. He underwent
a full metastatic workup including PET scan, MRI of the brain
and staging mediastinoscopy. He cleared all of his
mediastinal lymph nodes with the chemoradiotherapy and his
MRI of the brain and PET scan demonstrated no evidence of
metastatic disease and traumatic response of the tumor. We
therefore, after an extensive discussion with all doctors
involved as [**Name5 (PTitle) **] as the patient, elected to take him forward
for a high-risk salvage pneumonectomy and omental flap.
Past Medical History:
Thalasemia minor
Social History:
Ex smoker
Family History:
NC
Physical Exam:
General- pleasant male in NAD
HEENT- PERRLA, NAD
Neck- no cervical, axillary, supraclavicular or infraclavicular
adenopathy
REsp-CTAB
Cor-RRR, no M/R/G
Abd- soft, NT, ND, no HSM
Neuro- numbness in 4th and 5th finger right hand
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2153-7-25**] 05:55AM 22.9* 4.30* 8.8* 27.7* 65* 20.5* 31.8
18.4* 421
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2153-7-23**] 05:10PM 80* 4 6* 8 2 0 0 0 0
ADD ON
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Spheroc Ovalocy Schisto Burr Pencil Tear Dr [**Last Name (STitle) **]
[**2153-7-23**] 05:10PM 2+ 2+ 3+ NORMAL 2+ NORMAL 1+ 1+
OCCASIONAL 2+ 1+ 1+ 1+
ADD ON
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2153-7-25**] 01:20PM 13.9* 27.0 1.2*
[**2153-7-25**] 05:55AM 421
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2153-7-25**] 05:55AM 95 13 0.8 136 4.8 95* 35* 11
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2153-7-24**] 05:55AM 72
CPK ISOENZYMES CK-MB cTropnT
[**2153-7-24**] 05:55AM NotDone1 <0.012
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 <0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2153-7-25**] 05:55AM 9.7 3.7 2.1
PITUITARY TSH
[**2153-7-23**] 01:30AM 1.4
THYROID Free T4
[**2153-7-23**] 01:30AM 1.2
OTHER ENDOCRINE Cortsol
[**2153-7-23**] 01:30AM 29.6*1
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2153-7-25**] 11:29 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: Eval for abscess/infectious source s/p pneumonectomy
Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with lung ca s/p radiation and now s/p
pneumonectomy with rising wbc and low grade temps
REASON FOR THIS EXAMINATION:
Eval for abscess/infectious source s/p pneumonectomy
CT CHEST, ABDOMEN, AND PELVIS WITH INTRAVENOUS CONTRAST
INDICATION: 55-year-old man with lung carcinoma status post
radiation and pneumonectomy with rising white blood count and
low-grade fever. Rule out abscess/infectious source status post
pneumonectomy.
COMPARISON: FDG-PET [**2153-6-13**] and [**2153-4-19**]
TECHNIQUE: MDCT axial images of chest, abdomen, and pelvis were
obtained following administration of oral contrast and 130 cc of
Optiray. Coronal and sagittal reconstructed images were also
obtained.
CT CHEST WITH INTRAVENOUS CONTRAST:
There is air seen in the subcutaneous tissues of the chest on
the left. Patient is status post right pneumonectomy. There is
hydropneumothorax seen on the right. There is air seen in the
mediastinum. Patient is status post mediastinal lymph node
dissection. There are no pathologically enlarged lymphatic node
seen in the mediastinum, hilar, or axillary regions. There are
calcifications seen in the coronary arteries. There is a patchy
opacity seen in the left upper lobe anteriorly, that could
represent post-radiation change. There are no other opacities or
lung nodules identified in the lung parenchyma. Trachea, left
main and segmental bronchi are patent. There is no pericardial
effusion seen.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: Spleen, pancreas, liver,
gallbladder, stomach, duodenum are unremarkable. Abdominal loops
of large and small bowel are unremarkable. Adrenal glands are
unremarkable. Multiple lesions, heterogeneously hypoenhancing
compared to renal parenchyma are seen in kidneys bilaterally,
almost entirely replacing the right kidney. There are several
large masses also seen in the left kidney. There are abnormally
enlarged lymphatic nodes seen in the retroperitoneum, including
adjacent to right renal hilum between aorta and IVC, right
paraaortic, right retrocrural. The largest nodes are adjacent to
right renal hilum measuring approximately 20 mm in diameter and
right retrocrural measuring approximately 15 mm in diameter.
These nodes ,previously not FDG-avid on PET, significantly
increased in size compared to that previous examinations. There
is no free air and no free fluid in the abdomen. There is
extensive mesenteric peritoneal stranding in the abdomen, that
could be due to patient treatment/debilitation, but peritoneal
tumor involvement cannot definitively be excluded amd attention
on follow-up exam is recommeded.
CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon,
urinary bladder, distal ureters, prostate, seminal vesicles are
unremarkable. There is no free fluid and no pathologically
enlarged pelvic or inguinal lymphatic nodes seen.
BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic
lesions in the skeletal structures. Thoracotomy signs seen in
the right posterior right rib. There are deformities, consistent
with old fractures seen in the right lateral fifth and sixth
ribs, and left fifth and sixth lateral ribs.
Coronal and sagittal reconstructed images were reviewed, and
were essential in delineating anatomy and pathology as described
above.
IMPRESSION:
1. Multiple bilateral heterogeneously hypoenhancing renal
masses, highly suspicious for metastatic disease to kidneys.
Infection is also on the differential list. These lesions are
amendable to ultrasound-guided biopsy.
2. Pathologically enlarged retroperitoneal lymphatic nodes,
suspicious for tumor involvement.
3. Status post right pneumonectomy, there is hydropneumothorax
and. Subcutaneous emphysema.
4. Extensive mesenteric peritoneal stranding, that could be
consistent with debilitation, tumor involvement cannot be
excluded.
_________________________________________________________
CHEST (PA & LAT) [**2153-7-24**] 8:00 AM
Reason: assess for interval changes, for 7AM please
[**Hospital 93**] MEDICAL CONDITION:
55 year old man s/p R. pneumonectomy
REASON FOR THIS EXAMINATION:
assess for interval changes, for 7AM please
PA AND LATERAL CHEST, [**7-24**].
HISTORY: Right pneumonectomy.
IMPRESSION: PA and lateral chest compared to [**7-19**] through
[**7-22**].
Volume of fluid in the right pneumonectomy space has increased
slightly since [**7-22**]. Mediastinum is midline. Left lung is
clear. There appears to be an air and fluid collection in the
soft tissues of the right chest wall that may have enlarged
since [**7-20**], but this area is incompletely imaged on
nearly all of these plain radiographs.
Brief Hospital Course:
55M w/ stage 3b Rt lung Ca s/p chemorads now s/p Rt
pneumonectomy with omental flap [**2153-7-18**]. Pt tolerated procedure
well, transferred to ICU post-op, extubated on 6LNC, in stable
condition. Epidural for pain control. Post-op CXRY significant
for left sided pneumothorax, for which a chest tube was placed
to suction w/o complication, with resolution of pneumothorax.
[**7-19**]/POD#1- Kefsol- D/C left chest tube, good u/o, NPO,
ABD-nondistended.
[**7-20**] - POD#2-Kefsol- Temp 100.3/ WBC 17k; clear liqs- no free H2O
for Na 131; good u/o; Hct 27.7 from 31.3. O2 5L NC. Epidural.
Transfer to floor.
[**7-21**]- kefsol/ Temp-100.6. Epidural d/c'd, regular diet, PO pain
meds, PCA, d/c central line; d/c foley 12mn. OOB/IS/PT
[**7-22**]- POD#3- Chst tubes removed; tolerating cl liqs w/ min amt
belching.
9/3-4 Episode SVT (3runs, longest 30sec @225bpm)-asx, given
lopressor 5IV x3, lytes with worsening hyponatremia, Lopressor
increased- 50''. + flatus. T 100.6 - Kefsol, cx sent. Po pain rx
changed to dilaludid from percocet. OOB/IS/PT
[**7-23**] EKG: no a-fib, slight V4 ST-T depression; lopressor cont
50''. Temp 100.8- +u/a, levo x5d started. WBC elevated- 19.8.
F/U cx results- no other + findings. Lasix 20 mg x1, bowel meds.
OOB/IS/PT. Following Na for Na 130-132- free H20 restriction.
[**2153-7-24**]- WBC remains elevated-22K- T 101.2.Cx pnding. [**7-24**] CXR:
air/fluid collection soft tissues R. chest wall that may have
enlarged since [**7-20**] OOB/IS/PT. Lasiz IV 20. Lopressor ^'d
75''.
[**2153-7-25**]- POD#7 kefsol/ Levo #[**1-21**]. T-100.4-101.2/92-94% RA, 79NSR.
Right pleural fluid tapped- negative cx. Chest CT done- see
pertinent results- renal cuts--abnormality to be eval as
outpatient. ID consulted- probable oncologic etiology of fever,
no further tx necessary in settiing of negative cx data. Dispo
planning for home w/ VNA support [**7-26**]- Monitor fever and
symptoms.
POD#8- Patient stable, comfortable for discharge to home in
company of wife. Abdominal [**Name2 (NI) 14073**] to be d/c in 7 days, f/u appt
in 2 weeks. VNA support post pneumonectomy w/VNA Care
Group-[**Numeric Identifier 67198**].
Addendum-CX/ID Data
[**7-22**] sputum: oropharyngeal flora
[**7-22**] Blood: pending
[**7-22**] Urine: <10,000 organisms
[**7-23**] Blood: pending
Medications on Admission:
Meds: tylenol prn
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for prn pain.
Disp:*120 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for temp.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
8. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
stage 3b Rt lung Ca s/p chemorads now s/p Rt pneumonectomy with
omental flap.
PMH: thalassemia minor
Discharge Condition:
good
Discharge Instructions:
CAll Dr[**Name (NI) 1816**]/Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for:
fever, shortness of breath, chest pain, foul smelling or
excessive drainage from incision sites.
Resume regular medications as stated on discharge instructions.
Take new medications as ordered. Pain medications, antibiotics
YOu may shower when you get home. No tub baths or swimming for 4
weeks.
Monitor incision sites for reddness, excessive foul smelling
drainage as noted above.
VNA support for monitoring status at home
Followup Instructions:
CAll Dr[**Name (NI) 1816**]/Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for an
appointment before [**Month (only) **] ends- next 2-3 weeks.
Return to [**Hospital Ward Name 121**] 2 in 7 days for abdominal staple removal.
Completed by:[**2153-7-27**]
|
[
"599.0",
"512.1",
"427.89",
"162.8",
"354.2",
"V15.82",
"282.49",
"593.9",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.4",
"34.79",
"34.91",
"40.3",
"03.90",
"34.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11431, 11489
|
8122, 10420
|
393, 450
|
11634, 11641
|
1947, 3462
|
12200, 12462
|
1681, 1685
|
10488, 11408
|
7499, 7536
|
11510, 11613
|
10446, 10465
|
11665, 12177
|
1700, 1928
|
242, 355
|
7565, 8099
|
478, 1597
|
1619, 1637
|
1653, 1665
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,129
| 120,834
|
33730
|
Discharge summary
|
report
|
Admission Date: [**2201-3-7**] Discharge Date: [**2201-4-10**]
Date of Birth: [**2118-4-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
difficulty speaking
Major Surgical or Invasive Procedure:
[**2201-3-19**] Exploratory laparotomy, right colectomy and open
cholecystectomy
[**2201-3-31**] Open tracheostomy and percutaneous endoscopic-guided
gastrostomy tube
History of Present Illness:
82 yo man with a complicated PMH including Afib on coumadin,
stroke, vasculopathy (s/p right CEA, CABG, AAA), malignancy
(prostate cancer s/p resection and XRT as well as
cholangiocarcinoma with possible metastaic disease),
hypothyroidism, now off coumadin since [**2-27**] after a recent GIB in
the setting of significantly supratherapeutic INR ~8, who
presents today with 5 discrete episodes of a Broca's type
aphasia with reported return to baseline between events. The
patient was in his usual state of health after his recent
hospital discharge, when he awoke this morning at 730 am to an
[**8-2**] minute episode of garbled speech. He was aware of the
problem and could understand his wife, and was quite frustrated.
The episode resolved and he had another [**8-2**] minute episode at
breakfast. He decided to head to an OSH at [**Location (un) **], and had the
exact same episode of similar duration in route. At [**Location (un) **], he
was hypotensive initially at 93/52. Head CT was apparently
unchanged from prior imaging (showed left cerebellar
encephalomalacia and evidence of atrophy by my read) and INR was
1.8. He received 325 mg ASA x 1 and was transferred to [**Hospital1 18**]
for further evaluation. He apparently had one additional
episode of the same nature and duration en route to [**Hospital1 18**] or on
arrival here. He is currently at his baseline.
.
Review of Systems:
Only significant for "blurred" vision most of the day yesterday,
as if he was looking through tears. Otherwise, no HA, F/C, N/V,
dysphagia, changes in hearing, smell, taste, weakness, numbness,
tingling.
Past Medical History:
-Afib on warfarin
-Reports 3 strokes in past, unclear nature
-CAD/CABG ~15 years ago
-AAA
s/p likely CEA many years ago
-Anemia- recent GIB at [**Location (un) **] with Hct drop to 21 in setting of
INR ~8. Was reversed and anticoagulation held since [**2-27**]. Had
EGD and colonoscopy with a possible mass at right hepatic
flexure
by one document, extent of bleeding not clear
-Cholangiocarcinoma, s/p biliary stent [**9-29**]
-Prostate cancer s/p resection and XRT
Social History:
Lives with wife. [**Name (NI) **] EtOh or drug abuse. Off tobacco x 40
years,
smoked 1 ppd x 25 years.
Family History:
Believes his mother had stroke in her 80s
Physical Exam:
Vitals: T 98.8 HR 73nsr, BP 108/52, RR 29 96%on trach mask 0.50
General: NAD
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: supple, no bruits, trach in place
Lungs: mildly coarse b/l
CV: regular rate and rhythm, + SEM
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, well healing miline incision, stable mild erythema
peri-incisional
Ext: warm, 1+ lower extremity edema
Pertinent Results:
Notable OSH labs:
WBC 12.6 (75% PMN) H/H 10.4 and 31.2, plt 349
TnI 0.12
PT 17.0/INR 1.8/PTT 36.7
[**3-7**] MRI head: No evidence of acute infarct or abnormal
enhancement. Chronic left cerebellar infarct.
[**3-7**] MRA neck: Mild-to-moderate atherosclerotic disease with
probable ulcerated plaque at the left internal carotid origin.
Otherwise, the MRA is normal.
[**3-7**] MRA head: Head MRA demonstrates normal flow signal within
the arteries of anterior and posterior circulation.
[**3-11**] GI bleeding scan: No evidence of active bleeding.
[**3-13**] CT torso: impression: 1. 4-cm mass in the ascending colon
likely represents the patient's known colon carcinoma. Please
note that there is a second lesion in the sigmoid colon that is
suggestive of a larger polyp.
2. Multiple liver lesions concerning for metastatic disease.
3. Enhancing soft tissue around the common hepatic duct as well
as the right and left hepatic ducts. While this appearance is
more typically seen in cholangiocarcinoma, metastasis to the
biliary tree from colon carcinoma is included in the
differential diagnosis. A biliary stent is present and there is
mild intrahepatic biliary ductal dilatation.
4. Small amount of ascites surrounding the liver and in the deep
pelvis.
5. Infrarenal aortic aneurysm measuring 4.1 cm.
6. Chronic loculated pericardial effusion.
7. Small-to-moderate bilateral pleural effusions and chronic
interstitial changes in the lung bases.
[**3-19**] SPECIMEN SUBMITTED: Right Colon, Hydrops Gallbladder.
Procedure date Tissue received Report Date Diagnosed
by
[**2201-3-19**] [**2201-3-19**] [**2201-3-23**] DR. [**Last Name (STitle) **].
[**Doctor Last Name **]/mb˜…
DIAGNOSIS:
I. Right colon (A-Z):
1. No malignancy identified.
2. Four adenomas, 0.4 to 4.7 cm in greatest dimension.
3. Twenty-four lymph nodes with no malignancy identified.
4. Appendix, within normal limits.
II. Gallbladder (AA-AB):
1. Mild chronic cholecystitis, with marked distention and
dilatation.
2. Fibrotic nodule on serosa.
[**3-19**] echo: The left atrium is moderately dilated. No spontaneous
echo contrast is seen in the body of the left atrium. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is mildly
depressed (LVEF= XX %). The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. There
are simple atheroma in the ascending aorta. The descending
thoracic aorta is moderately dilated. 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 severe aortic valve stenosis (area
<0.8cm2). Moderate to severe (3+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
moderate thickening of the mitral valve chordae. Moderate (2+)
mitral regurgitation is seen. There is no pericardial effusion.
[**4-7**] CXR: moderate right pleural effusion persists in a patient
with huge enlargement of the cardiac silhouette and the
tracheostomy tube in place.
Recent lab results:
[**2201-4-9**] 02:09AM BLOOD WBC-11.7* RBC-2.87* Hgb-8.6* Hct-26.6*
MCV-93 MCH-29.9 MCHC-32.2 RDW-17.2* Plt Ct-384
[**2201-4-6**] 07:23PM BLOOD PT-13.3 PTT-29.5 INR(PT)-1.1
[**2201-4-9**] 02:09AM BLOOD Glucose-148* UreaN-39* Creat-0.9 Na-141
K-4.1 Cl-105 HCO3-26 AnGap-14
[**2201-4-9**] 02:09AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.1
Micro:
[**2201-3-14**] CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE
TOXIN BY EIA.
[**2201-3-23**] rectal swab:R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final
[**2201-3-26**]):
ENTEROCOCCUS SP.. MODERATE GROWTH.
Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ >256 R
[**2201-3-30**] MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2201-4-2**]): No MRSA isolated.
[**2201-4-4**] CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE
TOXIN BY EIA.
Brief Hospital Course:
82 yo man with a complicated PMH including Afib on coumadin,
prior strokes, vasculopathy (s/p right CEA, CABG, AAA),
malignancy (prostate cancer s/p resection and XRT,
cholangiocarcinoma s/p biliary stent with possible metastatic
disease, as well as colonic mass path pending), hypothyroidism,
now off coumadin since [**2-27**] after a recent GIB with a Hct of 20
in the setting of significantly supratherapeutic INR ~8, who
presents today with 5 discrete episodes of a non-fluent aphasia
with reported return to baseline between events. His INR at the
outside hospital was subtherapeutic this afternoon at 1.8 and he
was somewhat hypotensive there. He was admitted to the
neurology service.
.
General exam reveals a systolic ejection murmur and bilateral
lower extremity edema. Neurological exam including language was
normal, with the exception of slight right NLFF. His MRI did not
show any evidence of stroke. His MRA showed mild-to-moderate
atherosclerotic disease with probable ulcerated plaque at the
left internal carotid origin. The neurology resident witnessed a
few of these episodes which were preceded by tachycardia on
telemetry, otherwise no aura, characterized by abrupt onset of
expressive aphasia during which he could only stutter syllables
but no words, though comprehension was intact, vital signs
normal, and remainder of neurological examination normal. He
proceded to have a cluster of at least five of these within a
few hours, which were all stereotyped, and so after speaking to
his [**Hospital3 **] Gastroenterologist who felt that his bloody
bowel mvts were most likely related to hemorrhoids rather then
the hepatic flexure polyp, we decided that the risk-benefit
ration was in favor of anticoagulation for these presumed TIAs
in the context of his vasculopathy to prevent stroke and so we
started him on a Heparin drip with goal INR 50-70. We also
ordered a bedside video-EEG to r/o seizures and no further
episodes of aphasia occurred with normal background. He had some
mild BRPBR but vital signs were stable and Hct was slowly
trending downward. He eventually required transfer to the ICU
after his Hct dropped further.
.
He was stabilized in the ICU, but received 12L of IVF. He
developed fluid overload and was transferred to the cardiology
floor for diuresis prior to GI surgery, which was acheived with
IV lasix. ECHO showed severe aortic stenosis with moderate
aortic and mitral regurgitation, mild focal LV systolic
dysfunction, mild pulmonary artery systolic hypertension, and
massive biatrial enlargement.
.
On [**3-19**] he went to the operating room for an exploratory
laparotomy, right colectomy, open cholecystectomy and his care
was transferred to the general surgical service. Post
operatively he was admitted to the surgical ICU. He was
continued on flagyl for a +Cdiff on [**3-14**] for a total of 2 weeks.
He was fluid resuscitated for hypotension and low urine outbut
and was continued on lopressor IV for heart rate control. He
was continued as NPO with IV fluids. On post op day 2 ([**3-21**]),
he had increased work of breathing and tachypnea. It was
decided to electively re-intubate him for management of his
respiratory distress. He was maintained on CPAP+PS and diuresis
was started with lasix. Cardiology continued to follow him
during his ICU stay. On POD 4 ([**3-23**]) he was started on TPN
while awaiting the return of bowel function and later in the
evening he was extubated. On POD 5 ([**3-24**]) he was tachypneic
with increased work of breathing and was reintubated the morning
of [**3-25**] for respiratory distress. His chest xray showed some
increasing right pleural effusion. He was started on tube feeds
via an NGT on POD 6 ([**3-25**]) and the TPN was discontinued. Diuresis
was continued as tolerated with intermittent lasix and later a
continuous lasix IV drip. On POD 8 ([**3-27**]), the ICU team
performed a thoracentesis of his R pleural effusion with 800cc
withdrawn. He had return of bowel function on approximately POD
8 with +bowel movement. He received 2units pRBC on [**3-28**]. On POD
10 he continued to be unable to wean from the ventilator with
failed spontaneous breathing trials. A discussion was had with
the patient and family and it was decided to proceed with trach
and PEG placement. He went to the operating room again on [**3-31**]
for open trach and PEG placement. He tolerated the procedure
well and was started on tube feeds via the PEG on [**4-1**].
Cardiology again saw the patient for occasional episodes of SVT
and the patient was continued on lopressor and diuresis as
tolerated. He was seen by PT and OT and rehab screening was
initiated. His ventilatory settings were weaned down and he was
able to tolerate trach collar on [**4-1**] for a short time. He
continued to require rest at night and tolerate trach collar
during the day. Diuresis was continued with a lasix drip. He
was found to be Cdiff positive again on [**4-5**] and was started on
flagyl and oral vancomycin. He was followed for some mild
erythema around his abdominal incision which improved and
remained stable. On [**4-8**] he tolerated trach collar x 24 hours
with no vent rest and the lasix drip was discontinued. He
continued to auto-diurese and was continued on intermittent
lasix IV BID and later TID. His trach was changed to a size 8
fenestrated on [**4-9**]. He was seen by speech therapy for a
pacimer valve. He continued on trach mask and was doing well.
His vital signs remained stable and he was able to get out of
bed to the chair daily. At the time of discharge he was at his
admission weight and doing well.
Medications on Admission:
-Warfarin- off since [**2201-2-27**]
-Zocor 30 mg/d
-Lasix 20 mg/d
-Metoprolol 50 mg/d
-Levothyroxine 100 mcg/d
-Allopurinol 300 mg/d
-Colace 100 mg [**Hospital1 **]
-Sennokot 2 tabs qhs
-Prilosec 20 mg/d
Allergies: NKDA
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-24**]
Puffs Inhalation Q6H (every 6 hours) as needed.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs
Miscellaneous Q2H (every 2 hours) as needed.
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 16 days.
9. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 16 days.
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP<90 or HR<60.
12. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
14. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Five (5) mg
Intravenous PRN (as needed) as needed for SVT (HR > 120).
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 78040**]
Discharge Diagnosis:
Lower GI bleed
respiratory failure
malnutrition
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 11471**] office or return to the emergency room for any
increased abdominal pain, nausea or vomiting, fever >101.5F,
increased redness or drainage from the incision, difficulty
breathing, chest pain or anything else that concerns you.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) 2819**] in [**1-25**] weeks, call ([**Telephone/Fax (1) 6347**] to
schedule an appointment.
|
[
"263.9",
"427.31",
"578.9",
"V12.54",
"424.1",
"414.00",
"575.11",
"211.3",
"V10.46",
"197.7",
"518.5",
"428.0",
"285.1",
"428.21",
"V45.81",
"008.45",
"155.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"45.73",
"96.72",
"96.04",
"99.15",
"43.11",
"31.1",
"34.91",
"51.22",
"45.93"
] |
icd9pcs
|
[
[
[]
]
] |
14975, 15044
|
7707, 13339
|
333, 502
|
15136, 15145
|
3269, 7684
|
15449, 15586
|
2775, 2819
|
13611, 14952
|
15065, 15115
|
13365, 13588
|
15169, 15426
|
2834, 3250
|
1936, 2142
|
274, 295
|
530, 1917
|
2164, 2636
|
2652, 2759
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,827
| 112,075
|
15617
|
Discharge summary
|
report
|
Admission Date: [**2105-8-10**] Discharge Date: [**2105-8-20**]
Date of Birth: [**2038-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
fever and coccygeal pain
Major Surgical or Invasive Procedure:
1. bedside debridement of right ischial necrotic tissue [**2105-8-11**]
History of Present Illness:
67-year-old man with paraplegia (as a result of an inflammatory
spinal cord process of unknown etiology), a chronic indwelling
Foley catheter, and a known sacral decubitus ulcer was evaluated
on an outpatient basis on [**8-1**] and was found to have a
leukocytosis (WBC 14K); Staph aureus was cultured from his
sacral decub. Cefpodoxime 200 mg twice daily was started.
Despite this intervention, he remained febrile, and he began
having yellow drainage from his ulcer. He was therefore brought
to the ED on [**8-10**]. There, he was hypotensive (80s/60s). Blood
and urine cultures were drawn, dexamethasone was given, empiric
vanc, levoflox, and flagyl were started, and 3.6 liters of fluid
were infused. He was admitted to the ICU.
On further review of systems, the patient reports a history of
progressive night sweats with chills over the past 5-6 months.
He's also had a cough productive of increasing amounts of white
sputum for the two months PTA. He has limited sensation but has
felt increased pain in his sacral decub recently. His
left-sided, burning chest pain, right-sided abdominal pain, and
R>L shoulder pain all started with the onset of his paresis and
have progressed steadily since then.
Blood pressure promptly returned to the range of the patient's
relatively low baseline with early goal directed therapy. He
was admitted to the ICU under the sepsis protocol but required
ICU-level care for less than 48 hours.
Fevers are most likely due to sacral osteomyelitis. Bone scan
non-diagnostic, but suggestive of osteomyelitis. MRI likely not
possible due to IVC filter; would confirm this with radiology.
Since we can probe to bone on physical exam, then the diagnosis
becomes increasingly likely. Referred to orthopedics consult
for bone biopsy and discussion of possible ulcer debridement.
Vancomycin and ciprofloxacin were started pending biopsy.
Continue aggressive wound care.
3. Pulmonary Embolism: Goal INR [**3-14**]. Warfarin currently being
held. Anticipate resuming it today; will need to monitor INR
closely on combination of warfarin and cipro.
4. Asthma: Continue advair and albuterol.
5. CAD: ASA, simvastatin
6. CHF: Monitor fluid status and respiration; if flashes in
context of fluid loading for sepsis protocol diurese.
7. Depression: continue citalopram.
8. Back Pain/Chronic Pain: Continue Dilaudid, baclofen, and
gabapentin.
9. FEN/GI: On HH diet. Replete lytes as indicated.
10. PPX: Bowel regimen, anti-coagulation with coumadin, PPI.
11. Communication: Patient declines to name family members or
other persons who could make decisions on his behalf or be
contact[**Name (NI) **] regarding this admit.
12. Code: Full-discussed admit, no advanced directives or HCP.
13. Access: RIJ CVC (presep) placed in ED [**8-10**], R AC PIV.
14. Dispo: Pending osteomyelitis work-up.
Past Medical History:
1. Inflammatory disease of the spinal cord of uncertain
etiology. MRA [**10-15**] negative for vascular malformation. Initial
CSF analysis showed elevated protein (82) without oligoclonal
bands. NMO blood titer negative, RPR negative, Lyme serology
negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal,
neuromyelitis IgG negative, ESR 70, CRP 66.8. Ultimately
treated with broad spectrum antibiotics, corticosteroids (two
weeks of Solu-Medrol followed by a prednisone taper), and 5 days
of mannitol without improvement. He is followed by neurology
for a dense paraplegia (T4) with neuropathic pain, restrictive
shoulder arthropathy, and a neurogenic bladder requiring a
chronic indwelling foley.
2. Chronic sacral decubitus ulcer, previously treated with a VAC
dressing
3. Multiple UTI (including Pseudomonas)
4. Pulmonary embolus [**11-14**] s/p IVC filter placement
5. Asthma
6. Two-vessel coronary artery disease s/p CABG 4-5 years ago
7. Systolic CHF (EF 25-30% on [**2-15**] TTE)
8. Repaired liver laceration
9. Chronic back pain
10. Vitiligo
11. Feeding tube
12. Depression
13. MRSA from sacral swab and sputum
14. Prior transient episodes of leg paralysis
15. Right frontal lobe brain lesion biopsied [**11-14**] and c/w
gliosis; resolved on repeat imaging
16. Abnormal visual evoked potentials
Social History:
He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**]. He is retired from a job in the
maritime industry. Divorced 24 years ago. Three children.
Quit smoking [**2076**]. Quit drinking [**2080**]. No history of illicit
drug use or abuse.
Family History:
No stroke, aneurysm, no seizure, no AAA.
Physical Exam:
97.7, 98/68, 80, 20, 97%
Gen: Well appearing male in NAD lying in bed.
HEENT: MMM, lips slightly pale, smooth tongue.
Chest: CTA bilaterally, no w/r/r.
CV: RRR, physiologic splitting S2, no m/r/g.
Abd: Soft, nontender/nondistended, g-tube in place, c/d/i.
Extremities: Warm, well perfused, no C/C. Trace pedal edema
bilaterally.
Skin: Vitiligo on hands. Large round 10 cm diameter pressure
decubitus ulcer on sacrum with appropriate dressing. Appears
clean with granulation tissue in center, no s/sx of infection.
Neuro: CN grossly intact. A&O x 3, pleasantly conversant.
Pertinent Results:
[**2105-8-20**] 07:25AM BLOOD WBC-7.6 RBC-3.66* Hgb-9.8* Hct-30.4*
MCV-83 MCH-26.9* MCHC-32.3 RDW-18.8* Plt Ct-319
[**2105-8-19**] 05:00AM BLOOD PT-14.3* PTT-30.4 INR(PT)-1.3*
[**2105-8-20**] 07:25AM BLOOD Glucose-142* UreaN-9 Creat-0.5 Na-140
K-4.3 Cl-104 HCO3-29 AnGap-11
[**2105-8-13**] 06:55AM BLOOD ALT-10 AST-8 AlkPhos-100 TotBili-0.1
[**2105-8-20**] 07:25AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2
[**2105-8-10**] 07:00PM BLOOD Cortsol-7.9
[**2105-8-10**] 07:00PM BLOOD CRP-120.3*
[**2105-8-10**] 08:25PM BLOOD Lactate-0.8
[**2105-8-10**] 07:09PM BLOOD Lactate-0.7
[**2105-8-10**] 02:22PM BLOOD Lactate-2.5*
[**2105-8-17**] 4:00 pm TISSUE ISCHIAL BONE.
GRAM STAIN (Final [**2105-8-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2105-8-20**]):
ESCHERICHIA COLI. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2105-8-18**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2105-8-18**]):
NO FUNGAL ELEMENTS SEEN.
URINE CULTURE (Final [**2105-8-12**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
STUDY: Left upper extremity venous ultrasound.
INDICATION: 67-year-old male with redness, swelling, and pain in
the left upper arm. Assess for DVT.
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left internal
jugular, left subclavian, left axillary, left basilic, left
cephalic, and left brachial veins are performed. Normal
compressibility and waveforms are demonstrated.
IMPRESSION: No evidence of deep vein thrombosis of the left
upper extremity.
MRI OF THE PELVIS WITHOUT AND WITH IV CONTRAST:
IMPRESSION:
1. Large right decubitus ulcer involving the right posteromedial
buttock and right proximal medial thigh with right ischial
tuberosity osteomyelitis.
2. Midline sacral decubitus ulcer with probable osteomyelitis
involving the S4 vertebral body and absence of the S5 vertebral
body and coccyx suggesting osseous destruction.
3. No evidence of fistulous connection between the GI tract with
either the sacral or decubitus ulcer. No focal fluid collections
to suggest an abscess are present.
4. Diffuse signal abnormality and enhancement of the visualized
pevlic musculature suggestive of a myositis which may be
inflammatory in nature.
BONE SCAN: IMPRESSION:
Limited study but findings consistent with osteomyelitis of the
distal sacrum, coccyx, and right ischium.
CXR: Clear Chest
Brief Hospital Course:
1. Acute Osteomyelitis secondary to Decubitus Ulcer due to E.
Coli
- S/p Bone Biopsy
- E. Coli -> Vancomycin/Zosyn for total 6 weeks
- Flagyl x 6 weeks
- PRS was consulted for wound care, and recommended Dakins
solution with wtd dressings
- ID consultation
- Follow up with [**Hospital **] clinic 8/20/07@0930
2. Hypotension - Chronic
- Presumed neurogenic due to spinal cord injury
3. UTI - Enterococcal
- Vancomycin day [**10-23**] (for this)
4. Pulmonary Embolism
- IVC Filter
- Coumadin held for biopsy, restarted at 2 QHS
5. Depression
- Antidepressants were continued
6. CAD Native Vessle, Systolic CHF
- Aspirin
- B-Blocker
- ACEI
7. Parapalegia
- Kinaire Bed
- Turns Q2h
- PT evaluation
8. Lung Nodule
- Outpatient Workup
11. Communication: Patient declines to name family members or
other persons who could make decisions on his behalf or be
contact[**Name (NI) **] regarding this admit.
12. Code: Full-discussed admit, no advanced directives or HCP.
Medications on Admission:
1. trazadone 25 mg at bedtime
2. coumadin 2 mg qPM
3. tylenol 650 mg q8h prn
4. dilaudid 2 mg q4h prn
5. prostat 30 cc tid
6. xanax 0.25 mg po bid (started [**8-8**])
7. vitamin C 500 mg [**Hospital1 **]
8. aspirin 81 mg po daily
9. baclofen 5 mg po three times daily
10. bisacodyl supp every other day
11. cefpodoxime 200 mg twice daily
12. citalopram 40 mg po daily
13. docusate 100 mg po bid
14. omeprazole 40mg po daily
15. senna 2 tabs [**Hospital1 **]
16. simvastatin 40mg po qhs
17. advair 250/50 [**Hospital1 **]
18. neurontin 800mg tid
19. magnesium gluconate 500mg po bid
20. MVI with minerals daily
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q4H (every 4 hours) as needed for wheeze.
6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
18. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. Sodium Hypochlorite 0.5 % Solution Sig: One (1) Appl
Miscellaneous ASDIR (AS DIRECTED).
20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
21. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for pain.
22. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation Q6H (every 6 hours) as needed.
23. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
24. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
twice a day for 5 weeks.
25. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 5 weeks.
26. BED
Kinair Bed
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute Osteomyelitis
Septic Shock - E. Coli
Decubitus Ulcer
Chronic Hypotension (neurogenic)
UTI Bacterial (Enterococcal)
Pulmonary Embolism
Depression
CAD Native Vessle
Systolic CHF
Parapalegia
Lung Nodule
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital if you experience high fevers, chills,
nausea/vomitting, bleeding from the ulcers
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2105-9-28**] 9:30
|
[
"785.52",
"707.09",
"038.42",
"451.82",
"730.05",
"428.0",
"V12.51",
"599.0",
"344.1",
"414.01",
"730.08",
"V45.81",
"996.62",
"493.90",
"V58.61",
"995.92",
"707.05",
"518.89",
"707.03",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.49",
"77.69",
"38.93",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
13140, 13206
|
9195, 10165
|
339, 412
|
13455, 13461
|
5608, 7102
|
13614, 13768
|
4959, 5001
|
10825, 13117
|
13227, 13434
|
10191, 10802
|
13485, 13591
|
5016, 5589
|
7325, 9172
|
7292, 7292
|
275, 301
|
440, 3280
|
7138, 7259
|
3302, 4639
|
4655, 4943
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,727
| 167,661
|
41184
|
Discharge summary
|
report
|
Admission Date: [**2146-12-25**] Discharge Date: [**2146-12-27**]
Date of Birth: [**2081-4-17**] Sex: M
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Headache/collapse
Major Surgical or Invasive Procedure:
EVD placement
History of Present Illness:
65 yo M with no PMH who presents after onset of headache
deteriorating to AMS with diffuse SAH. Per wife, patient woke
up today in USOH. Around 1600 today he started to develop a
headache that was abrupt in onset although at the time didn't
seem to be a worst HA of life. Around [**2065**], wife noted that
patient became abruptly worse with AMS and then became
unresponsive. He was at the time moving all extremities but not
coherent. Wife called 911 and patient was taken to an OSH. At
the OSH, pt was MAE but not responding to commands and
disoriented, was intubated and CT head showed large diffuse
SAH.Pt tranferred to [**Hospital1 18**] for further management. On transport
to [**Hospital1 **], pt became significantly tachycardic to the 170-180's
without hemodynamic instability. He was given 10mg pancuronium
1.5hrs PTA at [**Hospital1 18**].
At [**Hospital1 18**], pt with initial tachycardia to 180's.Initial exam with
possible paralysis on board. Repeat CT head was done emergently
showing large diffuse SAH with IV extension.Consultation for
SAH.
Past Medical History:
None
Social History:
Wife denies that patient smokes, drinks, or uses recreational
drugs.
Family History:
No family history of SAH
Physical Exam:
PHYSICAL EXAM:
GCS E: 1 V: 1 Motor 1
O: T: 99 BP: 122/79 HR: 68 R vent 20 O2Sats 96%
Gen: Intubated/sedated
HEENT: Pupils: 6mm bilateral non reactive
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Intubated, GCS 3
Cranial Nerves:
I: Not tested
II: 6mm equal round and non reactive to light.
III, IV, VI: Unable to assess
V, VII: unable to assess
VIII: Unable to assess
IX, X: Unable to assess
[**Doctor First Name 81**]: Unable to assess
XII: Unable to assess.
Motor: Normal bulk and tone bilaterally. No purposeful
movement.
BUE no response to painful stim. BLE withdraws to painful
stimuli.
Reflexes: No cough/gag.
Toes downgoing bilaterally
Exam upon discharge:
expired per brain death criteria
Pertinent Results:
CT Head: extensive SAH & IVH involving both lateral, 3rd, & 4th
ventricles; diffuse edema
Brief Hospital Course:
Pt presented to ED with fixed and dilated pupils and massive
hemorrhage on CT. EVD placed emergently showing high ICPs. Pt
was monitored closely in ICU with no improvement in exam. Family
discussion was held to discuss grave prognosis. [**Location (un) 511**]
Organ Bank also spoke with family and they stated he would want
to donate his organs. He was met brain death criteria in the
afternoon of [**2146-12-27**].
Medications on Admission:
None
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Massive intracerbral hemorrhage
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2146-12-27**]
|
[
"584.9",
"780.01",
"V66.7",
"V49.86",
"348.5",
"348.89",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"02.39",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3038, 3047
|
2533, 2953
|
310, 326
|
3123, 3133
|
2418, 2418
|
3186, 3223
|
1551, 1577
|
3009, 3015
|
3068, 3102
|
2979, 2986
|
3157, 3163
|
1607, 1875
|
253, 272
|
354, 1421
|
1924, 2344
|
2427, 2510
|
1890, 1908
|
1443, 1449
|
1465, 1535
|
2365, 2399
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,128
| 193,197
|
14645
|
Discharge summary
|
report
|
Admission Date: [**2144-2-23**] Discharge Date: [**2144-2-26**]
Date of Birth: [**2063-9-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
intermittent L-sided chest pressure.
Major Surgical or Invasive Procedure:
Cardiac catheterization.
History of Present Illness:
An 80yoM with no prior CAD history who presented to [**Hospital1 **] ED
this AM with anterior wall chest tightness [**6-10**] associated with
SOB and left arm paresthesias occurring for over 12 hours. Pain
began yesterday evening while Pt. was trying to sleep, and waxed
and waned intermittently throughout the night. Pt. denied
nausea, vomiting, diaphoresis, lightheadedness, dizziness. Pt.
reports similar symptoms of chest pressure in the past, but not
persistent like current sensation. Pt. also found to be
hypertensive (SBP 180s). CE found to be CK 500, MB 77 Tn 3 on
presentation. Admitted to ICU there started on ASA, plavix,
heparin and integrillin. Had 2 episodes of recurrent CP in CCU,
during one had a vagal episode with ?apnea-->bagged and came to.
Transferred here to CCU for evaluation and ? cath if chest pain
persists. Had recurrent CP while here, maxed out on IV TNG and
with frequent Morphine boluses. Sent to cath lab overnight for
continued pain despite maximal medical therapy.
Past Medical History:
prostate ca s/p brachytherapy, PVD, h/o pancreatic mass (? ca),
resected and 8 month hospitalization s/p colostomy (now
reversed), chronic hip pain, s/p laminectomy for spinal stenosis
Social History:
lives with second wife and 12yo son. Manages a maintenance
company. h/o tobacco use (quit in [**2105**]), and 2 drinks per year
(on [**Holiday 944**]).
Family History:
mother and siblings with diabetes, mother with [**Name (NI) 5895**] Dx,
father died s/p MI, brother with CVA.
Physical Exam:
gen: NAD, cooperative.
HEENT: PERRL/EOM intact, OP clear, MMM, no JVD, no carotid
bruit.
neck: no masses, no LAD.
CV: RR, nl s1, s2 and split, 2/6 systolic murmur at LSB.
chest: good air movement b/l, faint crackles no wheezes.
abd: soft, nt/nd, +bs, no organomegaly.
extr: cool, cap refill<2 sec, 2+ dp pulses, no cyanosis, no LE
edema.
neuro: a&ox3, cn ii-xii intact; motor, sensory, coordination,
and language grossly non-focal.
Pertinent Results:
TTE [**2144-2-24**]: 1. The left atrium is mildly dilated. 2.There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). 3.Right ventricular chamber size is
normal. Right ventricular systolic function is normal. 4.The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No aortic regurgitation is seen. 5.The mitral
valve leaflets are structurally normal. No mitral regurgitation
is seen. 6.There is no pericardial effusion.
.
Cardiac cath [**2144-2-24**]: Initial angiography revealed a total
occlusion of the proximal LCX. Eptifibatide was continued
prophylactically. A 6 French
3.5 XB guiding catheter was felt to be too aggressive given the
mild proximal LMCA disease and a 6 French JL4 guiding cathater
was used, providing good support for the intervention. We were
unable to cross into the distal vessel with an Asahi ProWater
guidewire but a ChoICE PT XS wire was easily directed distal to
the occlusion with restoration of flow. The lesion was dilated
with a 2.0 x 12 mm Voyager balloon at 8 ATM. Angiography at this
point demonstrated a long area of diffuse disease in the LCX. A
2.5 x 28 mm Cypher DES was deployed across the distal portion of
the diseased segment at 16 ATM. A 2.5 x 18 mm Cypher was
deployed in the proximal LCX in overlapping fashion with the
first stent at 18 ATM and the SDS was advanced and used to
dilate the overlap of the two stents at 18 ATM. A 2.5 x 15 mm NC
Ranger was used to postdilate both stents with inflations of 18,
18, and 20 ATM. Final angiography revealed no residual stenosis,
no apparent dissection, and normal flow. The patient left the
lab free of angina and in stable condition. FINAL DIAGNOSIS: 1.
One vessel coronary artery disease. 2. Normal ventricular
function. 3. Acute posterior myocardial infarction, managed by
successful PTCA and stenting of the LCX with overlapping 2.5 x
18 mm and 2.5 x 28 mm Cypher DES. Final angiography revealed no
residual stenosis, no apparent dissection, and normal flow.
.
[**2144-2-24**] 02:13AM BLOOD ALT-27 AST-87* LD(LDH)-366* CK(CPK)-528*
AlkPhos-70 TotBili-0.8
[**2144-2-24**] 11:01AM BLOOD CK(CPK)-512*
[**2144-2-24**] 02:13AM BLOOD CK-MB-88* MB Indx-16.7* cTropnT-0.78*
[**2144-2-24**] 11:01AM BLOOD CK-MB-83* MB Indx-16.2*
[**2144-2-24**] 10:10AM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE
[**2144-2-25**] 05:50AM BLOOD WBC-6.1 RBC-4.30* Hgb-13.4* Hct-37.7*
MCV-88 MCH-31.1 MCHC-35.6* RDW-13.1 Plt Ct-184
[**2144-2-25**] 05:50AM BLOOD Plt Ct-184
[**2144-2-25**] 05:50AM BLOOD PT-12.8 PTT-27.6 INR(PT)-1.1
[**2144-2-25**] 05:50AM BLOOD Glucose-97 UreaN-20 Creat-1.0 Na-138
K-4.1 Cl-105 HCO3-28 AnGap-9
[**2144-2-25**] 05:50AM BLOOD WBC-6.1 RBC-4.30* Hgb-13.4* Hct-37.7*
MCV-88 MCH-31.1 MCHC-35.6* RDW-13.1 Plt Ct-184
[**2144-2-24**] 10:10AM BLOOD %HbA1c-6.1*
Brief Hospital Course:
An 80yoM with posterior STEMI, s/p Cypher DESs to totally
occluded proximal LCx.
.
# CAD s/p posterior wall STEMI (without obvious STE on ECG),
peak CK 528. Pt. had small hematoma at R groin cath site
post-cath, pressure was applied and distal pulses remained
palpable. Pt. was initiated on ASA, plavix, statin, BB, ACE-i.
Pt. initially hypervolemic on exam, likely from fluid overload,
diuresed well with minimal lasix. TTE revealed EF 75-80% (mild
symmetric LVH); continue ACE-i for afterload reduction,
euvolemic at discharge. Pt. was monitored on telemetry and no
events were recorded during the hospitalization. Pt. was seen
by physical therapy and cleared for discharge home, referred to
cardiac rehabilitation center.
.
# Pt. had several blood sugars >200 and an HbA1c 6.1%. Possible
first diagnosis of diabetes mellitus. Significant family
history. Recommended diet control and exercise to patient with
PCP follow up.
.
#Anemia: mild, secondary to minimal blood loss with phlebotomy
and cardiac cath. Recommended outpatient follow-up. Hct. stable
at discharge.
.
# Pt. complained of chronic hip pain during this admission. He
is eager to have this worked up as an outpatient.
.
# Patient was instructed to call for appointment with his PCP
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37063**] and an appointment was made for cardiology
follow-up on [**2144-3-9**] at 3pm with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] at [**Hospital1 **].
Medications on Admission:
On transfer: heparin 750 U/hr, integrillin 2, nitroglycerin,
ASA, lopressor 2.5mg iv x 2, plavix, zocor 40.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain: place under your
tongue if you feel any chest pain or recurrence of your heart
attack symptoms. If symptoms don't remit within 5 minutes, take
another and call your doctor or call an ambulance immediately.
Disp:*30 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Posterior ST-elevation MI.
Discharge Condition:
good, stable.
Discharge Instructions:
Please continue to take all medications exactly as prescribed.
Do not miss a single dose of your aspirin or plavix medication
because it could allow your stent to close and another heart
attack could occur. Call your primary care doctor or your
cardiologist before you discontinue any of your medications. If
you experience chest pain/pressure, shortness of breath, or
lightheadedness, please call your PCP or return to the hospital.
Followup Instructions:
Please follow up with your PCP [**First Name11 (Name Pattern1) 900**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 37064**].
.
You have an appointment to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] (Cardiology) at
[**Hospital **] Hospital on [**2144-3-9**] at 3pm. His office number is
[**Telephone/Fax (1) 6256**].
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2144-2-26**]
|
[
"443.9",
"410.61",
"V10.46",
"414.01",
"285.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.66",
"00.46",
"99.20",
"88.52",
"36.07",
"37.22",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
7908, 7914
|
5343, 6883
|
353, 380
|
7985, 8001
|
2387, 4198
|
8483, 9039
|
1808, 1919
|
7041, 7885
|
7935, 7964
|
6909, 7018
|
4215, 5320
|
8025, 8460
|
1934, 2368
|
276, 315
|
408, 1414
|
1436, 1622
|
1638, 1792
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,977
| 198,062
|
500
|
Discharge summary
|
report
|
Admission Date: [**2159-10-24**] Discharge Date: [**2159-11-10**]
Date of Birth: [**2090-1-18**] Sex: F
Service: MEDICINE
Allergies:
Losartan / Aspirin / Lisinopril-Hctz
Attending:[**First Name3 (LF) 4153**]
Chief Complaint:
pain in left shoulder
Major Surgical or Invasive Procedure:
left shoulder hemiarthroplasty [**2159-10-24**]
History of Present Illness:
69 yo somalian woman with 6week old left hyumerous fx intial
presented 4weeks out from presumed injury while being transfered
to stretcher for dialysis came in to [**Hospital1 **] mc for shunt eval
fistogram showed left humerous fx because of left arm shunt dr
[**Last Name (STitle) **] felt that the only way could fix the humerous would
jepodize the shunt the patiebt who need the hemodaylisas access
switch to the rt side
Past Medical History:
1. Type 2 diabetes
2. Diabetic nephropathy
3. Status post left femur fracture
4. Hyponatremia
5. Hypercholesterolemia
6. Unsteady gait
7. Cataracts
8. Back pain
9. Hypertension
10. Anemia of chronic disease
Social History:
Lives with son who is very involved and well informed regarding
her care needs. Non smoker. No EtOH
Family History:
Noncontributory
Physical Exam:
heent wnl
chest exp rhochi decresaed bs
[**Last Name (un) **] rrr no mrg
abd sft nt nd
ext left arm swollen eccchymotic pain ful rom
neuro intact
Pertinent Results:
[**2159-10-24**] 03:12PM BLOOD WBC-12.1*# RBC-3.72* Hgb-10.5* Hct-33.6*
MCV-90 MCH-28.1 MCHC-31.1 RDW-20.7* Plt Ct-267
[**2159-10-24**] 03:12PM BLOOD Plt Ct-267
[**2159-10-24**] 03:12PM BLOOD Glucose-160* UreaN-29* Creat-3.7* Na-141
K-3.2* Cl-98 HCO3-30 AnGap-16
[**2159-10-24**] 01:20PM BLOOD Type-ART FiO2-50 pO2-212* pCO2-37
pH-7.58* calHCO3-36* Base XS-12 Intubat-INTUBATED
Vent-CONTROLLED
[**2159-10-24**] 02:51PM BLOOD Glucose-237* Lactate-2.7* Na-136 K-3.3*
Cl-99*
[**2159-10-24**] 01:20PM BLOOD Glucose-193* Lactate-1.5 Na-138 K-3.4*
Operative report ([**2159-10-24**]):
Service: ORT Date: [**2159-10-24**]
Date of Birth: [**2090-1-18**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4158**]
PREOPERATIVE DIAGNOSIS: Left proximal humerus fracture.
POSTOPERATIVE DIAGNOSIS: Left proximal humerus fracture.
PROCEDURE: Left proximal humerus hemiarthroplasty.
INDICATIONS: Mrs. [**Known firstname 4159**] [**Known lastname 4160**] is a 69-year-old female patient
with a complex medical history including end-stage renal
disease on dialysis, diabetes. She fell approximately 4 to 6
weeks ago, sustaining a two-part proximal humerus fracture
that has not healed. Over the last 2 weeks of her medical
admission to manage respiratory issues, it was noted that the
flow from her arterial venous fistula which is on the injured
side of her extremity was deficient. An angiogram was
obtained which demonstrated the presence of the humerus
fracture. It is unclear when this fracture occurred,
presumably it could have occurred during transportation given
that the patient has no history of falling. The fracture was
significantly displaced, and
significantly angulated. The patient received alternative
hemodialysis access and the left upper extremity fistula was
left at this point unused in preparation for possible surgery
to address the humerus fracture. the patient has so far not
develop any healing
or callus on films. I think this is not unusual given her
medical
history and
believe a repair of this 2-part humerus fracture would
probably result in a non [**Hospital1 **] and I therefore believe that the
approach to address her fracture instability surgically is to
perform a hemiarthroplasty. The family agrees and she now
presents for procedure.
PROCEDURE IN DETAIL: The patient was brought to the
operating room and after the successful induction of general
anesthesia was placed in the beach-chair position. The left
upper extremity was prepped and draped in the usual sterile
manner. Via the deltopectoral approach, the fracture was
exposed. There was significant soft tissue scarring but no
callous and there was good lateral
perfusion on the soft tissues which bleed considerably. This
is secondary to the presence of the fistula nearby.
Hemostasis was achieved with [**Last Name (un) 4161**] electrocautery. The
deltopectoral interval was found and the fracture was
exposed. The humeral head, lesser tuberosity and greater
tuberosity were osteotomized and preserved and the remaining
head was removed. The canal was exposed and reamed and
broached to accept a 12 mm Osteonics humeral prosthesis. A 21
mm humeral head was then selected and was found to give
appropriate fit and range of motion. At this point, the canal
was irrigated. The final components were then brought to the
field and cemented with one bag of PMMA cement. The final
components were assembled and the lesser tuberosity and
greater tuberosity were repaired over the prosthesis using
the threaded holes in the prosthesis. The wound was
copiously irrigated and closed in layers with 0 PDS and 2-0
nylon over a drain. Dr. [**Last Name (STitle) 1005**] was present for the entire
procedure. All counts of sponges and instruments were
correct. C arm imaging was used at the end of the procedure to
establish the appropriate height and anatomy was restored.
The patient tolerated the procedure well and was taken to
recovery room without incident. Dr. [**Last Name (STitle) 1005**] was present for
the entire procedure.
CT head ([**11-2**]):
FINDINGS: There is no acute intra- or extra-axial hemorrhage or
shift of normally midline structures. The ventricles, cisterns
and sulci are somewhat prominent, likely due to atrophic
changes. Again identified are scattered hypodensities within the
subcortical white matter consistent with small vessel ischemic
disease. A small area of decreased attenuation is identified
within the right basal ganglia consistent with prior lacunar
infarction, unchanged from prior studies. The [**Doctor Last Name 352**]-white matter
differentiation appears preserved. There has been interval
opacification of the mastoid air cells bilaterally. There is
minimal thickening of the right maxillary sinus. The visualized
soft tissues appear unremarkable.
IMPRESSION: No acute hemorrhage. Evidence of chronic small
vessel ischemic disease as well as prior lacunar infarcts,
unchanged.
[**11-8**] CT abd/pelvis
69 year old woman with diffuse, persistent abdominal pain, s/p
PEA arrest, elevated lactate
REASON FOR THIS EXAMINATION:
Please evaluate for mesenteric ischemia - angiogram protocol
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Diffuse persistent abdominal pain status post PEA
arrest with elevated lactate. Concern for mesenteric ischemia.
CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Tiny (2 mm)
nodule seen within the left lower lobe, not clearly visualized
at the time of the previous CT examinations. The visualized
portions of the heart and pericardium appear unremarkable. The
liver, spleen, and adrenal glands appear unremarkable.
Gallbladder contains a calcified stone in layering calcium
consistent with milk of calcium. There is stranding about the
inferior aspect of the pancreas within the mesenteric root. The
aorta is normal in caliber with mural calcifications consistent
with atheromatous disease. The kidneys appear atrophic
bilaterally. The large and small bowel loops are normal in
caliber. There is mucosal thickening within a short segment of
cecum. No other areas of abnormal bowel wall thickening are
identified. There is no free intraperitoneal air and no free
fluid within the abdomen. There is no pathologic appearing
mesenteric or retroperitoneal lymphadenopathy.
CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The bladder,
distal ureters, rectum and sigmoid colon appear unremarkable.
There are uterine calcifications. The uterus and adnexa appear
otherwise unremarkable. There is no pathologic appearing pelvic
or inguinal lymphadenopathy. There is diffuse stranding within
the subcutaneous tissues of the left buttock and right buttock
to a slightly less prominent degree. Multiple calcifications are
seen within the soft tissues of the buttocks consistent with
injection granulomas.
BONE WINDOWS: Bone windows demonstrate unusual contour of the
left femoral neck with bowing and heterogeneous lucency within
the femoral neck and greater trochanter. No suspicious lytic or
sclerotic osseous lesions are identified.
MULTIPLANAR REFORMATS: Coronal and sagittal reformations
demonstrate a short segment of mucosal thickening within the
cecum.
IMPRESSION:
1. Short segment of mucosal thickening within the cecum, finding
of uncertain significance. The differential diagnoses include
infectious, inflammatory, or ischemic colitis.
2. Peripancreatic stranding, finding that could indicate
pancreatitis. Clinical correlation is recommended.
3. Small bilateral pleural effusions and bibasilar atelectasis.
2 mm left lower lobe pulmonary nodule. If there is no history of
prior malignancy, this may be further evaluated by follow-up CT
in 1 year.
4. Cholelithiasis and milk of calcium within the gallbladder.
5. Unusual configuration of the left femoral neck, finding that
could suggest etiology such as fibrous dysplasia
Brief Hospital Course:
ORTHOPEDIC SURGERY:
on [**2159-10-24**] she was admitted to the sda area anesthesia saw her
and had cocerns about her respiratory status and had a cxr done
it showed no pna and shecwas taken to the or and underwent a
left shoulder hemiarthroplasty transfered to pacu stable
* * * * * * * * * * * * * * * * * * * *
MEDICINE:
Patient was transferred to medicine on [**2159-10-26**]. The plan at
that time was for patient to recive hemodialysis and to
discharged home. While in hemodialysis, patient became
hypotensive. House officer was called. While attempting to get
an ABG, patient had respiratory arrest and a code blue was
activated. Patient was found to have pulseless electrical
activity. Patient was successfully resuscitated and transferred
to the MICU. CTA was positive for pulmonary embolism and
patient was started on Heparin. Her EKG had ST and ST
depressions laterally and Echocardiogram showed no evidence of
right heart strain. Her blood pressure stabilized and she was
transferred back to the floor on [**2159-10-29**]. The remainder of her
hospital course was characterized by persistent intermittent
episodes of hypotension down to the 80's systolic. Measuring
blood pressure on Ms. [**Known lastname 4160**] is problem[**Name (NI) 115**] as she has a healing
surgical wound on her left arm and her right has poor
vasculature, presumably from multiple past lines. She was
regularly hypotensive (SBP 80's) during hemodialysis. Her blood
pressure responded well to 250 cc normal saline boluses.
Of note, during this admission patient had one episode of
unresponsiveness. Patient was treated with narcan with slight
improvement and aggressive electrolyte repletion (phosphate and
magnesium).) Vital signs were at her baseline throughout. No
acute changes on CXR or ECG. FSBG normal. Head CT negative.
She returned to baseline over the course of [**2-22**] hours and the
episode was attributed to excessive pain medications and
multiple electrolyte abnormalities. The remainder of her
hospital course is organized by problem below:
.
#Anticoagulation: patient transitioned from heparin to coumadin
without incident. Still attempting to titrate to maintain INR
between [**2-22**]. Her INR on the date of discharge was
supratherapeutic. Her coumadin should be held on [**11-10**] and
re-started on [**11-11**] at 1 mg qhs IF her INR comes down to
therapeutic range (goal [**2-22**]).
.
#. Humeral Fracture: Films were reviewed by orthopedic surgery.
No fracture or damage to hardware during CPR evident on plain
film on [**2159-10-29**]. She will need follow up with orthopedics for
removal of stitches.
.
#Blood loss - On two occaisions patient's hematocrit drifted
down. Neither could be entirely accounted for by surgery (per
ortho there was minimal blood loss, < 500 cc) or by the small
hematoma that developed at the surgical site. Pt had guaiac
poitive stool on [**10-30**], followed be several guiac negative
stools. GI was conculted and they did not feel a colonoscopy
was advisable in this patient given her recent arrest and
current state of anticoagulation. Patient also began to
complain of a new mild diffuse abdominal pain, we obtained an
abdominal CT scan which showed non-diagnostic bowel wall
thickening in the cecum but no concerning evidence of mesenteric
ischemia. Patient's hemaocrit stablized after receiving one
unit of blood and the plan is for the patient to receive a
colonscopy as an outpatient. She will need to follow up with
gastroenterology for this.
.
# Fever: Patient has intermittent fevers after returning to the
floor. Patient was initially treated with broad spectrum
antibiotics. PICC line was placed for access and femoral line
was discontinued with good resolution of fevers. All cultures
returned negative.
.
#Diarrhea: Patient has very poor oral intake and has loose stool
from a predominatly liquid diet at baseline. All stool cultures
were negative. CT of the abdomnen was only notable for
non-specific ceccal wall thickening. Patient was treated with
anti-diarrheal with some improvement in symtptoms.
.
#Hypernatremia: Stable. Patient on HD.
.
#. ESRD: Hemodialysis
.
#. DM: Had one episode of hypotglycemia (35). Glipizide was
decreased to 2.5 mg Q day and patient was maintained insuline
sliding scale.
.
# Hypophospatemia: At one point patient's phosphate level
dropped down to 0.5 despite being started on neutraphos.
Patient has very poor oral intake and has loose stool from a
predominatly liquid diet at baseline. Patient required
aggressive IV repletion with a goal phosphate greater than 3.
.
#. FEN: Patient recieved multiple speech and swallow
evaluations. She does not aspirate on thin liquids but it was
discovered that when coerced into eating solid food that she
would secrete it in her cheeks and later fall asleep and
aspirate large food particles. At home patient eats a
predominatly liquid diet by preference. Diet was changed to
full liquids with no further episodes of food aspiration
requiring suctioning.
.
#. FULL code: discussed with family
.
#. Communication: Through family as patient is Somalina speaking
ony and no translator was available.
.
Medications on Admission:
Hydromorphone 0.5-1 mg IV Q6H:PRN
Insulin SC
Folic Acid 1 mg PO DAILY
Nephrocaps 1 CAP PO DAILY
Glipizide 2.5 mg PO BID
Acetaminophen 325-650 mg PO Q4-6H:PRN pain, fever
Colace
Senna 1 TAB [**Hospital1 **]
Discharge Medications:
1. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
2. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
3. Glipizide 10 mg Tablet Sig: 0.25 Tablet PO QAM (once a day
(in the morning)).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID
(2 times a day).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Center
Discharge Diagnosis:
1. Plumonary embolism
2. GI bleeding
3. ESRD
4. left humerous fracture
5. S/P PEA arrest
6. Diarrhea
7. Hypophosphatemia
8. Hypomagnesemia
9. Hypernatremia
1. Plumonary embolism
2. GI bleeding
3. ESRD
4. left humerous fracture
5. S/P PEA arrest
6. Diarrhea
7. Hypophosphatemia
8. Hypomagnesemia
9. Hypernatremia
Discharge Condition:
stable
Discharge Instructions:
dc to rehab
keep wound dry and clean
left shoulder non weight bearing
take dc meds as ordered
Physical Therapy:
Activity: Ambulate
Left upper extremity: Non weight bearing
Sling: At all times
Treatments Frequency:
staples out 2weeks [**2159-10-24**]
Please take all medications as ordered
keep wound dry and clean
left shoulder non weight bearing - keep elevated in sling/on
pillow for comfort
Followup Instructions:
1. Please call ([**Telephone/Fax (1) 1300**] to make an appointment with your
primary care doctor in [**2-22**] weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 4156**] MD, [**MD Number(3) 4157**]
Completed by:[**2159-11-10**]
|
[
"458.9",
"250.40",
"261",
"427.5",
"812.01",
"998.89",
"E928.8",
"518.5",
"V58.67",
"403.91",
"272.0",
"415.11",
"785.51",
"787.91",
"792.1",
"276.0",
"280.0",
"285.21",
"585.6",
"275.3",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"39.95",
"96.71",
"99.60",
"81.81",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15427, 15477
|
9297, 14470
|
321, 371
|
15836, 15845
|
1392, 6504
|
16296, 16559
|
1192, 1209
|
14726, 15404
|
15498, 15813
|
14496, 14703
|
15869, 15964
|
1224, 1373
|
15982, 16069
|
16091, 16273
|
260, 283
|
6533, 9274
|
399, 828
|
850, 1058
|
1074, 1176
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,069
| 101,309
|
4574+55589
|
Discharge summary
|
report+addendum
|
[** **] Date: [**2116-7-14**] Discharge Date: [**2116-7-23**]
Service: ORTHOPAEDICS
Allergies:
Codeine / Versed / Colchicine / Lipitor
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Right Thigh Pain s/p Fall
Major Surgical or Invasive Procedure:
[**2116-7-15**]: s/p ORIF right hip
History of Present Illness:
The patient is a [**Age over 90 **] year old female with history of
Hypertension, AFib, CVA to L insula [**12/2112**], diastolic CHF with
last EF 55% in [**12/2115**], mild-moderate MR, minimal AS, pulm
hypertension, and Amiodarone-induced hypothyroidism who was
admitted after a fall and found to have R intertrochanteric
femoral fracture.
.
Pt lives alone and was at home putting away dishes when she
suffered an unwitnessed fall. Did not hit her head and denies
LOC. She remembers all the events. Her R leg was seen to be
shortened and externally rotated and Xray showed R
intertrochanteric fracture. Ortho was consulted in the ED.
.
In the ED her vitals were: 98.6 70 138/97 98% on RA. Labs
showing slight worsening of her Hct to 25.6 from baseline 27-29.
Hyponatremic to 128 with concurrent hypochloremia to 94, HCO3
low at 20, and BUN/Cr at baseline 36/2.4. UA with mild sign of
infxn but also with 3-5 Epi's. UCx pending. CXR without acute
process. Of note, pt with h/o prolapsed uterus and Foley was
placed. No head or neck scans were done in the ED.
.
EKG showing: AFib, no RVR, normal axis, normal QRS's, normal T
waves. Slightly late R wave progression with clockwise
transition. Except for rhythm, normal EKG. In the ED she got
2mg IV Morphine. Foley placed. 18g placed in R hand, 1L NS
given.
.
Her cardiac ROS is negative for all symptoms. She endorses being
able to do laundry in the basement and go up 2-3 flights of
stairs without chest pain or shortness of breath on exertion.
She is able to do all her ADL's without symptoms. No fatigue,
lethargy, no chest pain, shortness of breath, paroxysmal
nocturnal dyspnea, orthopnea, palpitations. She denies any
history of cardiac surgical interventions including AMI's,
caths, or CABG.
Past Medical History:
Hypertension
Atrial fibrillation, diagnosed [**2108**] c/b R arm thrombus
s/p CVA to L insula [**12/2112**] w/ very mild right facial asymmetry
and some attentional/memory problems
Colonic GI bleed x 4 ([**2111**], [**2112**], [**2113**], [**2114**]) on Coumadin
Diastolic Heart Failure (EF 70-75% in [**2112**])
Moderate Mitral regurgitation
Moderate Aortic regurgitation
Diverticulosis
Gout
Amiodarone-induced hypothyroidism, [**11/2115**]
h/o E.Coli & VRE UTI, [**2112**]
Right cataract surgery, [**2114**]
Dyspepsia
s/p R breast excision ([**5-/2112**]) atypical ductal hyperplasia
s/p open appendectomy 40 years ago
Social History:
Patient lives alone in [**Location (un) 2312**] since the death of her husband
9 year ago. She has no children, but has a very supportive
nephew and [**Name2 (NI) 802**] who visit her frequently and help her with her
medications and appointments. She is retired, but previously
worked as a "stitcher" for many years.
Tobacco: Never
EtOH: drank wine with dinner, quit after her stroke in [**2112**]
Illicits: Never
Contact [**Name (NI) 19447**]: HCP/Nephew: [**Name (NI) **] [**Name (NI) 19442**], MD [**Telephone/Fax (1) 19443**]
Family History:
No hx of colon cancer of GI bleeds. Females have a history of
mitral valve prolapse. Mother died of CHF/diabetes. Father
died of MI.
Physical Exam:
On [**Telephone/Fax (1) **]:
Vital Stats: 97.6 153/67 66 17 97% RA
General: Pleasant female in no distress, appears younger than
[**Age over 90 **]yo. Conversant, appropriate, some discomfort from R leg pain
Eyes: PERRLA, no scleral icterus, EOMI
ENT: Mouth dry appearing, with dentures in, but no apparent
lesions or trauma
Carotid pulses easily palpable bilaterally. Prominent external
jugular veins noted, but no HJ reflux
Respiratory: CTAB anteriorly, deferred posterior exam, good air
movement no accessory muscle use
Cardiac: Grossly regular S1/S2 with AS type
crescendo-decrescendo murmur through precordium but best at
BUSB's, S2 is present. Bilateral radials are strong, bilateral
DP's palpable
Gastrointestinal: Abd soft, NT ND, benign, BS+
Extremities: Trace pitting edema around ankles but doesn't
appear grossly volume overloaded. R leg is shorter and
externally rotated
Neurological: CN 2-12 intact, no grossy facial droop, BUE
strength normal, deferred BLE exam, but sensation and pulses
intact.
Discharge:
RLE: SILT sural/saph/tibial/sup fibular nerves
Motor intact
Compartments soft
DP/PT pulses 2+
Pertinent Results:
On [**Age over 90 **]:
[**2116-7-14**] 08:20PM BLOOD WBC-7.1 RBC-3.04* Hgb-8.7* Hct-25.6*
MCV-84 MCH-28.6 MCHC-34.0 RDW-15.4 Plt Ct-221
[**2116-7-14**] 08:20PM BLOOD Neuts-83.8* Lymphs-7.7* Monos-6.6 Eos-1.6
Baso-0.3
[**2116-7-14**] 08:20PM BLOOD PT-12.5 PTT-24.5 Plt Ct-221 INR(PT)-1.1
[**2116-7-14**] 08:20PM BLOOD Glucose-115* UreaN-36* Creat-2.4* Na-128*
K-4.4 Cl-94* HCO3-20* AnGap-18
[**2116-7-14**] 08:20PM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8
Pertinent Labs during Hospital Course:
[**2116-7-15**] 05:25AM BLOOD TSH-5.3* Free T4-1.6
On Discharge:
Pertinent Imaging:
[**2116-7-14**]
AP VIEW OF THE PELVIS, TWO VIEWS OF THE RIGHT HIP: Comminuted
right
intertrochanteric proximal femoral fracture is demonstrated with
varus
angulation and mild lateral displacement of the distal fracture
fragment. The hips demonstrate mild degenerative changes with
joint space narrowing. The sacroiliac joints and pubic symphysis
are not diastatic. There is diffuse demineralization of the
osseous structures. Degenerative changes are also seen involving
the lower lumbosacral spine. There are diffuse vascular
calcifications.
[**2116-7-14**]
CXR: There is moderate enlargement of the cardiac silhouette.
The mediastinal and hilar contours demonstrate unchanged
tortuosity of the thoracic aorta with vascular calcifications.
The pulmonary vascularity is not engorged. There are linear
opacities within the left lung base and right mid lung field
compatible with subsegmental atelectasis. There is no
pneumothorax or pleural effusion. No focal consolidation is
seen. Compression deformity of a low thoracic vertebral body is
present but similar compared to the prior study.
[**2116-7-15**]
HIP RADIOGRAPH:
Brief Hospital Course:
Ms [**Known lastname 19444**] was admitted on [**2116-7-14**] for a right hip fracture.
On [**Date Range **] she was found to be hyponatremic with concurrent
hypochloremia and renal failure. She was seen and evaluated by
the medical service who cleared her for surgery. On [**2116-7-15**]
she underwent open reduction internal fixation of the right hip
without complication. She was extubated and transferred to the
recovery room in stable condition. In the recovery room she was
transfused one unit of blood cells for post operative anemia.
She was transferred to the floor and there were no overnight
events on the night of surgery. She is being discharged in
stable condition to rehabilitation facility.
Medications on [**Date Range **]:
AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1
(One) Tablet(s) by mouth once a day
AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
(One) Tablet(s) by mouth once a day
DONEPEZIL [ARICEPT] - 5 mg Tablet - 2 (Two) Tablet(s) by mouth
once a day Start with 1 tablet once a day for 1 week and then
increase to 2 tablets per day --> PT DOESN'T KNOW IF SHE'S
TAKING OR NOT
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
(One) Tablet(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - one
Tablet(s) by mouth daily
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 40 mg
Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily
LEVOTHYROXINE 75 mcg daily
MULTIVITAMIN - (OTC) - Tablet - one Tablet(s) by mouth daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours) for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Right intertrochanteric fracture
Discharge Condition:
AAO X 3
Ambulatng with [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 4650**]
Discharge Instructions:
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
-Keep pin sites clean and dry.
-Sutures/staples will be removed at your first post-operative
visit.
Activity:
-Continue to be wbat your right leg.
-You should not lift anything greater than 5 pounds.
-Elevate rightleg to reduce swelling and pain.
-Do not remove splint/brace. Keep splint/brace dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Followup Instructions:
Staples should be taken out in 2 weeks. Follow up with [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 19448**] in 2 months.. call [**Telephone/Fax (1) 9769**] to schedule
appointment.
Completed by:[**2116-7-17**] Name: [**Known lastname 3174**],[**Known firstname 825**] Unit No: [**Numeric Identifier 3175**]
Admission Date: [**2116-7-14**] Discharge Date: [**2116-7-23**]
Date of Birth: [**2025-5-31**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Versed / Colchicine / Lipitor
Attending:[**First Name3 (LF) 3176**]
Addendum:
Addendum: Hospital Course [**Date range (1) 3177**]
Chief Complaint:
AMS, LOW UOP, NSTEMI
Major Surgical or Invasive Procedure:
[**2116-7-15**]: s/p ORIF right hip
History of Present Illness:
see hospital course for medicine/cardiology HPI
Past Medical History:
Hypertension
Atrial fibrillation, diagnosed [**2108**] c/b R arm thrombus
s/p CVA to L insula [**12/2112**] w/ very mild right facial asymmetry
and some attentional/memory problems
Colonic GI bleed x 4 ([**2111**], [**2112**], [**2113**], [**2114**]) on Coumadin
Diastolic Heart Failure (EF 70-75% in [**2112**])
Moderate Mitral regurgitation
Moderate Aortic regurgitation
Diverticulosis
Gout
Amiodarone-induced hypothyroidism, [**11/2115**]
h/o E.Coli & VRE UTI, [**2112**]
Right cataract surgery, [**2114**]
Dyspepsia
s/p R breast excision ([**5-/2112**]) atypical ductal hyperplasia
s/p open appendectomy 40 years ago
Social History:
Patient lives alone in [**Location (un) 3178**] since the death of her husband
9 year ago. She has no children, but has a very supportive
nephew and [**Name2 (NI) 3179**] who visit her frequently and help her with her
medications and appointments. She is retired, but previously
worked as a "stitcher" for many years.
Tobacco: Never
EtOH: drank wine with dinner, quit after her stroke in [**2112**]
Illicits: Never
Contact [**Name (NI) 3180**]: HCP/Nephew: [**Name (NI) **] [**Name (NI) 3181**], MD [**Telephone/Fax (1) 3182**]
Family History:
No hx of colon cancer of GI bleeds. Females have a history of
mitral valve prolapse. Mother died of CHF/diabetes. Father
died of MI.
Physical Exam:
VS: T 96.8 100/45 88 22 96 on 2L
Ins/ Outs TODAY: +1720/660 Net +1340
GEN: no acute distress, alert and oriented x3, in general looks
fatigued, slightly labored breathing
HEENT: EOMI. PERRLA. Dry oral mucosa. JVP elevated at level of
jaw. Cards: RRR S1/S2 heard. +II/VI systolic murmur at RUSB,
cannot appreciate radiation to carotids. No carotid bruits.
Pulm: crackles 1/2 up lung fields
Abd: soft, NT, +BS. No HSM.
Extremities: surgical incision right thigh c/d/i, staples
intact, not wrapped. Right LE 2+ pitting edema. No calf
tenderness. No LE erythema.
Skin: ecchymosis on UE B/L, inner thigh ecchymosis on right.
Neuro/Psych: Cranial nerves grossly intact. Unable to assess
strength as range of motion as patient is too fatigued to
participate.
Pertinent Results:
[**2116-7-23**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] L.
Approved
.
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Moderate cardiomegaly with left lower lobe atelectasis
and blunting of the costophrenic sinus, suggesting co-existing
pleural effusion. As mentioned in the previous report, the
possibility of superimposed pneumonia cannot be excluded.
No evidence of pneumonia in the right lung.
.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2116-7-23**] 06:50AM 11.6* 3.52* 9.9* 30.4* 86 28.1 32.6 16.4*
372
. CK
[**2116-7-22**] 07:30 286*1
[**2116-7-20**] 05:50 397*1
[**2116-7-19**] 23:57 571*1
[**2116-7-19**] 20:45 654*1
[**2116-7-19**] 12:21 893*1
.
[**2116-7-18**] 6:51 pm URINE Site: CLEAN CATCH Source:
Catheter.
**FINAL REPORT [**2116-7-20**]**
URINE CULTURE (Final [**2116-7-20**]):
STAPHYLOCOCCUS SPECIES. ~1000/ML.
Brief Hospital Course:
This [**Age over 90 **] y/o F with a h/o HTN, AFib not on coumadin, CVA to L
insula [**12/2112**], h/o dCHF EF 55% in [**12/2115**], amiodarone-induced
hypothyroidism. The patient was transferred from the ortho
service to the medicine service [**2116-7-18**] in the setting of AMS and
low urine output [**2116-7-18**]. Given poor PO intake, low urine
output, prerenal ARF with FeNa<1%, and clinically dry physical
exam, she was given IV fluid boluses. The following day she
began requiring 2L O2 to maintain sats at 96%, her SBP was in
the 90-100s, and cardiac enzymes were elevated CKMB 48, CPK 893,
Troponin .84, and ECG showed T wave inversions in the lateral
leads. Cardiology was consulted and felt that any antiplatelet
or anticoagulation stronger than aspirin would be innapropriate
given her history of GI bleeding and the fact that she would
require large volume blood replacement to survive which would
likely lead to pulmonary edema and demise. She dropped her
pressures after a lasix bolus and was transferred to far 3 for
lasix drip. After 1.5 days of lasix drip she was euvolemic and
her oxygen requirement resolved. She was also started on
ceftriaxone and azithromycin for UTI and CAP. Her delerium
slowly improved, however she was not 100% and this was felt to
be partially induced by hospital induced delerium. The patient
had a slight increase in her White count on the day of
discharge, however she was afebrile, her CXR was unchanged, she
had no symptomatic changes. This was felt to be a stress
response, but must be followed.
.
.
.
Altered mental status: This was felt to be due to delerium [**2-18**]
waxing and [**Doctor Last Name 2364**] mental status. This was likely complicated by
her underlying mild cognitive impairment in past, and there may
be a component of sundowning.
.
Plan:
Continue ABX for PNA
PT and rehab in an out of hospital setting
.
NSTEMI/CAD: CKMB and CK trended down throughout her stay on the
cardiology service. Stimulus for NSTEMI not known, however,
considering underlying infection vs post-op stress. Retroactive
CE show first elevation in CKMB on [**2116-7-17**]. This was before the
episode of AMS and low urine output. Most likely NSTEMI
secondary to post-op stress. Patient is not a candidate for
cardiac cath secondary to renal failure and high risk with
contrast load, also has h/o many GI bleeds and therefore
contraindicated for double antiplatelet therapy post cath.
- Continue ASA 325mg
- D/c simvastatin as patient has history of myalgias
- Hold Plavix for now considering on ASA and enoxaparin and high
risk of GI bleed.
- PT re-consult today - Pt OOB in chair this AM.
.
Possible infectious source: Treating for possible PNA.
- Continue Ceftriaxone and Azithromycin for a total of 7 days,
can discharge on cefpodoxime. Would recheck CBC in two days to
ensure downward trend.
.
Afib- no RVR, not on coumadin secondary to bleeding risk. No
longer on amiodarone.
- Monitor on tele
.
ARF on CKD: Cr elevated yesterday (baseline in [**2115**] Cr 2.7),
likely prerenal secondary to acute on chronic CHF and poor fluid
flow and diuresis with lasix gtt.
- diuresis on hold
- Monitor Cr daily
.
Anemia: normocytic. [**Month (only) 412**] be contributing to decreased sats.
Likely secondary to blood loss during surgery, underlying poor
kidney function, and possibly anemia of chronic disease.
- Continue B12
- Continue mulitivitamin.
- H/H daily, transfuse if Hct <21%
- Recommend outpatient follow up and workup for anemia if it
does not improve after recovery from surgery.
.
Hypothyroidism: due to amiodarone toxicity, TSH 5.3 on [**2116-7-15**],
but acute stress of surgery and NSTEMI, recommend rechecking TSH
as outpatient.
- Continue Levothyroxine at home dose.
.
FEN: replete lytes, PO cardiac heart healthy as tolerated,
continue current bowel regimen
Proph: Cont enoxaparin 30mg SC daily, continue Omeprazole 20mg
daily
Access: 2 peripheral IVs
Code: Full for now
Medications on Admission:
75mcg levothyroxine daily
20mg lasix MWF
20mg prilosec MWF
200mg amiodarone daily
2.5mg amlodipine daily
20mg lisinopril daily
1mg doxazosin daily
5000IU vit D daily
2 tums
1-500mg cranberry extract
1000mcg vit B12 daily
1 spray of miacalcin daily
100mg colace daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours) for 4 weeks.
12. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no
BM in 36 hrs.
14. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**]
Discharge Diagnosis:
Primary Diagnoses:
Right intertrochanteric hip fracture
NSTEMI
Acute on chronic systolic congestive heart failure
Secondary Diagnoses:
Altered Mental Status
Pneumonia
Atrial Fibrillation
Post operative blood loss anemia
Hyponatremia
Hypochloremia
Acute on Chronic Renal failure
Hypothyroidism
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 came to the hospital because you broke your hip. You had
surgery to repair your fracture. After the surgery, you had a
heart attack. You were medically managed for your heart attack.
You also had an exacerbation of your congestive heart failure.
We gave you medications to remove excess body fluid. You will
need to weigh yourself daily and consult your doctor if you are
3lbs or more above your baseline weight for 3 or more days. We
are also treating you for a pneumonia with antibiotics.
We made the following changes to your medications:
-Stop Doxazosin
-Stop Amlodipine
-Stop Amiodarone
-Stop Furosemide (Lasix)
-Start Acetaminophen 1000g up to three times daily as needed for
pain
-Start Aspirin 325mg daily
-Start Cefpodoxime 200mg two times daily for 3 more days
-Start Miralax 17g daily as needed for constipation
-Start Bisocodyl 10mg daily as needed for constipation
-Start Senna 2 tabs daily as needed for constipation
-Start Enoxaparin 30mg subcutaneous daily for 4 weeks
Please follow up with your Orthopedic physicians, your
appointment is already scheduled below. Their recommendations
are:
Please follow these instructions for your wound care for your
hip:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
- TAKE OUT STAPLES IN 2 WEEKS. FOLLOW UP WITH [**Doctor Last Name **]
(appointment is below).
Activity:
-Continue to be full weight bearing on your right leg.
- Avoid nicotine products to optimize healing.
- Continue taking the Lovenox to prevent blood clots.
Please make an appointment to follow up with your primary care
doctor once you leave the rehabilitation facility.
It was a pleasure taking care of you. We wish you a speedy
recovery.
Followup Instructions:
Take out staples in 2 weeks. Follow up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3183**]
(appointment is below). You will need to obtain an X-ray before
your appointment (see details below).
Department: ORTHOPEDICS
When: THURSDAY [**2116-8-6**] at 10:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 809**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2116-8-6**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], NP [**Telephone/Fax (1) 809**]
Building: [**Hospital6 189**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name **] Garage
Please make an appointment to follow up with your primary care
doctor once you leave the rehabilitation facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3185**] MD [**MD Number(1) 3186**]
Completed by:[**2116-7-23**]
|
[
"428.0",
"403.90",
"416.8",
"428.23",
"396.3",
"274.9",
"244.9",
"285.1",
"276.1",
"584.9",
"427.31",
"410.71",
"E885.9",
"486",
"820.21",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
20730, 20824
|
15081, 16654
|
11737, 11775
|
21162, 21162
|
13990, 15058
|
23068, 24108
|
13059, 13196
|
19351, 20707
|
20845, 20960
|
19059, 19328
|
5077, 5129
|
21345, 21870
|
13211, 13971
|
20981, 21141
|
5144, 6289
|
21899, 23045
|
11677, 11699
|
9490, 10985
|
11803, 11852
|
21177, 21321
|
11874, 12497
|
12513, 13043
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,187
| 114,281
|
54834
|
Discharge summary
|
report
|
Admission Date: [**2161-6-4**] Discharge Date: [**2161-6-9**]
Date of Birth: [**2077-3-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Unresponsive, hypotension
Major Surgical or Invasive Procedure:
1. Arterial line
2. Right internal jugular triple lumen catheter
3. PICC placement
History of Present Illness:
84F with h/o HepB, diabetes, C/O unresponsive episode at nursing
home at 1100 am, found hypotensive in the 80's/sys and o2 was in
the 70's. Upon ambulance arrival BP wnl and placed on
non-rebreather.
Pt was transferred to ED. In ED, blood pressure was 70/40
initially. A RIJ and two peripheral IVs were placed and fluid
resuscitation was started as well as IV pressors with norepi at
2mcg/kg/min. A foley was placed and frank pus returned with +
U/A. She was started on vancomycin and zosyn.
Labs were significant for sodium of 150, BUN/Cr of 100/2.7, K of
6.3, lactate of 3.6 and ABG = 7.15/8/159/15.
Imaging significant for head CT unremarkable, cxr with
questionable retrocardiac opacity.
On arrival to the MICU, patient's VS. 97.6, HR 91, SBP 89/37,
rr=16, 96% RA. At time of arrival, she had received 3.5L NS and
was on 0.1 of norepi. She is alert in NAD does not speak
English, so cannot answer questions.
Review of systems:
cannot be obtained due to pt not responsive
Past Medical History:
Diabetes
hepatitis B, no known cirrhosis
dementia
HTN
CKD? - a few months prior to admission BUN went from 20s to 38.
reportedly cr is 1.0
OA with reported femoral neck frx in past
Social History:
Pt lives in nursing home in [**Location (un) **], demented at baseline.
She can feed herself and is interactive at baseline. As per
son, she is alert and oriented to name only at baseline.
Non-ambulatory and incontinent of stool and urine. No smoking
or tobacco history
Family History:
NC
Physical Exam:
On arrival to ICU
Vitals: 97.6, HR 91, SBP 89/37, rr=16, 96% RA.
General: alert, not interacting does not speak english
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, cvp = 1, no LAD
CV: rrr no mrg
Lungs: ctab, no wrr
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: cold, clammy. pulse 1+ b/l in LE. She has a dry ulcer on
lateral calcaneous of R foot.
Back: she has 2 unstagable decubitis dry ulcers on back
Neuro: PERRLA, exam is grossly intact.
Pertinant discharge:
BP 145/75, HR 86
General: Alert oriented to person. Knows she is in the hospital
but does not know date
Skin: 2 unstagable decubitis dry ulcers on buttocks and on each
heal
Pertinent Results:
ADMISSION LABS:
[**2161-6-4**] 12:00PM BLOOD WBC-15.9* RBC-4.39 Hgb-13.1 Hct-43.0
MCV-98 MCH-29.8 MCHC-30.4* RDW-16.9* Plt Ct-326
[**2161-6-4**] 12:00PM BLOOD Glucose-146* UreaN-121* Creat-2.7*
Na-151* K-6.2* Cl-128* HCO3-8* AnGap-21*
DISCHARGE LABS:
[**2161-6-8**] 04:27AM BLOOD WBC-7.3 RBC-3.12* Hgb-9.5* Hct-29.1*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16.6* Plt Ct-216
[**2161-6-8**] 04:27AM BLOOD Glucose-213* UreaN-18 Creat-0.9 Na-141
K-3.7 Cl-116* HCO3-16* AnGap-13
URINE CULTURE ([**2161-6-4**]):
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 8 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 64 I
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
C.DIFF NEGATIVE ([**2161-6-6**])
CT HEAD ([**2161-6-4**]): No acute intracranial process.
CXR ([**2161-6-4**]): The lungs are clear, without focal airspace
consolidation to suggest pneumonia. Linear atelectasis is seen
at the left lung base. A right side IJ catheter tip terminates
in the mid SVC. There is no pleural effusion or pneumothorax.
Apical pleural thickening is seen. The heart size is normal.
Calcifications are present within the aortic
arch.
RENAL U/S ([**2161-6-5**]): Normal renal echotexture without evidence of
hydronephrosis.
Brief Hospital Course:
1. Severe sepsis with shock (hypovolemic/septic): Initial SBP in
the low 70s. When a foley was placed, it drained frank pus. She
required pressor support with norepinephrine and vasopressin.
After 7 Liters of NS, she was weaned off of pressor medications
and after 12L her blood pressure, renal function and mental
status improved.
2. Urinary tract infection: A renal ultrasound was done which
did not show any signs of pyelonephritis. Urine cutlure grew out
two types of Klebsiella, both sensitive to all antibiotics
tested except for intermediate sensitivity to nitrofurantoin.
Ceftriaxone was continued until the day of discharge with
ciprofloxacin presribed to complete a 10-day course (through
[**Date range (1) 112057**]).
3. Encephalopathy, toxic-metabolic: Likely related to
UTI/sepsis. Improved throughout admission. Was oriented to name
and "hospital" at discharge which her son reports as baseline.
4. Acute renal failure: Initial creatinine 2.7 with BUN in 100s.
Improved with fluid resuscitation
5. Hyperkalemia: Potassium 6.2 on admission. As her renal
failure improved, her potassium levels remained within normal
limits.
6. Metabolic acidosis: Her metabolic acidosis was primarily
nongap but she did have a significant gap acidosis most likely
secondary to lactic acidosis and renal failure. Bicarb
autocorrected throughout admission but had not completed
normalized on last check.
7. Hypernatremia: Sodium 150 on admission with increase to 157
on arrival to ICU. Her free water deficit was corrected with
1/2NS in D5w. Over 24hrs her serum sodium corrected to 140s. Her
serum sodium was within normal limits for remainder of hospital
stay.
8. Diarrhea: Developed diarrhea while in the ICU. Cdiff assay
was negative.
9. Pressure ulcers: Gluteal and heel. Wound care recommended:
* Turn and reposition off back q 2 hours and prn
* Limit sit time to 1 hour at a time using a pressure
* Redistribution cushion
* Cleanse wound with wound cleanser then pat dry then place
sacral Mepilex border
change every 3 days
* Critic aid clear [**Hospital1 **] to reddened tissue including labial
ulcer
* No dressing needed to heel - aloe vesta daily for skin
conditioning
* Waffle boots
10. Diabetes mellitus type 2: Her glipizide was held during
hospitalization but restarted at discharge. Long-acting insulin
was also held with finger sticks in the 100-200 range.
11. Hypertension: Olmesartan was held in the setting of
hypotension. On day of discharge BP was 140s/70s.
CHRONIC ISSUES:
1. Dementia: Namenda was held during hospitalization as this is
not a formulary medicatin. Restarted on discharge.
2. Hepatitis B, chronic: Tenofovir was continued, dosed for GFR
TRANSITIONAL ISSUSE:
1. Antibiotics: ciprofloxacin presribed to complete a 10-day
course (through [**Date range (1) 112057**]).
2. Held medications
- Olmesartan: could be restarted if blood pressure remains
elevated
- 70/30 insulin: could be restrated if finger stick blood
glucose remains elevated
Medications on Admission:
tylenol
benicar 10mg daily
glipizide 15mg daily
megace 625mg/5mL
omeprazole 20mg
viread 300mg PO daily
donepezil 10mg q day
amenda 10mg [**Hospital1 **]
cromolyn 4% instill 2 drops each eye TID
Senna
novolin 70/30 24U qAM 14U q5pm
MVI
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO once a day.
4. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. cromolyn 4 % Drops Sig: Two (2) Ophthalmic three times a
day.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 6
days.
10. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
11. glipizide 5 mg Tablet Sig: Three (3) Tablet PO once a day:
15 mg daily.
12. Megace ES 625 mg/5 mL Suspension Sig: One (1) PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
1. Shock (septic and hypovolemic)
2. Urinary tract infection (klebsiella)
3. Acute renal failure
4. Encephalopathy, toxic-metabolic, with underlying dementia
5. Metabolic acidosis
6. Pressure ulcers (heal/buttock), unstageable
7. Diarrhea
8. Anemia
9. Hypertension
10. Diabetes type II
11. Hepatitis B, chronic
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for low blood pressure, which was from a
combination of dehydration and a urinary tract infection. You
improved with IV fluids and antibiotics. You should continue
antibiotics to complete a course (through [**6-15**]).
Followup Instructions:
I spoke with your primary physician. [**Name10 (NameIs) **] will coordinate a visit
to your nursing home.
|
[
"250.00",
"599.0",
"995.92",
"787.91",
"070.32",
"038.9",
"785.52",
"584.9",
"707.25",
"707.03",
"403.90",
"276.7",
"585.9",
"707.07",
"285.21",
"276.0",
"294.20",
"349.82",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8705, 8788
|
4443, 6948
|
327, 412
|
9142, 9142
|
2750, 2750
|
9581, 9689
|
1939, 1943
|
7739, 8682
|
8809, 9121
|
7479, 7716
|
9319, 9558
|
3003, 4420
|
1958, 2731
|
1382, 1428
|
262, 289
|
440, 1363
|
2767, 2987
|
9157, 9295
|
6964, 7453
|
1450, 1633
|
1649, 1923
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,545
| 189,678
|
2492
|
Discharge summary
|
report
|
Admission Date: [**2199-5-19**] Discharge Date: [**2199-6-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
altered mental status, hypoxia
Major Surgical or Invasive Procedure:
right-sided thoracentesis [**5-20**]
History of Present Illness:
[**Age over 90 **]yo F with a PMH of SDH s/p burr hole evacuation [**2199-4-14**], recent
STEMI and medical management [**2199-4-17**], and multiple UTIs, now
presents with CHF, fevers, and altered mental status. Ms.
[**Known lastname 4402**] was discharged from [**Hospital1 18**] on [**2199-4-30**] after a 4d
hospitalization for altered mental status, felt to possibly be
due to UTI and/or pneumonia (treated with levaquin) and
benzodiazepine usage (ativan). Since discharge, she has been at
[**Hospital 100**] Rehab. She had been on her baseline O2 requirement of 2L
by nc, but over the last week, was noted to have increased O2
need and crackles on exam. Attempts were made to diurese her
with 40mg IV lasix daily. A foley catheter was placed on [**2199-5-14**]
for better I/O monitoring. After 3 days (which was 3 days prior
to admission), she was noted to begin having mental status
changes. Her family described her as being "wacky" and she had a
fall (to her knees, no head trauma) on [**2199-5-17**]. On [**2199-5-18**], she
continued to be disoriented and confused. She also began to drop
her O2 sats again despite the diuresis, with O2 sats dropping to
the low 90s. Her oxygen requirement was increased to 3L by nc
with improvement in her sats. A UA was checked and was
suspicious for a UTI, so she was started on levofloxacin. On the
morning of [**2199-5-19**], she again became hypoxic with O2 sats in the
80s which improved to the high 90s on a NRB. She continued to be
delirious and confused, so she was transferred to [**Hospital1 18**] for
further evaluation. In speaking to her RN at [**Hospital 100**] Rehab, the
patient was noted to have lost 6 lbs in the last week (wt of 131
-> 125 lbs) with diuresis and there was a concern that she was
becoming dry. She was also noted to have elevated fingersticks
on [**2199-5-18**], with a FS of 470 (she is NOT a diabetic). With her
delirium, she was not sleeping and was noted to have NOT slept
in the last 48 hrs, which was unusual for her. She had been on a
1:1 sitter because she was attempting to get OOB on her own and
was pulling at lines (foley, IV). [**Name6 (MD) **] her RN, the patient had
been afebrile. She had NOT been on O2 prior to her MI, but has
been on 2L of O2 since the beginning of [**4-20**].
.
In the ED, her VS were noted to be T 102.4, HR 100s, BP 138/82,
RR 28, sats 100% on NRB, 89-91% on RA. She was given 500cc NS in
ER, then 40mg IV lasix (once her CXR returned). She had 250cc
UOP in the ER. FS was 91. CT head was performed and showed
resolution of her SDH. Given that her D-dimer was elevated, a
CTA was performed and was negative for PE, but did show a large
R sided pleural effusion and left atrial clot. She spiked a
fever, so was given PR tylenol and levaquin IV. Her troponin
also returned elevated at 0.20 and she was given a rectal dose
of aspirin. She was admitted to the ICU for further monitoring
of her respiratory and mental status.
Past Medical History:
# SDH s/p burr hole on [**2199-4-14**]
- SDH dx [**2199-3-26**] after fallx2 (on coumadin for afib)
- had 6mm MLS to the right
- started on dilantin
- dx w/ pneumonia, treated w/ Augmentin
- readmitted [**4-6**] for worsening mental status changes
- rpt head CT showed worsening MLS, increased edema
- given ciprofloxacin for UTI
- underwent burr hole evacuation on [**2199-4-14**]
# STEMI s/p vfib arrest
- had witnessed CP -> cardiac arrest at rehab on [**4-17**] (was vfib)
- shocked x6, lidocaine bolus, then lidocaine gtt -> NSR
- then went into afib, amio bolus and then amio gtt
- was intubated for airway protection
- ECHO on [**2199-4-18**] showed EF 30-40%, with severe HK of inferior,
posterior, and lateral walls; RV function also depressed
- ? postulated to have a LCx lesion
# CHF - ? diastolic as ECHO in '[**98**] showed EF 60%
# atrial fibrillation
# ventral hernia
# multinodular goiter
# diverticulitis
- s/p fistula between bowel/bladder -> surgically corrected
# h/o MRSA in abdominal wound in [**2192-2-10**], nares negative in [**5-14**]
# HTN
# s/p hemangioblastoma at C5/6 level with cord compression [**2-15**]
bleed
- s/p neurosurgical decompression on [**2193-6-6**]
- has residual L-sided weakness and neuropathy
# macular degeneration
# h/o CVA (?) - dates unknown, has encephalomalacia in R MCA
territory
Social History:
Currently residing at [**Hospital 100**] Rehab (MACU). No tob, no EtOH. Was
independent prior to hospitalization in [**3-20**]. Baseline is alert,
oriented, walks w/ a walker.
Family History:
Non-contributory
Physical Exam:
VS: Tm 102.4 in ED, Tc 97.7, BP 130/72 (102-130/55-72), HR 97
(97-109), RR 24 (19-24), O2 sats 100% on 13L flow/50% FiO2
GEN: Disoriented, but redirectable. Oriented to year, but not
place or self. Speech not dysarthric, but intermittently
understandable.
HEENT: Sclera anicteric. Surgical pupils, minimally reactive on
R, but nonreactive on L. Unable to test EOMI as pt could not
cooperate w/ commands. OP erythematous and dry, with leftover
food and ? thrush. No frank exudates seen.
NECK: No supraclavicular or cervical lymphadenopathy. + JVD, to
about 8cm. Thyromegaly not appreciated.
RESP: Dull to percussion [**1-15**] way up on R, with decreased BS.
Crackles above on R. Crackles [**1-15**] way up on L. No wheezes or
rhonchi.
CV: Tachy, irreg irreg. No m/r/g.
ABD: Soft, NTND. + BS throughout. + ventral hernia, reducible.
EXT: 1+ pitting edema on dorsum of feet, [**1-16**] way up shin
bilaterally. Pulses dopplerable bilaterally at PT; palpable 2+
radial bilaterally.
SKIN: No rashes, no jaundice. Nickel sized stage II sacral decub
on R buttock.
NEURO: Appears delirious, oriented to year only. Follows some
command, but full neurological testing unable to be performed
due to inability to cooperate. Has strong and symmetric grip
bilaterally. Withdraws both legs to painful stimuli. Moving all
four extremities spontanesouly.
Pertinent Results:
EKG: Afib at rate of 96, normal intervals, R axis, poor R wave
progresion, Q wave in III, aVF, V1, no ST changes, flat T waves
in III, aVR, V1, V6, inverted T waves in aVL.
.
IMAGING:
ECHO [**2199-4-18**]: The left atrium is elongated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed (ejection
fraction 30-40 percent) secondary to severe hypokinesis of the
inferior, posterior, and lateral walls. 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 (apical half of free wall). The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial vs. physiologic
pericardial effusion.
IMPRESSION: inferoposterolateral myocardial infarct
.
TTE [**2199-5-20**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with
inferolateral hypokinesis/ akinesis. Overall left ventricular
systolic function is mildly depressed. The right ventricular
cavity is mildly dilated and there is probable right ventricular
hypertrophy. Right ventricular systolic function is normal.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
There is moderate mitral annular calcification with associated
mild mitral inflow gradient. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. The end-diastolic pulmonic regurgitation velocity
is increased suggesting pulmonary artery diastolic hypertension.
There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2199-4-18**],
findings are similar. LV ejection fraction may have been
underestimated in the prior study. There is evidence of severe
pulmonary artery systolic hypertension in both studies.
.
NOTE: Transthorcic echocardiography cannot adequately assess
left atrial thrombus; this can be better assess by
transesophageal echocardiography if clinically indicated.
.
CXR [**2199-5-19**]: Low lung volumes. Since prior exam, there has been
interval increase in bilateral moderate-sized pleural effusions.
The pulmonary vasculature congestion is seen. Stable appearance
of the right upper mediastinal mass, better seen on recent CT
and likely represents substernal goiter. Severe thoracolumbar
scoliosis is again seen and unchanged.
.
CTA [**2199-5-19**]: 1. No evidence of pulmonary embolism. There does
appear to be a filling defect in the left atrial appendage, seen
on multiple views, likely representing thrombus. Alternative
explanation includes a CT reverberation artifact that can be
seen with patients in atrial fibrillation. Recommend correlation
with transesophageal echocardiography.
2. Moderate-to-large right pleural effusion with associated
atelectasis of the majority of the right lower lobe. Small left
pleural effusion with likely left basilar pneumonia or
aspiration.
3. Stable prominent mediastinal lymphadenopathy.
4. Evidence of right ventricular strain including persistence of
contrast and dilatation of the IVC and hepatic veins.
5. Stable superior mediastinal mass, previously characterized as
a goiter.
.
CT head [**2199-5-19**]: Limited study due to patient motion. Previously
identified left subdural hematoma is not currently appreciated
and there is no midline shift.
Brief Hospital Course:
[**Age over 90 **]yo F with history of SDH s/p burr hole evacuation, recent
STEMI medically managed, now with Staph aureus bacteremia and
left atrial clot, transferred to the MICU for worsening hypoxia
and unresponsiveness, then called out to the floor for further
management of her multiple medical problems as below.
.
# Hypoxia: Admission CXR revealed effusions and pulmonary
edema. Transudative effusion was tapped while in the MICU with
moderate improvement in her oxygen requirement. Repeated CXRs
revealed stable b/l pleural effusions (R>L) with amount of
pulmonary edema varying with diuresis vs. fluid administration;
there were no infiltrates. Once transferred to the floor, her
oxygen requirement increased so that she was requiring 10L
shovel mask in order to maintain O2 sats and did not improve
despite diuresis. The cause of her hypoxia is clearly
multifactorial as she has known diastolic CHF and with a. fib at
rate 90s-100s may have been affecting filling time and worsening
diastolic dysfunction. Additionally, now has systolic dysfxn
with EF 45% post STEMI. Her declining mental status also has
led to hypoventilation. Decision was made with family not to
pursue intubation/MICU transfer if her respiratory status were
to further decompensate on the floor. She was maintained on
shovel mask as above, while on the floor.
.
# Mental status changes: Throughout her hospital course, her
mental status waxed and waned, and delirium was thought to be
multifactorial given her age, hospitalization, infection,
sedating medication (zyprexa), and hypercarbia. While on the
floor, her mental status continued to decline so that she was
largely unresponsive. Repeat CT head did not reveal rebleed in
the setting of anticoagulation. ABG did reveal hypercapnea with
pCO2 in the 60-70 range, however family wishes were not to
intubate nor transfer to the ICU for noninvasive measures such
as bipap. She remained somnolent and largely unarousable on the
floor.
.
# MRSA bacteremia: Admission blood cultures showed [**2-17**] MRSA.
She was started on vancomycin and surveillance cultures have
shown no MRSA growth since [**5-25**] (at which time [**1-17**] were
positive). The source of her bacteremia is not entirely clear
although she has a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] that was seen on CTA chest
(although not well visualized on TTE) and this may have been
seeded. She does have a right shoulder effusion, but clinically
and on orthopedics evaluation, it does not appear to be a septic
joint. imaging did reveal erosive changes of shoulder, but in
discussion with radiology, these findings are consistent with
degenerative disease in [**Age over 90 **] yo shoulder as opposed to infection
as cause of erosive changes. Thus, right shoulder effusion was
not tapped. Additionally, pleural effusion when tapped was
transudative and cultures were negative so as not to evoke this
as source of her bacteremia. Furthermore, CT abd/pelvis/chest
did not reveal other sources of possible infection. Midline and
right IJ pulled on [**2199-5-30**] and new PICC line was placed. Given
the evolution of code status and family wishes to a focus on
comfort due to lack of substantial clinical improvement,
antibiotics were continued until discharge at which time they
were discontinued.
.
# Left atrial thrombus: Seen on CTA chest, but poorly
visualized on TTE and TEE not performed. Likely formed in the
setting of v. fib arrest and chronic atrial fibrillation as she
was not on anticoagulation most recently prior to this admission
given her recent SDH and subsequent burr hole evacuation. As
above, in the setting of her bacteremia, there was concern that
the clot was likely seeded. As above, subsequent surveillance
cultures have been negative while on vancomycin therapy. She
was originally placed on heparin gtt and was then transitioned
to PO coumadin which, given her decline in mental status and
transition to focus on comfort was discontinued.
.
# Acute renal failure: In the setting of diuresis and holding
of IVF administration to optimize her respiratory status, her
renal function worsened and she became oliguric most likely to
prerenal etiology as above. Given her tenuous respiratory
status on shovel mask on the floor IVF were intermittently
administered while on the floor without significant improvement
in urine output nor renal function.
.
# CV:
a. CAD: s/p STEMI and v. fib arrest in [**4-/2199**], medically
managed. She was continued on ASA, BB, and statin while able to
take oral medications. These were also discontinued with
decline in MS.
.
b. Pump: EF 45% w/ inferolateral hypokinesis s/p STEMI as
above, diastolic dysfunction as well. She was admitted on ACEI,
but held in MICU [**2-15**] borderline blood pressures. As above,
imaging revealed bilateral pleural effusions (tapped x1
revealing transudate). She was diuresed prn without improvement
in O2 requirements on the floor and additionally developed
increased bicarb in the setting of diuresis (contraction), but
also in the setting of worsening respiratory acidosis as above
(increasing pCO2).
.
c. Rhythm: Atrial fibrillation with largely in the 90s-100s
occasionally requiring IV lopressor for rate control when unable
to take PO meds. She was transitioned from heparin gtt to
coumadin as above.
.
# Anemia: Hematocrit remained lower than previous BL 32-34 (MCV
elevated), but stable in the 27-30 range. Although she was
anticoagulated, there was no clear source of bleed to account
for this new baseline. CT head negative for rebleed [**5-30**]. Iron
studies reveal low iron at 17, TIBC 213, and ferritin of 171 and
appears to reflect iron deficiency anemia and element of ACD
given low TIBC. B12 and folate were normal.
.
# Subdural hematoma: No significant residual deficits post
bleed (previously with significant RUE weakness). Neurosurgery
evaluated her on this admission and cleared her for the
reinitiation of anticoagulation as SDH had resolved. Repeat CT
[**5-30**] while on anticoagulation showed no change from prior/no
acute bleed.
.
# Hyperglycemia: No documented h/o DM, but consistently
elevated BS while here (100-150) likely in the setting of acute
illness/stress response. HgbA1C was nml at 5.8% so as not to
suggest ongoing impaired glucose tolerance. She was maintained
on insulin sliding which, but finger sticks and SS coverage were
discontinued to maintain patient's comfort.
.
# UTI: Had enterococcus sensitive to vancomycin at OSH that was
treated prior to this admission.
.
# F/E/N: PO as tolerated for comfort.
.
# Access: Left PICC placed [**5-30**].
.
# Communication: [**Name (NI) **] [**Name (NI) 4402**] (son, [**Name (NI) 382**] - [**Telephone/Fax (1) 12762**]
(home), [**Telephone/Fax (1) 12763**] (cell), son [**Name (NI) **] [**Telephone/Fax (1) 12764**].
.
# Code: DNR/DNI being discharged to inpatient hospice for
comfort care.
Medications on Admission:
amiodarone 100mg PO QD
ASA 81mg PO QD
RISS
lisinopril 2.5mg PO QD
megace 40mg PO BID
metoprolol 12.5mg PO BID
MVI 1 tab PO QD
pantoprazole 40m PO QD
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
MRSA septicemia
Left atrial thrombus
Hypoxia due to end stage COPD
Acute renal failure
Systolic and diastolic heart failure
.
Secondary:
Atrial fibrillation
Anemia
Subdural hematoma
Hyperglycemia
Discharge Condition:
Depressed mental status, significant although stable O2
requirement, being discharged to inpatient hospice.
Discharge Instructions:
You were admitted with heart failure (fluid in the lungs) due to
a fast heart rhythm. You were given medication to help remove
fluid from your lungs.
Please take your medications as below.
If you develop chest pain, shortness of breath, fevers,
confusion, or any other concerning symptoms, please contact your
doctor [**First Name (Titles) **] [**Name (NI) 100**] Rehab to help make you more comfortable.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 12646**] as
needed [**Telephone/Fax (1) 4615**].
Completed by:[**2199-6-4**]
|
[
"428.40",
"496",
"719.01",
"428.0",
"599.0",
"280.9",
"458.29",
"293.0",
"427.31",
"790.29",
"511.9",
"041.11",
"292.81",
"584.9",
"429.79",
"707.03",
"790.7",
"V66.7",
"V09.0",
"410.32",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17935, 18001
|
10799, 17735
|
291, 329
|
18250, 18360
|
6263, 10776
|
18816, 18969
|
4870, 4888
|
18022, 18229
|
17761, 17912
|
18384, 18793
|
4903, 6244
|
221, 253
|
357, 3300
|
3322, 4661
|
4677, 4854
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,848
| 147,174
|
54660
|
Discharge summary
|
report
|
Admission Date: [**2198-8-29**] Discharge Date: [**2198-9-22**]
Date of Birth: [**2155-4-24**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Continued purulent drainage, increased drainage around drain
insertion site, 10 kg weight loss
Major Surgical or Invasive Procedure:
[**2198-8-30**]: ERCP, drain exchange with upsize, feeding tube
placement
[**2198-9-3**]: Central line placement
[**2198-9-4**]: PPFT replaced
[**2198-9-7**]: CT guided drain upsizing, 10 -> 14 French
History of Present Illness:
43M s/p MVC on [**5-31**] and was transferred in from an OSH with
multiple injuries including an acute abdomen with avulsion of
small bowel and multiple liver lacerations. Following an ICU
course was found to have a R posterior large
necrotic liver lesion in which a drain was placed. He has been
treated with antibiotics and was readmitted x 1 for 9 days to
restart antibiotics and have new drain placed. He continued
antibiotics for one week following that admission and since that
time has the drain in place which drains approximately 70-80 cc
of milky pale thick drainage daily. The patient reports that the
drainage from around the catheter haa increased significantly
over the last few days, and it has developed a very bad odor
that has caused him to be unable to eat. Since the last
admission he has dropped another 10 kg, and has lost nearly 45
kg since the
MVC.
Patient denies recent fevers or chills, no chest pain or
shortness of breath, he reports abdominal pain associated with
the drain site area, and has poor appetite and occasional
constipation. He still is taking PO dilaudid intermittently for
musculoskeletal pain of the lower back and also neck from the
MVC. The collar has been removed. He reports no edema or
abdominal swelling. Reports very low energy and barely able to
move about house.
Past Medical History:
MVC with liver lacs leading to necrotic liver lesion
PSH:
Exploratory laparotomy, washout of hemoperitoneum, debridement
of laceration of the liver, ileocecectomy, ileocolostomy.
s/p Left ankle ORIF
s/p removal of adenoids
Social History:
Supportive wife, works in construction building houses
(currently not working)
+ETOH, unknown tobacco/IVDU
Family History:
Noncontributory
Physical Exam:
VS: 98.8, 118, 121/79, 20, 100%, 98.8 kg
Gen: Sl pale, more interactive
CV: Sl Tachy, reg rhythm
Lungs: CTA B/L
Abd: soft, mild tenderness most at drain site on rt lateral
abdomen and RUQ, Well healed abdominal incision, drain with
milky
light tan drainage, drain site slightly red with same tan
drainage around site and on dressing
Extr: no edema, 2+ DPs
Neuro: A+Ox3, Collar has been removed
Pertinent Results:
On Admission: [**2198-8-29**]
WBC-8.2 RBC-3.53* Hgb-8.7* Hct-28.9* MCV-82 MCH-24.5* MCHC-30.0*
RDW-16.2* Plt Ct-356
PT-15.6* PTT-30.0 INR(PT)-1.5*
Glucose-112* UreaN-6 Creat-0.4* Na-131* K-3.9 Cl-96 HCO3-28
AnGap-11
ALT-8 AST-19 AlkPhos-97 TotBili-0.6
Iron-15* calTIBC-113* Ferritn-828* TRF-87*
Albumin-2.9* Calcium-8.8 Phos-3.7 Mg-1.9
Brief Hospital Course:
43 y/o male admitted for continued medical issues following MVC.
On admission the patient had an abdominal CT performed showing:
1. No interval change in size of the larger hepatic abscess,
status post interval removal or dislodgement of a previously
placed pigtail drain catheter.
2. Pigtail catheter remains in appropriate position in a
subhepatic collection, which is contiguous with, but possibly
minimally communicating with, the larger collection.
3. Slight decrease in size of the loculated right pleural
effusion with pleural thickening and enhancement. There was
drainage occuring around the pigtail catheter requiring multiple
dressing changes daily.
On HD 2([**8-30**]) the patient underwent ERCP. Per report,
cannulation of the biliary duct initially was not possible using
a free-hand technique. Cannulation of the pancreatic duct was
successful and deep using a free-hand technique. A 5Fr 4 cm
pancreatic duct stent was placed to facilitate cannulation of
the bile duct. An additional cannulation attempt of the biliary
duct was successful and deep with a sphincterotome using a
free-hand technique. Contrast medium was injected resulting in
complete opacification. Fluoroscopy on the biliary tree showed
the common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles, cystic duct, and gallbladder
were filled with contrast and well visualized, and there was no
evidence of bile leak. A 10cm by 7FR Cotton [**Doctor Last Name **] biliary stent
was placed successfully in the main duct due to the stenotic
papilla following the sphincterotomy. Also, a nasojejunal
feeding tube was placed using standard endoscopic nasojejunal
feeding tube placement rechnique. The [**Last Name (un) **]-jejunal tube was
secured at 120 cm at the nose.
Immediately following the ERCP, the patient also underwent
exchange and upsizing to 10 Fr of the existing pigtail in the
subhepatic fluid collection. The intra-hepatic collection has
not had any intervention with this hospitalization.
Initially, the patient was kept NPO overnight per protocol
following the sphincterotomy, and on the following day, as the
day progressed, the patient was having increased abdominal and
back pain, and urine output decreased significantly. A foley was
placed for monitoring, and he received fluid boluses. A mild
elevation in the lipase was noted, and temp to 100.5 was noted
and blood cultures were obtained. 2 days following the ERCP the
patient had fever to 101.2, and was becoming tachycardic to the
140's. He was also reporting that the epigastric and back pain
were worsening.
On [**9-2**], due to continued decreased urine output, abdominal pain
and tachycardia, and fever, the patient was transferred to the
SICU. He was kept NPO, and was started on TPN folloewing central
line placement. Lipase peaked at 363 and then started to trend
down, however his abdominal exam still revealed pain and still
with significant back pain. The abscess pigtail drain was
draining 150 - 300 cc daily of purulent appearing, thick light
tan fluid. Blood cultures have remained negative throughout.
With resuscitaion and NPO status, the patient's symptoms started
to improve. Urine output improved, he was afebrile, and so was
transferred back to the surgical floor. He was continued on TPN.
He received 2 units of RBCs for symptomatic Hct 22.9 with
appropriate response.
As symptoms subsided, he was very slowly advanced on his diet,
and the tube feeds were started via the post pyloric feeding
tube, which had to be replaced while in the SICU due to
clogging. On [**9-3**] he underwent an abdominal CT, assessing the
severity of the pancreatitis. There was mild peri-pancreatic
stranding and thickening of gerotas fascia. The pigtail catheter
was still in appropriate position in the subhepatic fluid
collection. The patient was continued on TPN, and he remained
NPO. The pigtail drain dressing was noted to have drainage that
seems to increase when patient upright or ambulating. On [**9-7**] he
was sent to CT for another drain upsize to a 12 Fr drain. At the
time of the surveillance CT, it was noted that there is oral
contrast from the previous CT scan layering in the abscess
cavity, suggestive of a fistulous tract to the bowel. He
underwent a fluoro study with Optiray injected through the new
12Fr catheter. This sjowed the abscess cavity filling and a
small fistulous communication with what appeared to be the small
bowel. Upon return to the floor, the drainage has taken on a
brown and thick appearance. At this time he was made NPO and
will continue on TPN.
TPN was continued on the surgical floor until [**2198-9-20**]. Prior to
discontinuation of the TPN, Mr. [**Known lastname 9450**] received a CT scan with
injection of contrast through his pigtail catheter to further
elucidate the anatomy. The plan at that time was operative
intervention assuming the fistula was still patent. However, the
CT did not identify fistula. Per report, the following was
identified: "Opacification of the right perihepatic and
paracolic gutter abscess cavity without evidence of small bowel
fistulous communication on CT." Operative intervention was
therefore withheld. Mr. [**Known lastname 9450**] completed a few more days of TPN,
and then was transitioned to an oral diet. After several days of
increasing PO intake, he was consuming approximately 1800 kcal
per day. He was safely discharged on [**2198-9-22**] with PTBD
in place and planned follow-up in clinic.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Dronabinol 2.5 mg PO BID
2. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
3. Calcium Carbonate 500 mg PO TID
4. Vitamin D 400 UNIT PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Milk of Magnesia 30 mL PO DAILY:PRN constipation
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*2
2. Calcium Carbonate 500 mg PO TID
3. Vitamin D 400 UNIT PO DAILY
4. Milk of Magnesia 30 mL PO DAILY:PRN constipation
5. Multivitamins 1 TAB PO DAILY
6. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*40 Capsule Refills:*2
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth three times a day
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic abscess
post endoscopic retrograde cholangiopancreatography pancreatitis
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever > 101,
chills, nausea, vomiting, diarrhea, constipation, yellowing of
skin or eyes, drainage stops completetely or increases to
greater then 400 cc daily, drainage turns bloody in apprearance,
or develops a worsening odor, swelling of legs, increased
abdominal size, drainage around the drain is increasing, or the
drain site becomes red or painful.
You may shower, avoid having the drain hanging freely at any
time. Place a new drain sponge around the drain site daily and
as needed.
Please drain and record the drain bag three times daily and as
needed. Bring a copy of the drain output with you to clinic.
Please call if the output increases significantly, stops
completely, becomes bloody in appearance or develops a worsening
odor.
No heavy lifting greater than 10 pounds.
No driving if taking narcotic pain medication.
Please ensure you are hydrating well, and be sure to maintain
adequate nutrition.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2198-10-3**] 1:40
2. ERCP followup on [**2198-9-30**] for removal of bile duct drain.
Appointment is at 11:00 AM, please come to ERCP center at 10:30
AM ([**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Lobby to check in)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"567.22",
"577.0",
"576.2",
"511.9",
"572.0",
"263.9",
"783.7",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.93",
"51.87",
"38.93",
"96.6",
"54.91",
"99.15",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
9562, 9568
|
3107, 8577
|
366, 569
|
9706, 9706
|
2747, 2747
|
10905, 11422
|
2301, 2318
|
8987, 9539
|
9589, 9685
|
8603, 8964
|
9889, 10882
|
2333, 2728
|
231, 328
|
597, 1914
|
2761, 3084
|
9721, 9865
|
1936, 2161
|
2177, 2285
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,344
| 182,083
|
31200
|
Discharge summary
|
report
|
Admission Date: [**2116-11-3**] Discharge Date: [**2116-11-9**]
Date of Birth: [**2054-10-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
colonoscopy with biopsy
blood transfusion
History of Present Illness:
In brief, Pt is a 62-year-old male with h/o HCV cirrhosis, HCC
s/p liver transplant [**4-13**] (on tacrolimus), complicated by severe
early recurrence of hepatitis C and advanced fibrosis who
presents to the emergency department with fever x 1d and
hypotension.
.
Patient was in his USOH until Friday PM. Reports chills last
couple days. He noticed that he had a temperature of 99 this
morning with a MAXIMUM TEMPERATURE of 102.1 prior to the
hospital visit. Patient otherwise has been feeling well and
denies any focal symptoms including shortness of breath or
cough, abdominal pain, dysuria, skin lesions. He was somewhat
fatigued for the last few days. He has not had any nausea,
vomiting or diarrhea. Patient has been otherwise healthy and is
being followed by the transplant service. He reports driving to
Kittery with his wife yesterday, but no other travel or sick
contacts recently.
.
In the ED, initial VS were: 100.4, 87, 124/59, 16, 100%. Labs
were notable for WBC 15, Creat 1.3 (elevated from 1.0).
Triggered for episode of hypotension to SBP 70s. Received 3L IVF
and BP improved to SBP 90, but dropped again. Then received 4L
IVF and peripheral dopamine started. SBP then 110s. R IJ placed
and levophed started. Of note, he was AOx3 and with normal
mental status.
.
For infectious w/u, CXR was unremarkable. RUQ U/S showed normal
gallbladder, no ascites. U/A wnl. Lactate wnl. Hepatology and
transplant services consulted, and will follow along. He
received 1g acetaminophen PO, cefepime 2g IV x1, IV vancomycin
1g x1.
.
In the MICU, Pt received 7L IV fluids and was briefly treated
with norepinephrine before it was discontinued after a few
hours. His pressures remained in the 90s-110s. Pt was also
treated initially with broad spectrum antibiotics including
vancomycin, cefepime, levofloxacin, and metronidazole given his
fever of unknown origin and immuno-suppressed state. Pt
continued to spike fevers to 102F, but was otherwise
asymptomatic. Pt had a CT abdomen suggestive of transverse
colitis, perhaps infectious in etiology. Blood, urine, and stool
samples were sent for analysis, and Pt was transferred to the
liver-transplant floor.
.
On arrival to the floor, vitals were:
99.7F, 121/66, 84, 20, 95% RA.
Pt denies any symptoms or discomfort.
Review of systems:
(+) Per HPI
(-) Denies 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:
Liver Transplant Hx:
-[**2102**] HCV cirrhosis dx
- [**2105**] trial of interferon, and [**2112**] trial of
peg-interferon/ribavirin in [**2112**], but no response
-[**11/2115**] HCC dx 1.1x0.9cm segment V lesion and 2x1.5cm segment
VII
lesion s/p RFA for VI and VII segment lesions
-[**2116-4-9**] liver tx
-Post tx course c/b recurrent HCV cirrhosis confirmed by bx and
positive HBV serologies
-[**5-13**] started PEG-interferon/ribavirin and lamivudine/HBIg, had
good response with decrease in viral load from 32 million to <2
million.
-Post-tx course also c/b cholestatic hepatitis with elevated
bilirubin. Ultrasound, MRCP, ERCP have shown normal biliary
anastomosis and no stricturing, and normal hepatic arterial
anatomy with no hepatic artery thrombosis or stenosis.
-[**8-13**]: transjugular bx showed >stage II fibrosis in
transplanted liver [**2-5**] HCV recurrence
-[**8-13**]: grade I esophageal varices on EGD, grade I rectal
varices seen on c-scope
.
Other PMH:
-Basal cell carcinomas, removed
-Appendectomy
Social History:
He is married, lives in [**Location 1468**], lab manager at Millennium
Pharmaceuticals, and quit smoking in [**2099**]. He quit drinking
alcohol in [**2103**] after being diagnosed with liver disease.
Family History:
His brother has melanoma. His mother had breast cancer. Father
had a TIA, and his paternal grandfather died of a CVA.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild crackles at bases, no wheezes, rales, ronchi
Abdomen: soft, surgical scar present, non-tender, non-distended,
bowel sounds present, no organomegaly
GU: foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Physical Exam:
.
Vitals: Tm 98.6F, Tc 97.1, BP 88-102/50-64. HR 72-76, RR 18, 95%
RA.
.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild crackles at bases, otherwise clear
Abdomen: soft, surgical scar present, non-tender, non-distended,
bowel sounds present, no organomegaly
GU: foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
[**2116-11-4**] 11:46AM BLOOD Hct-21.7*
[**2116-11-4**] 03:35AM BLOOD WBC-6.8 RBC-1.94* Hgb-7.0* Hct-21.6*
MCV-111* MCH-36.1* MCHC-32.4 RDW-14.9 Plt Ct-57*
[**2116-11-3**] 11:39PM BLOOD WBC-13.5* RBC-2.05* Hgb-7.3* Hct-22.7*
MCV-110* MCH-35.8* MCHC-32.4 RDW-14.7 Plt Ct-68*
[**2116-11-3**] 04:00PM BLOOD WBC-15.1*# RBC-2.40* Hgb-8.8* Hct-26.9*
MCV-112* MCH-36.9* MCHC-32.9 RDW-14.5 Plt Ct-63*
[**2116-11-3**] 11:39PM BLOOD Neuts-83* Bands-2 Lymphs-7* Monos-8 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2116-11-3**] 11:39PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-2+ Tear
Dr[**Last Name (STitle) **]1+
[**2116-11-3**] 04:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Stipple-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2116-11-4**] 03:35AM BLOOD Plt Ct-57*
[**2116-11-4**] 03:35AM BLOOD PT-12.9 INR(PT)-1.1
[**2116-11-3**] 11:39PM BLOOD Plt Smr-VERY LOW Plt Ct-68*
[**2116-11-3**] 11:39PM BLOOD PT-13.8* PTT-150* INR(PT)-1.2*
[**2116-11-4**] 03:35AM BLOOD Glucose-99 UreaN-22* Creat-1.0 Na-137
K-3.9 Cl-110* HCO3-22 AnGap-9
[**2116-11-3**] 11:39PM BLOOD Glucose-106* UreaN-24* Creat-1.1 Na-138
K-4.0 Cl-112* HCO3-21* AnGap-9
[**2116-11-3**] 04:00PM BLOOD Glucose-122* UreaN-26* Creat-1.3* Na-134
K-4.3 Cl-103 HCO3-26 AnGap-9
[**2116-11-4**] 03:35AM BLOOD ALT-45* AST-54* LD(LDH)-240 AlkPhos-102
TotBili-0.4
[**2116-11-3**] 04:00PM BLOOD ALT-56* AST-60* AlkPhos-130 TotBili-0.4
[**2116-11-3**] 04:00PM BLOOD Lipase-62*
[**2116-11-4**] 03:35AM BLOOD Calcium-6.9* Phos-2.4* Mg-2.1
[**2116-11-3**] 11:39PM BLOOD Albumin-3.0* Calcium-6.8* Phos-2.6*
Mg-1.5*
[**2116-11-3**] 04:00PM BLOOD Albumin-3.8
[**2116-11-4**] 03:35AM BLOOD Cortsol-13.8
[**2116-11-4**] 03:35AM BLOOD tacroFK-6.9
[**2116-11-4**] 04:35AM BLOOD Lactate-1.2
[**2116-11-3**] 04:06PM BLOOD Lactate-1.3
[**2116-11-4**] 04:35AM BLOOD O2 Sat-63
[**2116-11-4**] 06:36AM BLOOD freeCa-1.06*
CT Abd/Pel [**2116-11-4**]
CT OF ABDOMEN: Patient is status post orthotopic liver
transplant. Since the prior study, there has been interval
development of bilateral small effusions, larger on the right
side. There is bibasal linear opacities noted, again new since
the prior study. No focal liver lesions. Satisfactory appearance
of the portal, superior mesenteric, and splenic veins. The
spleen remains enlarged measuring 15 cm in long axis. Note is
again made of paraesophageal varices. Since the prior study,
there has been interval development of moderate volume ascites,
predominantly perihepatic but also extending along both
paracolic gutters. The pancreas enhances normally throughout its
length. Subcentimeter hypodensities are seen in the right kidney
and are stable, likely representing small cysts. The left kidney
contains a 16 x 17 mm simple cyst in the left lower renal pole.
The kidneys enhance symmetrically with no evidence of
hydronephrosis. There is generalised large and small bowel wall
edema, likely secondary to ascites; however, this edema is more
pronounced in the right hemicolon suggestive of a possible
right-sided colitis. No evidence of pneumatosis or portal venous
gas. There are no discrete intra-abdominal fluid collections. CT
OF PELVIS: Air within the urinary bladder is likely secondary to
recent catheter placement. Satisfactory appearance of the
rectum. No enlarged inguinal or pelvic sidewall lymph nodes.
OSSEOUS STRUCTURES: Minimal degenerative changes are seen at
L5-S1. An 8 x 11 mm lytic area arising from the inferior
endplate of L1 likely represents a Schmorl's node and was
present on the prior study from [**2116-1-7**]. IMPRESSION: 1.
Interval development of small bilateral pleural effusions with
new linear airspace opacities in both bases. 2. Satisfactory
appearance of the liver transplant graft. 3. Splenomegaly. 4.
Paraesophageal varices. 5. Interval development of moderate
volume ascites with associated bowel wall edema. This edema is
more pronounced in the right hemicolon suggestive of a
right-sided colitis. Clinical correlation is advised.
Abd US [**2116-11-3**]
IMPRESSION: No ascites
[**2116-11-7**] Pathology: Distal ascending colon biopsies: No
diagnostic abnormalities seen. No viral inclusions seen on
routine stain. Immunostain for CMV is pending.
[**2116-11-7**] Colonoscopy w/ biopsy: Segmental continuous congestion
and loss of vascularity with no bleeding were noted in the
Distal ascending colon. 2 rectal varices noted. Not bleeding.
Other procedures: Cold forceps biopsies were performed for
histology and CMV staining at the Distal ascending colon. Cold
forceps biopsies were performed for microbiology (CMV cuiltures)
at the Distal ascending colon. Impression: Congestion and loss
of vascularity. in the Distal ascending colon 2 rectal varices
noted. Not bleeding. (biopsy, biopsy) Otherwise normal
colonoscopy to Distal ascending colon
[**2116-11-9**] 05:30AM BLOOD WBC-2.3*# RBC-1.92* Hgb-6.7* Hct-21.0*
MCV-109* MCH-35.0* MCHC-32.0 RDW-15.5 Plt Ct-64*
[**2116-11-4**] 03:35AM BLOOD Neuts-90.9* Lymphs-6.0* Monos-3.0 Eos-0.1
Baso-0
[**2116-11-8**] 04:55AM BLOOD PT-12.5 PTT-31.6 INR(PT)-1.1
[**2116-11-8**] 04:55AM BLOOD Glucose-80 UreaN-12 Creat-0.9 Na-139
K-4.1 Cl-113* HCO3-21* AnGap-9
[**2116-11-8**] 04:55AM BLOOD ALT-34 AST-45* AlkPhos-92 TotBili-0.5
[**2116-11-8**] 04:55AM BLOOD Albumin-2.9* Calcium-7.7* Phos-3.2 Mg-1.7
[**2116-11-3**] BLOOD CULTURE Blood Culture, Routine-FINAL -
no growth
[**2116-11-3**] URINE URINE CULTURE-FINAL - no growth
[**2116-11-4**] URINE Legionella Urinary Antigen -FINAL - no
growth
[**2116-11-4**] Blood (CMV AB) CMV IgG ANTIBODY POSITIVE
FINAL; CMV IgM ANTIBODY NEGATIVE -FINAL
[**2116-11-4**] CMV Viral Load (Final [**2116-11-6**]): CMV DNA not
detected.
[**2116-11-4**] 7:48 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final [**2116-11-6**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2116-11-6**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2116-11-5**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final [**2116-11-6**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2116-11-6**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2116-11-6**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2116-11-5**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
====
[**2116-11-5**] 1:18 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2116-11-5**]):
1+ (<1 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 [**2116-11-8**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
=====
[**2116-11-7**] BIOPSY VIRAL CULTURE: R/O
CYTOMEGALOVIRUS-PENDING
Brief Hospital Course:
62-year-old male with h/o HCV cirrhosis, HCC s/p liver
transplant (on tacrolimus), complicated by recurrence of
hepatitis C who presents with fever, hypotension, leukocytosis,
and acute renal failure, with fever of unknown origin.
.
# fever of unknown origin: patient initially met criteria for
septic shock with fever, hypotension, leukocytosis, and evidence
for end organ dysfunction. Received a total of 7L IVF and
briefly required norepi in MICU. Pt's BP has been stable on the
floor. Unclear source and no focal signs or symptoms aside from
mild diarrhea. Pt is immunosuppressed, making the differential
diagnosis very broad, including viral and bacterial causes. CXR
wnl. U/A wnl. RUQ wnl. negative Cdiff pcr. negative legionells
Lactate normal. No prior diarrhea or antibiotics. CT abdomen and
pelvis showing possible R-sided colitis. Pt was initially
treated with very broad antibiotics including vancomycin,
cefepime, levofloxacin, and metronidazole. This was narrowed to
ciprofloxacin / metronidazole on [**11-4**] to cover for colitis
after CT result showing possible R-sided colitis. Urine cultures
and blood cultures negative. Leukocytosis resolved, but Pt was
still febrile. Given his CMV positive graft and initially
negative CMV status, suspected CMV colitis, especially given his
recently completed 6 month course of valgancyclovir in [**Month (only) **]
[**2116**]. Discontinued cipro/[**Doctor Last Name **] on [**11-5**], started ganciclovir @
5mg/kg = 360 mg iv q12hrs. CMV blood viral load was not
detectable. Stool cultures were negative for viruses and common
infectious etiologies including C diff. Colonoscopy w/ biopsy to
look for CMV colitis on [**11-7**] showed only colonic congestion but
no other obvious lesions. Biopsies did not show any evidence of
acute inflammation or viral inclusions. CMV staining still
pending. Infectious diseases felt that CMV colitis given all the
evidence so far was unlikely, and ganciclovir was discontinued.
The source of the Pt's fever remains unclear, but is suspected
to be due to a transient viral gastroenteritis.
.
# Acute renal failure: suspect etiology to be poor perfusion
from distributive shock. Pt's Cr improved from 1.4 to 1.0 with
fluids (baseline 0.7-0.8). No new medications, no IV contrast,
no NSAIDs, no peripheral eosinophila so doubt AIN. Adequate UOP
arguing against obstructive process. Most likely hypovolemia /
hypotension, completely resolved w/ discharge Cr 0.9.
.
# HCV cirrhosis s/p transplant with persistent portal
hypertension (ascites, rectal varices). Tacro level normal at
6.9 on [**2116-11-4**], Pt was continued on home dose. Pt's bactrim for
ppx was also continued, as well as his home furosemide and
spironolactone and lamivudine suppression.
.
# HCV recurrence. Pt's peg-IFN, which he receives every Friday,
was held to avoid confounding his fever curve. His ribavirin and
filgastrim were continued. Pt had a very rapid and strong
relapse of his HCV post-transplant. He has not been very
responsive to therapy, with most recent viral load 1,290,000
IU/mL on [**2116-10-28**]. Pt states that despite his anemia /
pancytopenia, he would prefer to continue treatment with
interferon and ribavirin (see below), and would like to discuss
additional treatments such as telaprevir or boceprevir. We have
advised the Pt to discuss his treatment options with his
outpatient hepatologist, Dr. [**Last Name (STitle) **].
.
# Anemia. Chronic, due to HCV treatment, exacerbated by
dilution. Pt was transfused 1 x PRBCs on [**11-4**] for Hct 21 from
baseline ~30, likely dilutional plus ribavirin effect, with
appropriate bump to 24. Pt was transfused 1 unit PRBCs again
prior to discharge after slowly drifting down to ~ 21 on day of
discharge. Pt may need erythropoietin injections to maintain his
hematocrit while he remains on anti-HCV therapy.
.
TRANSITIONAL ISSUES:
-Cause of Pt's fevers and diarrhea remain unknown. Although path
did not show any evidence of CMV colitis, it is still possible,
and Pt was informed to take his daily temperature. If Pt
develops fevers, abdominal discomfort, and diarrhea, would
consider further abdominal imaging / repeat colonoscopy given
continuing suspicion for CMV.
-Pt has been a poor responder to traditional HCV therapy w/
interferon and ribarvirin. He will need to discuss his treatment
options with Dr. [**Last Name (STitle) **].
-Pt's anemia / pancytopenia has worsened, perhaps due to his HCV
therapy. [**Month (only) 116**] need erythropoietin or regular Hct checks and
transfusions as needed.
Medications on Admission:
- tacrolimus 1.5 mg [**Hospital1 **]
- sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
- lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
- ribavirin 200 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
- peginterferon alfa-2a 180 mcg/mL Solution Sig: Ninety (90)
mcg Subcutaneous 1X/WEEK (FR).
- filgrastim 300 mcg/mL Solution Sig: Three Hundred (300) mcg
Injection 2X/WEEK (MO,TH).
- furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
- spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
- famotidine 20 mg [**Hospital1 **]
Discharge Medications:
1. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ribavirin 200 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
7. filgrastim 300 mcg/mL Solution Sig: One (1) mL Injection
2X/WEEK (MO,TH).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. peginterferon alfa-2a 180 mcg/mL Solution Sig: Ninety (90)
mcg Subcutaneous once a week: 90 mcg weekly on Fridays.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
fever of unknown origin, ? viral gastroenteritis
Secondary:
Liver transplant with recurrent HCV, stage II fibrosis
pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Last Name (Titles) 30922**],
You came to the hospital because you had fevers. You then
developed diarrhea. You were initially treated with antibiotics
for a suspected bacterial infection, but none of your stool
cultures revealed any pathogenic bacteria, so this treatment was
stopped. Because of your prior CMV negative status and your
receipt of a CMV positive liver, you were placed on antiviral
medications to prevent CMV infection, which you stopped
approximately one month ago. This timing and your symptoms as
well as imaging showing some inflammation of your colon were
concerning for CMV colitis. You were started on antiviral
therapy and had a colonoscopy with biopsy, which showed that you
did not have any evidence of active CMV colitis. You were seen
by our infectious disease specialists, who felt that given all
the evidence, you are very unlikely to have CMV colitis, and
your antiviral medications were stopped. The exact cause of your
fevers remains unclear, but they have subsided and your diarrhea
has improved. You may have had a fleeting viral gastroenteritis,
which has resolved on its own. We suggest that you continue
monitoring your body temperature daily and call Dr. [**Last Name (STitle) **] if you
develop worsening diarrhea. You also had worsening anemia, and
you were given blood transfusions. You may need to start
additional medications to increase your red blood cells and
should discuss this with Dr. [**Last Name (STitle) **].
We did not give you interferon this week because we were trying
to avoid complicating your fever curve. You will need to discuss
the best strategy for treating your HCV with Dr. [**Last Name (STitle) **].
We have not made any changes to your medications. Please
continue to take them as previously prescribed.
Followup Instructions:
Department: TRANSPLANT
When: THURSDAY [**2116-11-12**] at 10:00 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
Name: [**Last Name (LF) **],[**First Name3 (LF) **] F.
Address: [**Street Address(2) 73637**], [**Hospital1 **],[**Numeric Identifier 25306**]
Phone: [**Telephone/Fax (1) 25302**]
Appt: [**11-16**] at 10:45am
Completed by:[**2116-11-9**]
|
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"E878.0",
"558.9",
"570",
"V16.8",
"995.92",
"V10.83",
"584.8",
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"070.70",
"996.82",
"780.60",
"038.9",
"284.19",
"456.1",
"456.8",
"571.5",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
18981, 18987
|
13075, 16914
|
312, 356
|
19169, 19169
|
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|
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|
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|
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|
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|
3125, 4149
|
4165, 4367
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,655
| 128,819
|
25504
|
Discharge summary
|
report
|
Admission Date: [**2156-10-5**] Discharge Date: [**2156-10-21**]
Date of Birth: [**2107-5-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Halo vest placement
Tracheostomy
History of Present Illness:
This is a 49 year-old man who fell down a flight of stairs
(approx 15) on [**10-4**] with uncertain loss of consciousness.
He went to bed and woke up with a headache, so he went to a
hospital. There he was noted to have a fracture of C2 and was
transferred to [**Hospital1 18**] by ambulance. On arrival at [**Hospital1 18**] he was on
a backboard with a cervical collar in place and comlained of
neck pain.
Past Medical History:
s/p C4-6 fusion after fall ([**8-15**])
s/p CABG
HTN
angina
MS ([**12-17**])
Social History:
+tobacco
EtOH: [**2-16**] drinks 1-3x/wk
No drugs
Family History:
Noncontributory
Married
Physical Exam:
On arrival:
T98.9 P111 BP 171/108 R20 94%RA
Gen: Awake, GCS=15, able to speak full sentances
HEENT: PERRL (2-3bilat) Paresthesias/numbness over back of head.
Neck: c-collar in place, trachea midline. C-spine tender.
Chest: Atraumatic. Equal breath sounds bilaterally
CV: RRR, S1S2, no murmurs appreciated
Abd: Atraumatic. Mild diffuse tenderness, no rebound/guarding.
FAST negative.
Pelvis: Stable
Rectal: Normal tone, no blood.
Ext: No deformities noted. Abrasion over right tibia. Left
arthroscopy scars. Decresed sensation in distribution of left
axillary nerve (patient reports this is old). 4/5 strength L
median nerve distribution (patient reports prior hand injury).
Back: No enderness or step-offs. Atraumatic.
Nro: [**6-17**] everywhere except [**5-18**] thumb abduction (as noted above).
Complains of neck pain with LE movement. 2+ reflexes all
extremities, sensation grossly intact.
Pertinent Results:
[**2156-10-5**] 02:00PM GLUCOSE-92 UREA N-5* CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2156-10-5**] 12:45PM URINE HOURS-RANDOM
[**2156-10-5**] 12:45PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2156-10-5**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2156-10-5**] 12:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-10-5**] 12:45PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-NOTDONE
[**2156-10-5**] 12:45PM URINE HYALINE-[**4-17**]*
[**2156-10-5**] 12:30PM GLUCOSE-93 UREA N-5* CREAT-0.9 SODIUM-140
POTASSIUM-6.1* CHLORIDE-101 TOTAL CO2-25 ANION GAP-20
[**2156-10-5**] 12:30PM UREA N-5* CREAT-1.0
[**2156-10-5**] 12:30PM AMYLASE-53
[**2156-10-5**] 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-10.1
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2156-10-5**] 12:30PM WBC-16.0* RBC-4.60 HGB-16.5 HCT-48.6 MCV-106*
MCH-35.8* MCHC-33.9 RDW-13.0
[**2156-10-5**] 12:30PM PLT COUNT-302
[**2156-10-5**] 12:30PM BLOOD WBC-16.0* RBC-4.60 Hgb-16.5 Hct-48.6
MCV-106* MCH-35.8* MCHC-33.9 RDW-13.0 Plt Ct-302
[**2156-10-6**] 02:30AM BLOOD WBC-10.6 RBC-4.60 Hgb-16.0 Hct-47.7
MCV-104* MCH-34.7* MCHC-33.5 RDW-13.2 Plt Ct-308
[**2156-10-7**] 01:35AM BLOOD WBC-18.6*# RBC-3.65* Hgb-12.7*#
Hct-37.2*# MCV-102* MCH-34.9* MCHC-34.2 RDW-13.2 Plt Ct-259
[**2156-10-8**] 02:30AM BLOOD WBC-17.2* RBC-3.73* Hgb-12.9* Hct-38.5*
MCV-103* MCH-34.6* MCHC-33.5 RDW-13.0 Plt Ct-258
[**2156-10-8**] 05:17PM BLOOD WBC-17.6*
[**2156-10-9**] 01:53AM BLOOD WBC-15.9* RBC-3.84* Hgb-13.1* Hct-39.4*
MCV-103* MCH-34.2* MCHC-33.3 RDW-13.4 Plt Ct-229
[**2156-10-10**] 01:24AM BLOOD WBC-21.2* RBC-3.93* Hgb-14.0 Hct-40.5
MCV-103* MCH-35.7* MCHC-34.7 RDW-13.0 Plt Ct-181
[**2156-10-11**] 02:35AM BLOOD WBC-22.3* RBC-3.74* Hgb-13.3* Hct-37.7*
MCV-101* MCH-35.6* MCHC-35.3* RDW-13.1 Plt Ct-208
[**2156-10-12**] 01:48AM BLOOD WBC-19.0* RBC-3.51* Hgb-12.6* Hct-35.3*
MCV-101* MCH-35.9* MCHC-35.7* RDW-13.0 Plt Ct-323#
[**2156-10-13**] 02:44AM BLOOD WBC-21.3* RBC-3.48* Hgb-12.2* Hct-35.5*
MCV-102* MCH-35.1* MCHC-34.4 RDW-13.0 Plt Ct-382
[**2156-10-14**] 04:41AM BLOOD WBC-26.0* RBC-3.37* Hgb-11.3* Hct-34.1*
MCV-101* MCH-33.5* MCHC-33.1 RDW-13.1 Plt Ct-534*
[**2156-10-15**] 01:54AM BLOOD WBC-29.4* RBC-3.34* Hgb-11.7* Hct-34.7*
MCV-104* MCH-35.1* MCHC-33.9 RDW-13.0 Plt Ct-667*
[**2156-10-16**] 01:55AM BLOOD WBC-23.0* RBC-3.21* Hgb-10.9* Hct-33.3*
MCV-104* MCH-34.0* MCHC-32.8 RDW-13.0 Plt Ct-705*
[**2156-10-18**] 08:00AM BLOOD WBC-25.8* RBC-3.39* Hgb-11.5* Hct-34.9*
MCV-103* MCH-33.9* MCHC-32.9 RDW-13.2 Plt Ct-971*
[**2156-10-19**] 04:51AM BLOOD WBC-23.7* RBC-3.24* Hgb-11.1* Hct-33.5*
MCV-104* MCH-34.2* MCHC-33.1 RDW-13.3 Plt Ct-840*
[**2156-10-20**] 07:10AM BLOOD WBC-18.3* RBC-3.44* Hgb-11.6* Hct-36.0*
MCV-105* MCH-33.8* MCHC-32.3 RDW-13.2 Plt Ct-902*
[**2156-10-21**] 06:55AM BLOOD WBC-16.4*
SPUTUM:
GRAM STAIN (Final [**2156-10-19**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
CATHETER TIP: no growth (final)
C DIFF: negative
BLOOD CULTURES ([**10-14**]): negative x 2
OF NOTE:
MRI OF THE CERVICAL SPINE.
CLINICAL HISTORY: Fracture after trauma. Now upper extremity
weakness.
TECHNIQUE: Sagittal T1-weighted, T2-weighted and STIR images and
axial gradient echo and T2-weighted images were obtained.
FINDINGS:
The study is degraded by patient motion. The C2 fracture shown
on the CT of the same day is again visualized, primarily on the
STIR images. At the level of the base of C2, where the posterior
inferior corner of C2 is displaced slightly into the spinal
canal, there is T2 hyperintensity in the spinal cord dorsally,
suggesting a contusion. Osteophytes are noted at C3-4 level.
There appears to be some edema in C4, where there is an anterior
fusion and metallic artifact from a cage. No fracture was seen
on the CT. There is also metallic artifact from the cage at
C5-6. The disc space osteophyte seen at C6-7 on the CT is
visible.
IMPRESSION:
1. The study is limited by motion, but there appears to be edema
in the dorsal aspect of the spinal cord at the level of the
inferior aspect of C2, suggestive of a spinal cord contusion.
2. The known fracture through the C2 pedicles and the base of C2
is visualized. There is minimal displacement of the fragment
from the posterior inferior aspect of C2 into the canal, but the
CSF around the spinal cord remains patent.
3. The postsurgical and degenerative disc disease changes at
other levels are visualized to some extent.
LIVER OR GALLBLADDER US (SINGL
INDICATION: Elevated bilirubin.
RIGHT UPPER QUADRANT ULTRASOUND: Limited views of the liver are
unremarkable. There is no evidence of ascites. The gallbladder
is decompressed and the wall is thickened. There is no evidence
of cholelithiasis or pericholecystic fluid. There is no intra or
extrahepatic biliary dilatation and the common bile duct
measures 3 mm. The flow within the portal vein is hepatopetal.
IMPRESSION: Decompressed gallbladder with wall thickening. No
evidence of acute cholecystitis.
CHEST (PORTABLE AP) [**2156-10-18**] 11:49 AM
CHEST: Tracheostomy tube is present. The tip of the Dobhoff tube
lies within the second part of the duodenum. The tip of the
central line lies in the region of the junction of the right
atrium and SVC.
Hazy opacity seen in the right lower lobe probably representing
an area of atelectasis. An early infiltrate in this region could
not be excluded. Elsewhere, the lung fields appear clear.
IMPRESSION: Atelectasis or possible pneumonic consolidation,
right lower lobe.
Brief Hospital Course:
The patient was hemodynamically stable on arrival. He was seen
on arrival in the ED by the Trauma Surgery service and the
Orthopedic Surgery service, and his initial evaluation confirmed
the hangman's type C2 fracture. Although his intiial neurologic
examination was essentially normal, a repeat exam revealed [**5-18**]
strength in the right upper extremity and decreased pinpick
sensation in all extremities. He underwent a STAT c-spine MRI
which showed possible spinal cord contusion but no evidence of
cord compression by fracture of epidural hematoma.
The patient was started on steroids and admitted to the Trauma
ICU. He was taken to the OR for a halo vest application. Prior
to the surgery he was delusional and combative, issues that
reoccurred multiple times during his hospital stay. In the OR he
was a difficult intubation because of his prior C4-6 surgery.
During his time in the ICU he there was concern that he was
having DTs (hypertension, tachycardia, agitation).
His WBC count increased while hospitalized and he was febrile in
the ICU. He was started on levofloxacin for what appeared to be
an evolving pneumonia; vancomycin was added when his clincal
status did not immediately improve, and then he was switched to
a combination of vancomycin, flagyl and zosyn.
Given his pulmonary status, DTs, and concern for difficulty with
reintubation because of the halo, he underwent a bedside
percutaneous tracheostomy on [**10-11**] with no complications. He
did continue to have periods of agitation and confusion.
During the rest of his stay in the ICU and on the floor he had
no major problems. [**Name (NI) **] had further imaging, including a HIDA
scan, and cultures sent to evaluate his high WBC count. He
remained afebrile during the last 5 days of his stay while still
on Zosyn and Vancomycin, and his blood cultures and urine
cultures were negative. His sputum culture grew coag-positive
Staph aureus; sensitivities were still pending at the time of
discharge. After a discussion with the ID fellow, he was
discharged on Zosyn and Vancomycin with plans to complete a full
14-day course.
He was seen daily by physical therapy and progressed well.
Medications on Admission:
Metoprolol
Isosorbide dinitrate PRN
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Disp:*30 Suppository(s)* Refills:*0*
2. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily) for 1 months.
Disp:*QS mg* Refills:*0*
3. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO twice
a day as needed for constipation.
Disp:*600 mL* Refills:*0*
4. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for SBP<90, HR<50.
Disp:*90 Tablet(s)* Refills:*0*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
Disp:*150 ML(s)* Refills:*0*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
12. Trazodone 50 mg Tablet Sig: 1-1.5 Tablets PO HS (at bedtime)
as needed for insomnia.
Disp:*45 Tablet(s)* Refills:*0*
13. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 mg
Intravenous Q8H (every 8 hours) for 4 days.
Disp:*54 mg* Refills:*0*
14. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg
Intravenous twice a day for 4 days.
Disp:*QS mg* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
C2 fracture
Spinal cord contusion
C7 Left lamina/inferior facet nondisplaced fracture
Pneumonia
s/p fall
Discharge Condition:
Stable
Discharge Instructions:
You should alert a nurse [**First Name (Titles) **] [**Last Name (Titles) **] if you have worsening
pains, fevers, chills, nausea, vomiting, shortness of breath,
chest pain, redness or drainage about the wounds, or if you have
any questions or concerns.
You should continue to have vigorous pulmonary care with chest
PT. The rehabilitaiton center will continue to monitor your
white blood cell count and temperature as necessary. You should
complete the full course of antibiotics (through [**10-24**]).
Followup Instructions:
Call Dr. [**Last Name (STitle) 363**] at ([**Telephone/Fax (1) 63719**] for a follow-up appointment in
approximately 2 weeks.
Call the Trauma Clinic at ([**Telephone/Fax (1) 376**] for a follow-up
appointment in 4 weeks.
|
[
"340",
"401.9",
"806.04",
"486",
"V45.81",
"413.9",
"291.0",
"008.45",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"33.22",
"93.41",
"96.04",
"96.72",
"02.94"
] |
icd9pcs
|
[
[
[]
]
] |
11702, 11799
|
7803, 9977
|
324, 359
|
11948, 11957
|
1936, 5104
|
12510, 12735
|
981, 1006
|
10063, 11679
|
11820, 11927
|
10003, 10040
|
11981, 12487
|
1021, 1917
|
5145, 7780
|
276, 286
|
387, 797
|
819, 898
|
914, 965
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,624
| 105,790
|
43929
|
Discharge summary
|
report
|
Admission Date: [**2132-8-3**] Discharge Date: [**2132-8-15**]
Date of Birth: [**2063-10-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Penicillins / Tetracyclines / Erythromycin Base /
Ciprofloxacin
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Hypotension, ARF
Major Surgical or Invasive Procedure:
Intubation, Arterial Line Placement, Central Veinous Access
History of Present Illness:
MICU HPI:
Reverend [**Known lastname 13469**] is a 68 year old homeless man with DM, HTN,
seizure disorder, chronic pain, recently admitted [**Date range (1) 94315**] for
presumed aspiration PNA c/b rhabdo and ARF discharged on
Clindamycin and Amlodipine for elevated BP now re-presenting to
ED with initially vague complaints of SOB, ongoing productive
cough of green sputum, and weakness as well as decreased UOP.
Also had reported 60 lb weight loss over last 4 months and
constipation x 1 month.
On initial ED triage, VS 97.9 116/96 75 14 99%RA but when
brought back to room SBP 50s-60s with HR 70s. Per report, pt
mentating normally with bounding pulses at the time. BP taken
manually in all 4 extremities and persistently low despite 5L
IVF. Pt complained of CP and EKG with ST depressions precordial
leads, I, AVL, STE III so Cardiology was consulted who felt
changes were likely reflective of demand ischemia related to
hypotension. He received rectal ASA 325mg and had normal bedside
echo with preserved EF. He was started on peripheral dopa for
hypotension with SBP up to 100s-110s but was subsequently
tachycardic to 120 with more pronounced ST depressions so RIJ
placed as well as A line and he was swicthed to levophed with
decreased HR to 70s and resolution of ST changes. He was
intubated for airway protection in setting of progressive
obtundation, reportedly was never hypoxic, and recieved
vancomycin and meropenem for ? sepsis due to history of PCN
allergy. Labs significant for WBC 10.5 with 12% bands, normal
lactate, ARF with Cr 4.8 from 1.1 [**7-30**], CK 698 (from peak [**2123**]),
trop 0.05. CT head for progressive obtundation was unremarkable
and CT torso with bibasilar infiltrates consistent with
aspiration.
.
At time of transfer, patient on 0.06 levophed, fentnayl, versed
with BP 135/57 HR 68.
Past Medical History:
1. Seizure history - describes as "[**Doctor Last Name 11332**] mal" but was previously
described as "tonic-clonic" with bilateral arm shaking, no LOC.
Was on Trileptal in the past, but was weaned off due to
associated hyponatremia, now on Keppra. Followed by Dr. [**First Name (STitle) 3322**]
[**Name (STitle) **] (EEG negative 2/[**2132**]).
2. Headaches - taken multiple narcotics in the past to
treat this, in addition to advil and tylenol. It was described
in
prior notes as starting on the left side of his head and
radiating anteriorly and down his back. He also has had
documented left face pain.
3. Type II DM
4. Peripheral neuropathy
5. Hypertension
6. Hypercholesterolemia
7. Diastolic Dysfunction (EF 60-70% on recent echo with LVH)
8. GERD
9. Depression/Anxiety
10. Lumbar spinal stenosis w/ history C3/C7 fractures
11. Degenerative joint disease
12. Neurogenic bladder
13. s/p left cataract surgery
[**37**]. Vitamin B12 deficiency
15. Atypical CP (last MIBI negative [**3-10**])
16. Hyponatremia (baseline 128-131)
17. h/o multiple falls due to multifactorial gait ataxia, also
followed by Dr. [**First Name (STitle) 3322**] [**Name (STitle) **]
18. 8-mm thecal mass, stable over several years, consistent with
nerve sheath tumor.
19. Likely prior left temporal infarct (per atrophy on head MRI)
Social History:
Homeless, retired Operating Room nurse, Buddhist monk, sister
living in
[**Name (NI) **] as only family but who has declined to take him in.
Tobacco: former smoker, ~45 pack year history (quit 30 years
ago)
.
Also, per records:
Pt has been living on the street for 3-4 months. Was engaged to
a woman many years ago but broke it off. He states he had many
relationships, and used to be bisexual. Now he is "celibate"
since becoming a priest and is not in any relationship.
Graduated from high school. College graduate. Worked on Masters.
Attended nursing school. Buddhist priest x 25 years. Was working
to counsel AIDS patients prior to becoming homeless (x 10
years). No social supports in [**Location (un) 86**]. All of his friends have
passed away.
.
Pt has a history of sexual abuse by his father's brother at age
[**6-8**]. Never told anybody, no treatment. Was also physically
abused by his father growing up.
Family History:
Mother died of esophageal cancer, ?EtOH abuse and depression.
Father died suddenly of heart attack.
.
Multiple family members with CAD including father, sister [**Name (NI) **] at
58 yo), all 4 grandparents
Type 2 DM (paternal grandfather)
Esophageal cancer (mother)
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: BP 70/40 initially, improving to 110/60 with levophed.
HR
70-80, sats 98% on 2L, RR 14
GEN: Intubated, sedated, responds to sternal rub only
HEENT: Moist mucus membranes, unable to appreciated JVP
CVS: S1,S2, no murmurs or rubs
RESP: CTA BL anteriorly
EXT: no edema, cool to touch
ABD: soft, nontender, nondistended, 2 ecchymoses on abdomen, no
ascites or organomegaly
NEURO: As above. Somnolent. Left surgical pupil. Right pupil 3mm
reactive.
SKIN: Ecchymoses abdomen. No rash.
Pulses: DP/PT 2+ BL
DISCHARGE PHYSICAL EXAM
T: 98.6 HR: 54 (54-76) BP: 116/78 RR: 18 O2: 95% RA - ambulatory
sat of 97% today
GEN: NAD, lying comfortably in his bed
HEENT: MMM, OP clear, no JVD
CV: RRR, no murmurs/clicks/rubs appreciated
PULM: CTA on left, slight crackles at right base - much
improved
ABD: protuberant, +BS, soft, NT/ND
EXT: L shoulder TTP at baseline, 2+ pulses
NEURO: alert, oriented, no focal defecits
Pertinent Results:
MICU LABS
[**2132-8-3**] 02:00PM PT-12.5 PTT-25.1 INR(PT)-1.1
[**2132-8-3**] 02:00PM PLT SMR-NORMAL PLT COUNT-256
[**2132-8-3**] 02:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2132-8-3**] 02:00PM NEUTS-50 BANDS-12* LYMPHS-21 MONOS-7 EOS-10*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2132-8-3**] 02:00PM WBC-10.5# RBC-4.39* HGB-12.5* HCT-37.6*
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.8*
[**2132-8-3**] 02:00PM CK-MB-16* MB INDX-2.3
[**2132-8-3**] 02:00PM LIPASE-55
[**2132-8-3**] 02:00PM ALT(SGPT)-18 AST(SGOT)-36 CK(CPK)-698* ALK
PHOS-53 TOT BILI-0.4
[**2132-8-3**] 02:00PM estGFR-Using this
[**2132-8-3**] 02:00PM GLUCOSE-110* UREA N-48* CREAT-4.8*#
SODIUM-140 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-18* ANION GAP-25
[**2132-8-3**] 02:17PM LACTATE-1.6 K+-4.3
[**2132-8-3**] 02:45PM URINE GR HOLD-HOLD
[**2132-8-3**] 02:45PM URINE UHOLD-HOLD
[**2132-8-3**] 02:45PM URINE HOURS-RANDOM
[**2132-8-3**] 02:45PM URINE HOURS-RANDOM
[**2132-8-3**] 02:50PM URINE RBC-0-2 WBC-[**3-6**] BACTERIA-OCC YEAST-NONE
EPI-[**3-6**]
[**2132-8-3**] 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2132-8-3**] 02:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2132-8-3**] 03:16PM cTropnT-0.05*
[**2132-8-3**] 08:39PM PT-12.6 PTT-27.1 INR(PT)-1.1
[**2132-8-3**] 08:39PM PLT COUNT-188
[**2132-8-3**] 08:39PM NEUTS-85.9* LYMPHS-9.3* MONOS-2.5 EOS-2.2
BASOS-0.2
[**2132-8-3**] 08:39PM WBC-11.8* RBC-4.20* HGB-11.3* HCT-36.8*
MCV-88 MCH-26.9* MCHC-30.7* RDW-14.9
[**2132-8-3**] 08:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2132-8-3**] 08:39PM OSMOLAL-308
[**2132-8-3**] 08:39PM ALBUMIN-3.8 CALCIUM-7.4* PHOSPHATE-4.8*#
MAGNESIUM-2.2
[**2132-8-3**] 08:39PM CK-MB-19* MB INDX-2.3 cTropnT-0.01
[**2132-8-3**] 08:39PM CK(CPK)-815*
[**2132-8-3**] 08:39PM GLUCOSE-150* UREA N-37* CREAT-2.8*#
SODIUM-143 POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-19* ANION
GAP-15
[**2132-8-3**] 08:40PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2132-8-3**] 08:40PM URINE OSMOLAL-430
[**2132-8-3**] 08:40PM URINE HOURS-RANDOM CREAT-83 SODIUM-73
POTASSIUM-15 CHLORIDE-37
[**2132-8-3**] 08:56PM freeCa-1.10*
[**2132-8-3**] 08:56PM O2 SAT-98
[**2132-8-3**] 08:56PM LACTATE-0.6
[**2132-8-3**] 08:56PM TYPE-ART TEMP-36.2 RATES-14/ TIDAL VOL-550
PEEP-5 O2-70 PO2-134* PCO2-44 PH-7.24* TOTAL CO2-20* BASE XS--8
-ASSIST/CON INTUBATED-INTUBATED
[**2132-8-3**] 10:08PM TYPE-MIX TEMP-36.2 RATES-16/0 TIDAL VOL-550
PEEP-5 O2-60 PO2-160* PCO2-43 PH-7.25* TOTAL CO2-20* BASE XS--8
-ASSIST/CON INTUBATED-INTUBATED
[**2132-8-3**] 10:11PM URINE EOS-NEGATIVE
REPEAT CXR [**2132-8-7**]:
IMPRESSION: Resolution of multifocal pneumonia. Small right
lower lobe
pulmonary nodule which has been evaluated on several prior CT
scans.
CXR [**2132-8-12**]
IMPRESSION:
No evidence of consolidation. Cardiomediastinal silhouette is
unchanged,
satisfactory position of new left-sided PICC line with minor
left lower lobe
atelectasis.
REPEAT EKG:
Sinus bradycardia. Compared to the previous tracing of [**2132-8-5**]
there is no
longer evidence for prior inferior myocardial infarction,
although it is still
probable.
DISCHARGE LABS: [**2132-8-15**]
Na: 140
K:4.0
Cl:109
Bicarb: 28
BUN: 12
Cr: 1.1
Hgb: 11.0
Hct: 34.6
Brief Hospital Course:
Pt arrived in the MICU intubated with arterial line and central
line for presumed sepsis and PNA since he was recently
discharged for aspiration PNA.
Overnight in the MICU he had no acute events, and was weaned
down on his ventilatory requirement. He was extubated the next
morning and restarted on his home seizure and HTN medications.
He was observed one more night in the ICU, and then determined
to be stable enough for transfer to the floor.
Problems addressed During Admission:
# Hypotension: Pt. was initially hypotensive and intubated,
given IVF, and treated with empiric antibiotics for presumed
sepsis. His sputum cx eventually showed MRSA and he was
continued on Vancomycin (Meropenem was DC'd). His hypotension
improved on hospital day 2 and once he was transferred to the
floor, his BP was monitored and home meds eventually restarted.
#. EKG changes: Likely demand related ischemia. Pt. complained
of some chest pain after being moved to the floor - repeat EKGs
were done which did not show any concerning changes from prior
and his cardiaac enzymes remained normal. CK trended down to
normal as well.
# Acidemia: Pt had combined anion gap metabolic and respiratory
acidosis on admission which resolved with administration of IVF.
His Cr was within normal limits for the rest of his hospital
stay.
# ARF: Likely prerenal in addition to ATN given hypotension. [**Month (only) 116**]
have been partly precipitated by increased antihypertensive
regimen +/- rhabdo as described in the MICU notes. Within 48
hours, baseline Cr normalized and it was 1.1 on the day of
discharge out of the hospital.
# PNA: Pt recently discharged on [**7-30**] with aspiration PNA on
Clindamycin and returned with persistent infiltrates. He was
originally started on Vanco/[**Last Name (un) **] and once sputum culture showed
MRSA the meropenem was DC'd and vanco continued for a total
course of 11 days. He had remarkable clinical improvement and
his repeat CXR after PICC line placement showed resolution of
prior infiltrates.
# Rhabdomyolysis: CK trended up to 800 from 600s on admission
but overall down since last admission peak of [**2123**]. CK continued
to trend down and was within normal limits on [**2132-8-6**]: level was
142.
# TYPE 2 DM: Was kept on NPH and ISS while admitted - typically
on NPH.
# Chronic Pain: Pt on chronic narcotics (Oxycontin 20mg [**Hospital1 **] and
Percocet for breathrough), although he was not discharged on
oxycontin from previous admission. He received percocet as
needed for back and shoulder pain. As described below, pt. was
discharged on [**2132-7-30**] with a script for 84 percocet. He was
readmitted on [**2132-8-3**] and on inspection of his home med bottles
before discharged, he only has 2 pills left. This was brought
to his attention and he was told that percocet would only be
prescribed for enough over the weekend until his appt. with Dr.
[**Last Name (STitle) **] on [**Last Name (STitle) 766**] at 12:30. No oxycontin was given.
# Hx of Seizure Disorder: Pt. was kept on his Keppra and
gabapentin was restarted on the floor.
# Depression: Per last DC summary, patient was on Paxil which
was again resumed. However, after confirming with Dr. [**Name (NI) **], pt.
should have been on Celexa. This was prescribed. Pt. insisted
he was on Cymbalta and in fact had some Cymbalta with his home
meds prescribed by another physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 5404**]. It was
explained AT LENGTH the importance of not taking both Cymbalta
and Celexa. The patient was asked to throw away the Cymbalta
which he refused to do.
# Social: The patient is a homeless Reverend/retired OR nurse.
Social worker [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) **] spent multiple hours with Mr. [**Known lastname 13469**]
attempting to get him into a shelter or facility. He claimed
during the admission that his wallet and glucometer were stolen.
Putting his belongings in the safe was offered on multiple
occasions by case management prior to this alleged theft, but
the patient refused this service. As described by social work,
Mr. [**Known lastname 13469**] [**Last Name (Titles) 23156**] both help-seeking and help-rejecting
behavior throughout his admission, making his disposition
difficult in terms of finding him placement as many shelters and
SNFs refused to take him.
*************Pt. had Cymbalta in his bag of medications
prescribed by Dr. [**First Name (STitle) **] [**Name (STitle) 5404**]. We did not continue this and
wrote him a prescription for the Celexa which Dr. [**Last Name (STitle) **] had
prescribed. Additionally, he was prescribed 84 percocet on
[**2132-7-30**] when he was discharged from the hospital. He only has 2
pills left in his pill bottle and he was readmitted on [**8-3**]. He received percocet here for pain and was prescribed 20
pills to give him for pain until he sees Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 766**].
He was not discharged from his last hospitalization on
Oxycontin and therefore he was not prescribed any after this
admission.
Medications on Admission:
1. Aspirin 81 mg Tablet PO DAILY
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID
3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
4. Pantoprazole 40 mg Tablet, One Tablet PO Q24H
5. Oxybutynin Chloride 5 mg Tablet 1 Tablet PO BID
6. Albuterol Sulfate 1 neb inhaled q6 hours
7. Metoprolol Succinate 25 mg Tablet PO daily
8. Isosorbide Mononitrate 60 mg Tablet 1 tablet PO daily
9. Nitroglycerin 0.3 mg Tablet SL prn chest pain
10. Atorvastatin 40 mg Tablet PO DAILY
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO every six (6) hours as needed for pain
13. Paroxetine 40 mg Tablet 1 tab PO daily
14. Toprol XL 25 mg Tablet 1 tab PO daily
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous qAM: 6-9units qPM.
17. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO every twelve (12) hours as
needed for pain.
18. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO every
six (6) hours for 5 days.
Disp:*48 Capsule(s)* Refills:*0*
19. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
21. Gabapentin 600 mg Tablet Sig: Two (2) Tablet PO twice a day.
22. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: [**1-4**] Tablet PO twice a
day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. Gabapentin 600 mg Tablet Sig: Two (2) Tablet PO twice a day.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual PRN as needed for chest pain: take one tab for chest
pain every 5 minutes if pain persists - not to exceed 3 tabs in
15 minutes. Call 911 for chest pain .
15. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
18. Glucometer
Please dispense one glucometer.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pneumonia - Sputum positive for methicillin resistant staph
aureus
Secondary:
Acute Renal Failure
Altered Mental Status
Rhabdomyolysis
Hypertension
Depression
Seizure Disorder
headaches
Peripheral Neuropathy
Hypercholesterolemia
GERD
Discharge Condition:
Stable, Ambulatory, at his baseline level of function
Discharge Instructions:
You were admitted to the hospital after you came in with some
confusion, low blood pressure, and renal failure. You went to
the medical ICU and a breathing tube was placed to help you
breath for about 24 hours. You were given fluids and
antibiotics and continued to improve. Your EKGs initially
showed some concerning changes which improved with treatment of
your acute problems.
PLEASE FOLLOW THE BELOW INSTRUCTIONS ON YOUR MEDICATIONS:
1. Your metoprolol was decreased from 25mg twice daily to 12.5
mg twice daily - take [**1-4**] tablet twice daily.
2. Stop taking Cymbalta - Dr. [**Last Name (STitle) **] has said you should be on
Celexa (Citalopram) 20mg daily.
3. You should no longer take any Clindamycin or levaquin.
4. You were prescribed 84 percocet on [**2132-7-30**] only 4 days
before you were brought back to the hospital. You only have 2
left and we are unable to prescribe you any more than enough to
get you to your appointment with Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 766**]. You
should discuss this on [**Last Name (STitle) 766**] at your follow up appointment.
5. When you were discharged from the hospital on your last
admission, you were not discharged on any oxycontin
You can resume your other home medications as prescribed from
your recent discharge from the hospital.
You stopped the paxil and went back on your prior regimen of
Celexa - discuss this further with your primary care doctor.
You should call your doctor or return to the hospital if you
develop any fevers, chills, worsening pain, chest pain,
shortness of breath, nausea, vomiting, diarrhea, abdominal pain,
or anything else that concerns you.
Followup Instructions:
Please follow up with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: PCP
Date and time: [**Last Name (LF) 766**], [**8-18**] at 12:30PM
Location: [**Location (un) **], [**Location (un) 86**], [**Numeric Identifier 718**]
Phone number: ([**Telephone/Fax (1) 10757**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
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icd9cm
|
[
[
[]
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] |
[
"96.04",
"96.71",
"38.93",
"38.91"
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icd9pcs
|
[
[
[]
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17752, 17758
|
9260, 14428
|
357, 419
|
18046, 18102
|
5806, 9135
|
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|
4562, 4831
|
16076, 17729
|
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|
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|
18126, 19796
|
9151, 9237
|
4846, 5787
|
301, 319
|
447, 2276
|
2298, 3613
|
3629, 4546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,117
| 104,087
|
45767
|
Discharge summary
|
report
|
Admission Date: [**2122-5-4**] Discharge Date: [**2122-5-9**]
Date of Birth: [**2050-3-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath and fatigue
Major Surgical or Invasive Procedure:
[**2122-5-4**] - Ascending aorta replacement with a 29mm Gelweave graft
and aortic valve replacement with a #23 [**Company 1543**] Mosaic tissue
valve.
History of Present Illness:
This is a 72-year-old female with a 13-year known history of a
bicuspid aortic valve. She was followed during this time with
progression of the aortic stenosis and some dilation of the
ascending aorta. During the most recent
echocardiogram, it showed an aortic valve area of 0.5 with a
peak gradient in the mid 30s and an ascending aneurysm that was
approximately 4 cm in size. Based on these findings, the
progression of the disease and the extreme small aortic valve
area, it was decided to proceed with repair. The risks and
benefits were explained to the patient and she agreed to
proceed. The patient agreed to undergo aortic valve replacement
with a tissue valve.
Past Medical History:
Aortic stenosis
Bicuspid Aorti Valve
Dilated Ascending Aorta
Hyperlipidemia
Osteoporosis
Neuropathy
Colon polyps
Social History:
Retired. Never smoked and drinks 4 alcoholic beverages per week.
Lives with her husband.
Family History:
None
Physical Exam:
82 SR 18 130/80
GEN: Well appearing 72 y/o female in NAD
HEENT: Unremarkable
LUNGS: CTA
HEART: RRR, 4/5 SEM
ABD: Soft, NT, ND, NABS
EXT: warm, well perfused, 1+ LE Edema. Pulses [**11-18**]+.
NEURO: Nonfocal
Pertinent Results:
[**2122-5-4**] - PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. 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%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is moderately dilated. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta.
5. The aortic valve is bicuspid. The aortic valve leaflets are
severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine.
1. A well-seated bioprosthetic valve is seen in the aortic
position with
normal leaflet motion and gradients (mean gradient = 5 mmHg). No
aortic
regurgitation is seen.
2. An ascending aorta tube graft is also seen.
3. Biventricular function is preserved
4. Other findings are unchanged
Brief Hospital Course:
Mrs. [**Known lastname 97516**] was admitted to the [**Hospital1 18**] on [**2122-5-4**] for surgical
management of her aorta and aortic valve disease. She was taken
directly to the operating room where she underwent an aortic
valve replacement with a 23mm tissue valve and replacement of
her ascending aorta. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. By postoperative day one she had awoke
neurologically intact and was extubated. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility. She had progressed well
with her mobility, and is ready to be discharged home today.
Medications on Admission:
Aspirin 81mg QD
Fosamax
lipitor 20mg QD
Vitamins/Minerals
Discharge Medications:
1. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Packet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. 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*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Bicuspid Aortic Valve, Aortic Stenosis, Dilated Ascending Aorta
- s/p AVR and Replacement of Ascending Aorta
PMH: Hyperlipidemia, Neuropathy, Osteoporosis, Colon polyps
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Follow-up with Dr. [**First Name (STitle) 1313**] in 2 weeks. ([**Telephone/Fax (1) 97517**]
Please call all providers for appointments.
Scheduled Appointments:
Provider: [**Name Initial (NameIs) 326**] (B) BONE DENSITOMETRY [**Name Initial (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**]
Date/Time:[**2122-8-10**] 11:00
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-9-15**] 2:00
Completed by:[**2122-5-9**]
|
[
"272.4",
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"E878.2",
"424.1",
"441.2",
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"998.2"
] |
icd9cm
|
[
[
[]
]
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[
"35.21",
"39.61",
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"36.99",
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] |
icd9pcs
|
[
[
[]
]
] |
4738, 4787
|
2952, 3770
|
351, 505
|
5000, 5009
|
1715, 2929
|
5723, 6327
|
1464, 1470
|
3878, 4715
|
4808, 4979
|
3796, 3855
|
5033, 5700
|
1485, 1696
|
280, 313
|
533, 1205
|
1227, 1341
|
1357, 1448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,338
| 103,006
|
46649
|
Discharge summary
|
report
|
Admission Date: [**2105-7-2**] Discharge Date: [**2105-7-4**]
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Anemia/Hypotension
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
86y/o F with h/o AFIB, Lacunar CVA, s/p nephrostomy tube for
nephrolithiasis, and recent ICU admission for sepsis who
presents with weakness for the past few days. She was brought
to the ED from [**Hospital3 **] because her nephrostomy tube had
fallen out.
.
Per the patient she had been feeling well, until a few days
prior to admission when she felt weak. She could describe no
antecedent events, or etiology for her sense generalized
fatigue. She did not report any lightheadedness, dizziness,
palpiations or chest pain. At times her breath can be
"smothering" but she has not had any recent SOB. Per the
patient, her bowel and bladder habbits are unchanged, and she
has not noticed any hematuria, dysuria, hematochezia, BRPR,
melena, hematemesis, nausea, or emesis. She denies any recent
fevers, chills, weakness, parasthesias, or numbness. Her
coumadin dose was held today, and decreased yesterday.
.
In the ED initial vital signs were T96.9 P116 88%RA with
tachypnea. At the time she was comfortable, aware, and talking
with headphones and a mircophone. Her stool was guiac negative,
her abdomen exam was benign, and a CXR demonstrated atelectasis.
Her HCT dropped from a baseline of 29 to 21, and her K was
elevated at 5.8 in the setting of a elevated Cr of 2.8 Further
imaging of the abdomen demonstrated diverticulosis, a
non-obstructive stone, a pericardial effusion, and no
retroperitoneal bleed. On transfer, she was ordered two units
of blood and her vitals were: T 98.5, BP 120/65, HR 90s, RR25
Sa: 95%3LNC.
On arrival to the floor she was comfortable, alert, and
oriented. She had no pain, although she reported feeling weak.
Vital signs: T35.9 P86, BP 61/46 (on Lower Leg), RR21 SA 91
3LNC. Her Access is PIV and PICC.
Past Medical History:
1. Severe hearing loss, associated with tinnitus.
2. Osteopenia.
3. Depression/anxiety, followed by Dr. [**Last Name (STitle) 3532**].
4. History of breast cancer.
5. Meningioma.
6. Hypertension.
7. Obesity.
8. Osteoarthritis.
9. Lumbar spinal stenosis.
10. Nepthrolithasis with nephrostomy tube
11. Sepsis
12. Afib w RVR
PAST SURGICAL HISTORY:
1. Cholecystectomy [**2089**].
2. Cataract surgery [**2095**].
3. Left radical breast mastectomy [**2064**].
Social History:
Lives in [**Location (un) **] in [**Location 1268**]. Husband lives in [**Location **]
x 17 years, deceased last year. No children. Previously used to
work in Pathology. No EtOH, tobacco, or illicits.
Family History:
NC
Physical Exam:
GEN: NAD, alert and interactive. Requested microphone use for
communication
VS: 96.6, 82, 88/63, 19, 94%
HEENT: mucous membranes [**Last Name (un) **], no OP lesions, No discernable JVP
at 50 degrees, neck is supple,
CV: No carotid bruits. Decreased upstroke and volume.
Irregularly irregular with faint S1 and S2. No S3 or S4. No
hyperdynamic PMI
PULM: Short shallow breaths. Dullness to percussion on the
left, with left basilar crackles.
ABD: BS+, soft, NTND, no masses or HSM, no flankdullness.
LIMBS: Cool extremities with 3+ LE, no tremors or clubbing
SKIN: No rashes. Two stage II decubs on posterior side.
Nephrostomy site c/d/i.
NEURO: CNII-XII nonfocal, strength 5/5 R and [**3-2**] Left arm and
leg. No facial droop or smile asymmetry.
Pertinent Results:
[**2105-7-2**] 07:00PM URINE COLOR-Brown APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025
[**2105-7-2**] 07:00PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-15 BILIRUBIN-MOD UROBILNGN-1 PH-5.0 LEUK-NEG
[**2105-7-2**] 07:00PM URINE RBC->50 WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2105-7-2**] 07:00PM URINE AMORPH-MANY
[**2105-7-2**] 07:00PM URINE EOS-NEGATIVE
[**2105-7-2**] 06:35PM GLUCOSE-135* UREA N-34* CREAT-2.8*#
SODIUM-131* POTASSIUM-5.8* CHLORIDE-96 TOTAL CO2-21* ANION
GAP-20
[**2105-7-2**] 06:35PM estGFR-Using this
[**2105-7-2**] 06:35PM ALT(SGPT)-43* AST(SGOT)-47* ALK PHOS-89
[**2105-7-2**] 06:35PM CALCIUM-8.8 PHOSPHATE-4.9*# MAGNESIUM-2.4
[**2105-7-2**] 06:35PM PT-44.1* PTT-34.5 INR(PT)-4.7*
[**2105-7-2**] 06:09PM COMMENTS-GREEN TOP
[**2105-7-2**] 06:09PM GLUCOSE-115* LACTATE-2.3* NA+-136 K+-4.8
CL--106 TCO2-19*
[**2105-7-2**] 06:05PM WBC-12.2* RBC-2.36*# HGB-6.8*# HCT-21.4*#
MCV-91 MCH-28.7 MCHC-31.6 RDW-14.8
[**2105-7-2**] 06:05PM NEUTS-85.5* LYMPHS-8.5* MONOS-5.7 EOS-0.2
BASOS-0.2
[**2105-7-2**] 06:05PM PLT COUNT-427
.
Imaging:
.
TTE [**2105-7-3**]: There is mild symmetric left ventricular hypertrophy
with normal cavity size and global systolic function (LVEF>55%).
The aortic valve leaflets (?#) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is a moderate to large sized
circumferential pericardial effusion (2.5cm inferior and 2.0 cm
lateral to the left ventricle, 1.5cm anterior to the right
atrium and right ventricle) with eccentuated respiratory
variation in transmitral Doppler E wave suggestive of impaired
ventricular filling. but no right atrial or right ventricular
diastolic collapse (may be absent in settings of pulmonary
artery hypertension).
Compared with the prior study (images reviewed) of [**2105-6-16**], the
pericardial effusion findings are new and c/w impaired
filling/early tamponade physiology
.
TTE [**7-4**] 11:08am
There is a large pericardial effusion. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology
.
TTE [**7-4**] 11am
Post pericardiocentesis. There is a small to moderate sized
pericardial effusion. There are no echocardiographic signs of
tamponade. Compred to the pre-tap study from today, the
pericardial effusion is smaller and tamponade has resolved.
Brief Hospital Course:
86y/o F with h/o AFIB, Lacunar CVA, s/p nephrostomy tube for
nephrolithiasis, and recent ICU admission for sepsis who
presents with weakness for the past few days. She was admitted
through the ED from [**Hospital3 **] because her nephrostomy tube
had fallen out. Pericardial effusion was incidentally found on a
CT abd/pelvis.
Pt was transferred to CCU for findings suggestive of cardiac
tamponade physiology on ECHO [**7-3**]. Her clinical status worsened
overnight. In the morning of [**7-4**] pt underwent emergent bedside
pericardiocentesis. She went into resp failure and was placed on
ventilatory support. The decision to make her [**Date Range 3225**] was made by
her HCP and she was kept on morphine drip titrated for comfort.
She went into asystolic arrest on [**7-4**] 6:30pm. She was DNR per
her HCP.
.
# Pericardial effusion - Echocardiography shows moderate to
large pericardial effusion with impaired ventricular filling c/w
early tamponade physiology. Diff dx of pericardial effusion
includes viral, neoplastic (hx of breast CA), uremic, CHF, fluid
overload from renal failure. Uremic unlikely as BUN of 38, and
in ARF, baseline Cr of 0.7-1.0. AM of [**7-4**] echo showed
increased severity of tamponade and pt appeared cold and
nonperfusing. Bedside pericardiocentesis performed with
resolution of tamponade on post-pericardiocentesis ECHO. She
continued to decompensate and was placed on respiratory support
per HCP wishes.
.
#. Hypotension: Initially presented to the floor with labile
blood pressures, but pressures were fluid responsive and
thereafter remained stable; there was no clinical evidence
suggestive of sepsis. She was transferred to CCU for management
of cardiac tamponade. She was noted to be hypotensive with low
urine output which did not resolve after pericardiocentesis. She
was started on pressors, intubated and continued to be
hypotensive sbp 60-100. Decision was made by her hcp to make her
[**Date Range 3225**] and she was taken off all support except morphine drip
titrated for comfort.
.
# Dyspnea - Unsure etiology. Bilateral pleural effusions on CT
scan and X-ray likely [**12-30**] tamponade physiology and elevated L
sided pressures. No history of asthma, COPD or CHF. Denies
anxiety. Pt too unstable to undergo pleurocentesis. She was
intubated per HCP wishes and maintained at FiO2 100% and PEEP 8.
She continued to desat 80s. The decision was made by her HCP to
change her status to [**Name (NI) 3225**] and she was taken off ventilatory and
pressor support.
.
#. ARF: Presented with Cr 3.1 from BL 0.7. Had a previous CT
stone protocol showing a non-obstructive pattern; no recent CT
contrast. Received Vancomycin prior to admission at [**Hospital 4382**] facility. Urine lytes, culture, were sent; CK and Vanc
levels were drawn. Urology is aware of the patient's disposition
and was following for possible replacement of nephrostomy tube.
Pt was admitted to CCU for management of pericardial effusion.
Pt had decreasing urine output via foley cath and on AM of [**7-4**]
it was noted that she had no output overnight. Oliguria likely
[**12-30**] hypotension and lack of perfusion from cardiac tamponade.
.
#. Bilateral Pleural Effusions. Likely due to tamponade
physiology.
.
# Anemia: likely [**12-30**] large bleed a/w pericardial tamponade
.
#. UTI: UA nitrate positive. Started on Zosyn with empirically
dosed Vancomycin. Urine and blood cultures sent.
.
#. AFIB with h/o RVR: Coumadin and ASA were held in the setting
of a bleed and the patient was rate controlled with Metoprolol 5
mg IV prn. All antihypertensives and antiarrhythmic meds were
held in the setting of shock and respiratory failure.
.
#. Elevated INR: Vitamin K IV and FFP given
pre-pericardiocentesis to reverse her anticoagulation.
Medications on Admission:
Venlafaxine 150 mg daily
Ascorbic Acid 500 mg daily
Aspirin 81 mg daily
Senna 2 tabs [**Hospital1 **]
Albuterol Sulfate neb q4PRN wheezing
Magnesium Hydroxide 400 mg/5 ml PO qam
Simvastatin 40 mg PO daily
Olanzapine 2.5 mg [**Hospital1 **]
Docusate 100 mg [**Hospital1 **]
Lisinopril 10 mg daily
Vitamin D 1000 units daily
MV daily
Nexium 20 mg daily
Lasix 40 mg daily
Bisacodyl 10 mg Sup.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pericardial tamponade
Respiratory failure
Renal failure
Shock
Discharge Condition:
Expired [**2105-7-4**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
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"599.0",
"275.3",
"276.7",
"311",
"V10.3",
"584.9",
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"427.31",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"37.0",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10245, 10254
|
6013, 9775
|
238, 258
|
10359, 10513
|
3543, 5990
|
2750, 2754
|
10216, 10222
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10275, 10338
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9801, 10193
|
2405, 2515
|
2769, 3524
|
180, 200
|
286, 2038
|
2060, 2382
|
2531, 2734
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,837
| 196,362
|
47581
|
Discharge summary
|
report
|
Admission Date: [**2188-8-11**] Discharge Date: [**2188-8-16**]
Date of Birth: [**2118-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Hypoglycemia, presumably due to an underlying UTI.
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
69 yo man with a history of CAD s/p PTCI ([**2180**]) & CABG ([**4-/2188**]),
s/p pacer for junctional bradycardia([**2186**]), afib on coumadin,
and ESRD on HD (being evaluated for renal tx) presented with
hypoglycemia from the rehab. he was just discharged from the [**Hospital1 **]
after a pacer with ICD placement. also was treated for PNA for
10 days. at his rehab he was found unresponsive. his FSG at that
time was 40. he was given some oral juice. suspected aspiration
during that episode. O2 satts of 90%. pt was given 1 amps D50
and the MS improved. in the ED was noted to have blood glucose
of 46. was given 1 amp of d50. Denies F/C/C, N/V/D/abd pain,
CP. c/o some SOB. VS in ED were 97.1 58 116/57 18 100/RA
Past Medical History:
Coronary Artery Disease - s/p Multiple PCI/Stents. Known cath
and LAD stent in [**8-/2187**] (3 vessel disease, systemic systolic
arterial hypertension, moderate LV systolic heart failure, nl LV
diastolic function, and successful PTCA of the LPL).
CABG - [**2188-4-15**] CABG X 3 (left internal mammary artery to left
anterior descending artery, saphenous vein graft to obtuse
marginal branch, saphenous vein graft to right coronary artery.)
History of Multiple MI's - most recent [**2187-9-5**]
Ischemic cardiomyopathy, EF 30-40% in [**4-12**]
Mild-mod MR
[**First Name (Titles) **] [**Last Name (Titles) 100555**] [**2186-7-6**]([**Company 1543**]), DDDR
Peripheral Vascular Disease
End-stage Renal Disease on Hemodialysis since [**8-11**]
Right Brachicephalic Av Fistula [**2187-12-6**]
Tunnelled Dialysis Catheter [**2187-8-5**]
Diabetes Mellitus Type II - now Insulin Dependent
Hypertension
Elevated Cholesterol
Neuropathy
s/p Appendectomy
s/p Bilateral Lower Extremity ORIF
Social History:
No current tobacco use. There is no history of alcohol abuse.
Separated from wife; has 4 grown kids. Close w/ son, [**Name (NI) **]. [**Name2 (NI) **]
HCP. [**Name (NI) **] recently in rehab/nursing home.
Family History:
There is no family history of sudden death. Extensive family
history of cardiac disease including early MIs (50s) and
multiple family members with diabetes. Mother died at age 58 due
to cerebral hemorrhage and also had h/o DM2. Father died at age
65 of a cerebral hemorrhage and also had h/o DM2. Brother died
at age 74 due to complications of DM1.
Physical Exam:
Vits: T 96.5; HR 78; BP 124/49; O2 96% on RA
Gen: NAD
Chest: bibasilar crackles
Heart: RRR, no M/R/G
Abd: soft, NT, ND, no HSM
Neuro: CN II-XII intact, no focal motor or sensory deficit
Extr: no edema, 2+ radial, pedal pulses
Pertinent Results:
Labs on admission:
[**2188-8-11**] 09:45PM GLUCOSE-36* UREA N-49* CREAT-5.7* SODIUM-133
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-24 ANION GAP-17
[**2188-8-11**] 09:45PM CK(CPK)-26*
[**2188-8-11**] 09:45PM CK-MB-NotDone cTropnT-0.15* proBNP-[**Numeric Identifier 25829**]*
[**2188-8-11**] 09:45PM WBC-15.2*# RBC-4.02* HGB-11.0* HCT-36.0*
MCV-90 MCH-27.3 MCHC-30.5* RDW-17.6*
[**2188-8-11**] 09:45PM NEUTS-88.0* LYMPHS-5.4* MONOS-5.6 EOS-0.9
BASOS-0.1
[**2188-8-11**] 09:45PM PT-14.8* PTT-34.3 INR(PT)-1.3*
[**2188-8-11**] 08:20PM GLUCOSE-24* UREA N-47* CREAT-5.6*# SODIUM-133
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-22 ANION GAP-18
.
Labs on discharge:
[**2188-8-16**] 07:25AM WBC-9.4 RBC-3.89* Hgb-10.5* Hct-34.2* MCV-88
MCH-27.0 MCHC-30.7* RDW-17.2* Plt Ct-161
[**2188-8-16**] 07:25AM PT-28.5* PTT-48.0* INR(PT)-2.9*
[**2188-8-16**] 07:25AM Glucose-113* UreaN-20 Creat-3.5* Na-135 K-3.4
Cl-101 HCO3-23 AnGap-14
[**2188-8-15**] 03:55PM ALT-12 AST-13 AlkPhos-116 TotBili-0.3
[**2188-8-16**] 07:25A Calcium-8.1* Phos-2.1* Mg-1.5*
.
Other important lab values:
[**2188-8-12**] 03:24AM %HbA1c-5.8
[**2188-8-11**] 09:45PM CK-MB-NotDone cTropnT-0.15* proBNP-[**Numeric Identifier 25829**]*
[**2188-8-12**] 03:24AM CK-MB-6 cTropnT-0.14*
[**2188-8-12**] 04:38PM CK-MB-NotDone cTropnT-0.14*
.
R-Upper Ext. US [**2188-8-12**]:
FINDINGS: The right internal jugular vein demonstrates
appropriate flow and compressibility. The right subclavian vein
where visualized demonstrates appropriate flow. Right axillary,
cephalic, and basilic veins demonstrate appropriate
compressibility and flow. One of the two brachial veins, from
approximately just below the elbow to the mid upper arm between
the elbow and shoulder demonstrates occlusive intraluminal
filling thrombus.
.
IMPRESSION: Deep venous thrombosis seen in the mid to distal
right brachial vein. Remainder of right upper extremity veins
appears patent.
.
Chest X-ray [**2188-8-13**]:
.
COMPARISON: [**2188-8-11**].
.
FINDINGS: As compared to the previous radiograph, the extent of
the right-sided pleural effusion has minimally increased. The
preexisting parenchymal opacity in the right lower lung is of
slightly different distribution but similar extent. Subtle
increase of the retrocardiac atelectasis. Otherwise, there is no
relevant change. The monitoring and
support devices are in unchanged position.
Brief Hospital Course:
69 yo man with a history of CAD s/p PTCI ([**2180**]) & CABG ([**4-/2188**]),
s/p pacer for junctional bradycardia([**2186**]), afib on coumadin,
and ESRD on HD p/w hypoglycemia and found to have a urinary
tract infection. The patient was admitted to MICU where
hypoglycemia was treated and resolved. The patient found to have
urinary retention; foley was placed that drained pus. Patient
was loaded on gentamicin based on prior urine cultures. He has
several sessions of hemodialysis initially complicated by
hypotension. During the last session of hemodialysis, the
patient maintained his pressures and was felt to be stable for
the floor. The patient did have frequent ectopy and pacer spikes
for which EP was consulted. EP felt pacer was working
appropriately. Patient transferred to [**Hospital Unit Name 196**] service for further
care. The patient was maintained on his prior medications and
monitored on telemetry. From a cardiac standpoint, the remainder
of his stay was uneventful. Please see UTI and ABDOMINAL PAIN
below.
.
# UTI: Patient c/o abdominal pain and described pain with urge
to urinate. Bladder scan [**Hospital Unit Name 9304**] urinary retention and a foley
was placed. Pus/ thick grey/white was noted coming from the
bladder. The patient's UA was grossly positive. He has a history
of non-fermenter, non-pseudomona (ie stenotrophomonas or
acinetobacter) that is multi-drug resisitent, but sensitive to
gentamicin. He was loaded with gentamicin and dosing continued
by renal. On discharge, he will continue to be renally dosed
with hemodialysis for a goal gent trough of 6 mcg/ml.
.
# HYPOGLYCEMIA: It was felt this may be attributed to new
infection see UTI above. In the hospital, he was covered on
sliding scale insulin.
.
# LOC: Loss of consciousness. Likely from hypoglycemia, but it
was needed to consider [**Hospital Unit Name 4448**] function as well. EP came and
interrogated the pacer which was ok, but monitor continues to
demonstrate ectopy and pace spikes occasionally on the t-waves.
Cardiac enzymes negative despite slight elevated tropinins,
CK-MB negative. Patient was continually monitored on telemetry
without incident.
.
# ESRD: missed HD due to admission. Patient initially with
hypotension with HD for the urgent session and HD session in am
[**8-12**]. However, HD continued thereafter without hypotension.
.
# Afib: We continued coumadin; he was given a dose on [**8-12**] to
catch up back into the theraputic range. He was later discharged
on 1 mg COUMADIN daily to follow-up for further adjustment.
.
# ABDOMINAL PAIN/DIARRHEA - Patient was found to be c.diff
positive. He was started on a fourteen day course of FLAGYL
which he will continue as an outpatient.
.
# HTN: He was continued on carvedilol and lisinopril.
.
Medications on Admission:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*60 Tablet(s)* Refills:*0*
2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*qs Tablet(s)* Refills:*0*
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*qs
Capsule, Sust. Release 24 hr(s)* Refills:*2*
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed. Disp:*qs * Refills:*0*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed. Disp:*qs * Refills:*0*
7. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold if SBP < 100 or HR < 60. Disp:*60 Tablet(s)*
Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
10. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Lactulose 20 gram Packet Sig: One (1) PO once a day.
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: One (1) 68 Subcutaneous qam.
13. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: One (1) 38 Subcutaneous qpm.
14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
17. Keflex 500 mg Capsule Sig: One (1) Capsule PO once a day for
5 days: on dialysis days, please take after dialysis.
19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
20. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
21. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours for 5 days.
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gentamicin
Hemodialysis dosed per Hemodialysis team. Dose during
hemodialysis. Goal is for a Gentamicin trough of 6 mcg/ml
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
7. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. Flagyl 250 mg Tablet Sig: One (1) Tablet PO three times a
day for 12 days.
Disp:*36 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 7168**]
Discharge Diagnosis:
Primary:
Urinary Tract infection
Clostridium difficile infection
.
Secondary:
Ischemic cardiomyopathy
Mitral Regurgitation
Atrial Fibrillation
Peripheral Vascular Disease
End-stage Renal Disease
Diabetes Mellitus Type II
Hypertension
Elevated Cholesterol
Discharge Condition:
stable. afebrile. chest pain free.
Discharge Instructions:
You were admitted after having low blood glucose. You were also
found to have a urinary tract infection and a Clostridium
difficile infection in your intestinal tract.
.
You were treated with GENTAMICIN for the urinary tract infection
and METRONIDAZOLE for the intestinal infection. You should be
continued on gentamycin at least for 14 days (but dosed during
hemodialysis). Please discuss this medication with your
hemodialysis team. You are to continue the METRONIDAZOLE until
[**2188-8-29**]. Your COUMADIN was adjusted to 1 mg daily. You
need to continue to check your blood (PT/PTT/INR) to continue to
adjust this medication as necessary. You should continue to take
your other medications as instructed.
.
Please make sure you follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 9304**].
.
If you experience any chest pain, chest pressure with jaw or arm
pain, difficulty breathing, or any other concerning symptoms,
please call 911 or come to the ER.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
You have a follow up appointment scheduled with Dr. [**Last Name (STitle) 1270**]
on Wednesday, [**8-27**] at 1:30pm.
.
Please check CBC and PT/PTT/INR on Monday [**2188-8-18**] for
adjustment of your COUMADIN (blood thinner). Please forward
those results to Dr.[**Name (NI) 15895**] office. Thank you.
.
You have an appointment with DEVICE CLINIC. Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2188-8-18**] 3:00
Completed by:[**2188-8-18**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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|
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366, 374
|
11761, 11798
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2982, 2987
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3001, 3620
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1147, 2128
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2144, 2353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,647
| 114,567
|
46389
|
Discharge summary
|
report
|
Admission Date: [**2113-3-29**] Discharge Date: [**2113-4-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Hypoxic respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a [**Age over 90 **]F with hx of Rheumatoid Arthritis,
osteroarthritis, malnutrition, recently admitted to [**Hospital1 18**] with
diffuse esophageal spasm with subsequent recent admission to [**Hospital1 112**]
with GIB, who recent finshed a course of abx for UTI, and is
currently undergoing treatement for Clostridium difficile
infection. She is brought to the ED today by her family, as
she's had a 7 day course of progressive lethargy, anorexia,
cough productive for clear sputum, & pleuritic chest pain.
There are no reported fevers or chills, nausea, vomiting,
aspiration events, recent travel, or smoking. The family does
report that she's had increasing erythema at the sacrum and
worsening of her lower extremity skin tears. They also report
that she's had dependent edema without changes in her urinary
habits.
ED Course: She was found to be slighly unresponsive and in no
apparent distress, and vital signs were remarkable for an oxygen
saturation in the mid-80's. She had a CXR done that revealed
infiltrates vs effusions bilaterally, and her labs were notable
for a WBC count of 17 with 92% PMNs. She was subsequently given
IV CTX/Flagyl/Azithromycin. Given her clinical findings and
ongoing hypoxia she was admitted to the [**Hospital Unit Name 153**] for observation.
Past Medical History:
1. Rheumatoid arthritis for
2. Osteoporosis.
3. Hiatal hernia.
4. Intermittent cognative impariment of unclear cause,
5. Failure to thrive
6. Urinary incontinence.
7. Intermittent leg edema
Social History:
Patient resided at the [**Hospital 599**] Nursing Home in past; however,
daughter and granddaughter took the patient home after discharge
on [**3-2**]. Her daughter [**Name (NI) 1258**] is very involved with her care. On
last admission, the did not want to send her to rehab. EtOH:
none. Tobacco: none. Illicits: None.
Family History:
noncontributory
Physical Exam:
Tmax: 36.2 ??????C (97.2 ??????F)
Tcurrent: 36.2 ??????C (97.2 ??????F)
BP: 143/119(125) {133/68(85) - 143/119(125)} mmHg
RR: 20 (20 - 30) insp/min
Heart rhythm: SR (Sinus Rhythm)
Peripheral Vascular: (Right radial pulse: 1+), (Left radial
pulse: 1+ (Right DP pulse: Not assessed), (Left DP pulse: Not
assessed)
Skin: sacral skin breakdown with surrounding erythema, dressed
bilateral skin tears
Neurologic: Responds to: voice, Movement: MAEW, Tone: increased
upper extremity tone
HEENT: AT/NC, patient did not open eyes, dry MM, poor dentition,
no JVD
CARDIAC: irregular rhythm, S1/S2, [**1-4**] holosystolic murmur @ RUSG
LUNG: decreased air movement bilaterally, without wheezes,
rales, or rhonci
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
M/S: moving all extremities well, no cyanosis, clubbing o
Pertinent Results:
CXR [**3-31**]
PORTABLE AP SEMI-UPRIGHT CHEST RADIOGRAPH: The cardiomediastinal
silloutte is stable, however partially obscured by large
bilateral pleural effusions that are unchanged. There is no
pulmonary edema or evidence of pneumonia
CXR [**3-30**]
IMPRESSION: Pulmonary edema with enlarging bilateral pleural
effusions significantly worse since [**3-3**].
KUB [**3-31**]
IMPRESSION: Paucity of bowel gas component, which could be seen
with obstruction. If clinically indicated, either a repeat study
or a CT may be obtained for better characterization
TTE [**3-30**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF 70-80%). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The supporting structures of the tricuspid valve are
thickened/fibrotic. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: hypertrophic, hyperdynamic left ventricle with very
small cavity size; at least moderate mitral regurgitation and
moderate-to-severe tricuspid regurgitation
Brief Hospital Course:
1. Aspiration Pneumonia
- Patient was maintained on Vancomycin and Zosyn
- Aspiration Precautions were continued
- Family declined PEG
- Geriatrics were consulted
2. C. Difficile Colitis
- Patient was maintained on Flagyl
- Plan was for 2 weeks post cessation of vanco/zosyn
- Serial toxin assay
3. Severe Malnutrition
- No NGT or PEG per family
- Continous Aspiration
4. Sacral Decubitus
- Vascular Consultation
- Wound Care Consult
- Wound Care
5. Coagulopathy
- Nutritional
# GOALS OF CARE: patient was extensively consulted on by
palliative care and geriatrics. Lengthy discussions with the
family. Patient was CMO/DNR/DNI with plans to discharge to
hospice on [**2113-4-6**], however she expired prior to discharge
Medications on Admission:
Docusate 100mg PO BID
Lidocaine patch 5% on 12 hrs, off 12 hrs daily
Megestrol 40mg qhs
Miconazole 2% topical daily
Mirtazapine 15mg qhs
Omeprazole 40mg daily
Sucralfate 1gm q6h
Boutreaux butt past daily
Oxycodone prn (rarely takes)
Senna 2 tabs daily prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspiration Pneumonia
C. Diff Colitis
Septicemia
Pressure Ulcers
Severe Malnutrition
Coagulopathy
Discharge Condition:
Expired
Discharge Instructions:
You are going home with hospice services. They will be your
primary contact for symptom management.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2113-4-11**]
1:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2113-4-13**] 12:00
|
[
"799.02",
"507.0",
"715.90",
"276.0",
"263.9",
"553.3",
"038.9",
"V43.64",
"294.8",
"788.30",
"530.81",
"707.09",
"338.29",
"733.00",
"286.9",
"724.5",
"783.0",
"783.7",
"V13.02",
"008.45",
"427.5",
"584.9",
"714.0",
"782.3",
"V66.7",
"294.9",
"276.2",
"530.85",
"707.03",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5804, 5813
|
4771, 5497
|
291, 297
|
5954, 5963
|
3089, 4748
|
6111, 6407
|
2200, 2217
|
5834, 5933
|
5523, 5781
|
5987, 6088
|
2232, 3070
|
222, 253
|
325, 1633
|
1655, 1847
|
1863, 2184
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,021
| 154,022
|
13928
|
Discharge summary
|
report
|
Admission Date: [**2176-7-28**] Discharge Date: [**2176-8-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
Right Percutaneous Nephrostomy Tube Placement
History of Present Illness:
89 F with hx of bladder cancer s/p urostomy 7 years ago, hx of
CAD, HTN, COPD and HL who presents to an OSH with new R sided
flank pain. At OSH, was found to have 5 mm R distal ureteral
stone and a positive UA. She was transferred her for further
management.
.
She developed her pain around midnight and has been without
fever or chills per the patient. She has been nauseated with dry
heaves and has not taken PO since last PM. She has noticed
decrease urostomy output since her pain started. It did not have
any blood or pus.
.
In the ED, initial vitals were T 98, P 88, BP 97/79, R 18 and
97% on RA. He received levofloxacin 750 mg IV at the outside
hospital. He received vanco 1 gm. She was ordered for cefepime
but did not receive it secondary to timing. She also received a
total of 500 cc IVFs at the OSH and 3 L IVFs in our ED. She got
4 mg IV morphine and 4 mg IV zofran in the ED, too.
.
She initially went to IR were she was found to be mildly
tachypneic and coughing. Her O2 saturations were normal on 2L
NC. She did have successful placement of a percutaneous
nephrostomy tube. She received 100 mcg fentanyl and 0.5 mg
versed. She was prone the entire procedure and had her O2 turned
up from 2L to 4L and had her sats in the low 90s the entire
time.
.
On arrival to the floor, she is having respiratory distress and
SOB. She is tripoding in her bed. She has no pain but just
cannot get comfortable. She received a nebulizer, 2 mg IV
morphine, 20 mg IV lasix and 4 mg IV zofran during this acute
process. She seemed more comfortable after the treatments.
Past Medical History:
Bladder Ca s/p urostomy 8 yrs ago
CHF unknown EF
HTN
HL
CAD, s/p MI and CABG
COPD
Anemia
Hx of CVA with resultant R eye blindness
Social History:
lives in [**State 33977**], was visiting her daughter on [**Location (un) **]. Has
past history of smoking. Unknown history of etoh. Is very
independent, lives with her daughter in [**Name (NI) 33977**] but still
plays golf a few times a week.
Family History:
non-contributory
Physical Exam:
Admission exam:
General Appearance: Well nourished, Anxious, Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical
adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
2/6 systolic murmur;
midline scar; hx of open heart surgery ? CABG
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bilateral bases, Wheezes : tight with inspiratory and
expiratory wheezes, Diminished: throughout)
Abdominal: Soft, Non-tender, has R sided urostomy in place
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2176-7-28**] 11:30PM BLOOD WBC-17.3*# RBC-4.27 Hgb-13.0 Hct-39.1
MCV-92 MCH-30.5 MCHC-33.4 RDW-13.4 Plt Ct-116*
[**2176-8-6**] 05:09AM BLOOD WBC-8.4 RBC-3.75* Hgb-11.5* Hct-34.4*
MCV-92 MCH-30.7 MCHC-33.5 RDW-13.8 Plt Ct-253
.
[**2176-7-28**] 08:44PM URINE RBC->50 WBC-21-50* Bacteri-FEW Yeast-NONE
Epi-0-2
.
[**2176-7-28**] 08URINE CULTURE (Final [**2176-8-1**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
.
SENSITIVITIES: MIC expressed in MCG/ML
.
_________________________________________________________
ENTEROCOCCUS SP.
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ <=2 S
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 <=16 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 2 S
.
.
[**2176-7-28**] 02:09PM BLOOD Glucose-119* UreaN-27* Creat-1.5* Na-139
K-5.3* Cl-104 HCO3-23 AnGap-17
[**2176-8-7**] 08:39AM BLOOD Glucose-123* UreaN-19 Creat-0.9 Na-139
K-4.0 Cl-100 HCO3-32 AnGap-11
[**2176-7-28**] 05:36PM BLOOD CK-MB-2 cTropnT-0.02*
[**2176-8-2**] 09:46AM BLOOD CK-MB-2 cTropnT-0.02*
[**2176-8-2**] 03:17PM BLOOD CK-MB-2 cTropnT-0.01
[**2176-8-3**] 04:08AM BLOOD CK-MB-2 cTropnT-0.01
[**2176-7-28**] 05:36PM BLOOD Calcium-7.6* Phos-3.5 Mg-1.4*
[**2176-8-5**] 03:48AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.1
Brief Hospital Course:
Mrs. [**Known lastname 41676**] is an 89 y/o woman with a h/o of COPD, CAD, HTN,
CVA, and bladder cancer s/p urostomy placed 7 yrs ago in
[**State 33977**] who presented with sepsis and post-obstructive
pyelonephritis.
.
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **]): Her initial
respiratory distress was most likely due to splinting [**2-20**]
abdominal pain from pyelonephritis and sepsis and then continued
after her infection was treated due to volume overload from
fluid resuscitation. She responded well to diuresis with Lasix,
which was started on [**7-31**] and d/c'ed on [**8-4**] because pt was
developing contraction alkalosis. Given pt's history of valvular
disease, Cardiology was consulted; they recommended maintaining
good control of heart rate given patient??????s valvular disease. She
was started on Diamox on [**8-5**] for her contraction alkalosis;
this resolved and Diamox was then D/C'd. By time of discharge,
she was stable on 2L O2 by nasal cannula.
.
SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): She was hypotensive
upon arrival to the unit, likely due to early sepsis from
pyelonephritis. She was started on pressors at admission; these
were d/c'ed on [**7-29**]. Lactate improved from 3.1 to 0.9. Diltiazem
was restarted at low dose on [**7-30**] to treat her ectopy (repeated
runs of PVCs), and her blood pressures returned to near
baseline.
.
PYELONEPHRITIS: Pt had stranding and an obstructing renal stone
on imaging and a positive U/A on presentation. OSH urine culture
showed Klebsiella and Morangella both sensitive to ceftriaxone
and cipro. Her urine cx here grew Enterococcus that was
sensitive to vanco, ampicillin, tetracycline, and
nitrofurantoin. This was consistent with post-obstructive
pyelonephritis. Pt was initially treated with meropenem and
Vancomycin; these were switched to Ampicillin and IV Cipro on
[**8-1**]. Leukocytosis improving, has been afebrile. On the floor,
switched to PO ampicillin and cipro on [**8-6**].
.
NEPHROLITHIASIS (KIDNEY STONES): 5 mm obstructing stone causing
hydronephrosis. S/p IR drainage, followed by IR and Urology. IR
is deferring treatment of stone until course of abx completed,
will need anterograde lithotripsy/ureteroscopy as outpt, likely
week of [**8-12**]. Dr.[**Name (NI) 6444**] office will arrange follow up.
.
HTN: Pt restarted on home dose of 60 mg diltiazem QID, and added
captopril 12.5 mg TID.
.
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): likely
secondary to obstruction, could be also secondary to poor
perfusion from question of early sepsis. Cr improved to
baseline.
.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,
EMPHYSEMA) WITHOUT ACUTE EXACERBATION: has hx of COPD, not on
oxygen at home; had increased O2 requirement here, likely from
fluid overload rather than COPD exacerbation. Received nebs PRN
for wheezing, SOB. Transitioned from BiPap to face mask to NC
and O2 titrated down.
.
HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC:
unknown coronary anatomy, but does not have any signs of
ischemia on her EKG or worrisome history of unstable angina. [**Month (only) 116**]
have mild componenet of heart failure given DOE. TTE from [**7-30**]
unchanged from that in [**2173**].
.
HX of CVA: normal neuro exam here
.
Hyperlipidemia: stable, continued statin
.
FEN: regular diet
.
PPx: pneumoboots, SQ heparin; no GI ppx indicated; bowel reg
Medications on Admission:
Diltiazem CD 120 mg daily
Furosemide 20 mg daily
KCL 20 meq daily
Simvastatin 40 mg daily
Calcium Carbonate 600 mg daily
Ferrous Sulfate 325 mg daily
Vitamin D
Discharge Medications:
1. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours).
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day: Do not restart your iron pills until after
you have finished your ciprofloxacin antibiotic.
8. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO once a day: Do not take with 2 hours of taking your
ciprofloxacin.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
14. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q2H (every 2 hours) as needed for PRN
wheeze.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
16. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**First Name5 (NamePattern1) 4542**] [**Last Name (NamePattern1) 6252**] Nursing & Retirement Home - [**Hospital1 41677**]
Discharge Diagnosis:
Primary: 1. Severe sepsis secondary to pyelonephritis
2. Respiratory failure
3. Obstructing nephrolithiasis
Secondary: 1. Chronic obstructive pulmonary disease
2. Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because of kidney stone that
caused a systemic bacterial infection. A tube was placed in
your back to allow urine to drain from the kidney. In the ICU,
you were treated for low blood pressure and difficulty
breathing. As these problems improved, you moved from the ICU
to the general care floor. We treated your infection with
antibiotics, and left the kidney tube in place so that urine can
drain.
Continue to take these antibiotics (ciprofloxacin and
ampicillin). The urology team will tell you when to stop them.
We started you on a new medicine for your blood pressure and
heart. Take captopril 12.5 mg three times per day.
Take aspirin 325 mg daily.
Followup Instructions:
You will receive a call (on your cell phone, [**Telephone/Fax (1) 41678**]) from
Dr.[**Name (NI) 6444**] Urology office to schedule removal of the stone. If
you do not hear from his office, please call his office at
([**Telephone/Fax (1) 41679**] to arrange follow-up.
|
[
"401.9",
"496",
"592.0",
"995.92",
"590.10",
"038.9",
"428.0",
"V45.81",
"V58.66",
"428.43",
"276.4",
"591",
"518.81",
"438.89",
"412",
"584.9",
"041.3",
"414.00",
"592.1",
"276.7",
"272.4",
"V10.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
10434, 10584
|
5199, 8593
|
278, 325
|
10849, 10849
|
3326, 5176
|
11722, 11995
|
2353, 2371
|
8803, 10411
|
10605, 10828
|
8619, 8780
|
11000, 11699
|
2386, 3307
|
222, 240
|
353, 1922
|
10864, 10976
|
1944, 2076
|
2092, 2337
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,917
| 113,367
|
42061
|
Discharge summary
|
report
|
Admission Date: [**2146-7-21**] Discharge Date: [**2146-7-26**]
Date of Birth: [**2071-5-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
severe aortic stenosis
Major Surgical or Invasive Procedure:
redo sternotomy/AVR(#23mm St.[**Male First Name (un) 923**] porcine) on [**2146-7-22**]
History of Present Illness:
76yo well developed male with history of Parkinson's disease
seeking deep brain stimulator device. Elective procedure on hold
due to severe aortic stenosis elevating risk. Past medical
history of CAD s/pCABG x 3 ([**2137**]), hyperlipidedmia. Patient
admits to noticing increasing fatigue over the last year, now
requiring daily naps. Reports lightheadedness when getting out
of
bed in the morning, and dizziness after 2-3 minutes of pulling
weeds. He can climb a flight of stairs but must pace himself,
ambulates 2 blocks before needing to stop due to shortness of
breath. He denies chest pain or syncope. Echocardiogram reveals
aortic valve area 0.8cm2, peak gradient 66mmhg, EF>60%.
NYHA Class: II
Past Medical History:
-aortic stenosis
-CAD, s/p CABG x 3 ([**2137**])
-hyperlipidemia
-sick sinus syndrome
-Parkinson's (rt hand tremors, RLE weakness, speech hesitancy)
-[**Year (4 digits) 499**] Ca s/p [**Year (4 digits) 499**] resection
- exlap for twisted bowel
-vein ligation
-vertebral fracture T5-6-7 secondary to fall, s/p fusion
-right arm fracture
-tonsillectomy
-left ankle fracture
-varicella zoster rt torso [**6-2**]
Previous Cardiac Surgery: [**2137**] CAGGx3- LIMA-LAD, SV-PDA,SV-OM1
Social History:
Retired to [**State 1727**]. Supportive friends. Usually walks the
neighbors labrador several times a week, none recent.
contact: [**Name (NI) **] [**Name (NI) 91288**] (brother) [**Telephone/Fax (1) 91289**]
Family History:
Father deceased age 70's, stomach Ca. Mother deceased age [**Age over 90 **],
CAD/CVA. Two brothers deceased, [**Name2 (NI) 499**] Ca.
Brother 82yo alive. Widowed, 3 adopted children.
Physical Exam:
Physical Exam on Admission
Pulse:68 Resp:14 O2 sat:96% on RA
B/P Right:128/56 Left:
General:well appearing in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade _4/6_____
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: cath site without hematoma Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right: radiating murmur Left: radiating
murmur
Discharge Exam:
VS 99.1 73 106/54 18 97%-RA
Gen: NAD
Neuro: A&O x3, MAE-nonfocal exam
CV: RRR no murmur. Sternum stable-incision CDI
Pulm: clear-slightly diminished in bases bilat
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused. trace pedal edema bilat
Pertinent Results:
Admission labs:
[**2146-7-21**] 08:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2146-7-21**] 08:53PM PT-11.4 PTT-31.9 INR(PT)-1.1
[**2146-7-21**] 08:53PM PLT COUNT-245
[**2146-7-21**] 08:53PM WBC-7.5 RBC-4.33* HGB-14.6 HCT-42.7 MCV-99*
MCH-33.8* MCHC-34.3 RDW-12.9
[**2146-7-21**] 08:53PM ALBUMIN-4.5
[**2146-7-21**] 08:53PM proBNP-303
[**2146-7-21**] 08:53PM ALT(SGPT)-6 AST(SGOT)-25 CK(CPK)-141 ALK
PHOS-64 TOT BILI-0.9
[**2146-7-21**] 08:53PM GLUCOSE-124* UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-23 ANION GAP-12
Discharge labs:
[**2146-7-26**] 05:55AM BLOOD WBC-11.0 RBC-2.87* Hgb-9.1* Hct-27.8*
MCV-97 MCH-31.7 MCHC-32.7 RDW-14.2 Plt Ct-196
[**2146-7-26**] 05:55AM BLOOD Plt Ct-196
[**2146-7-24**] 02:32AM BLOOD PT-13.6* PTT-30.2 INR(PT)-1.3*
[**2146-7-26**] 05:55AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-135
K-3.5 Cl-102 HCO3-26 AnGap-11
[**2146-7-26**] 05:55AM BLOOD Mg-2.0
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 99 ml/beat
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *3.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *50 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 33 mm Hg
Aortic Valve - LVOT pk vel: 0.[**Age over 90 **] m/sec
Aortic Valve - LVOT VTI: 26
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Normal regional LV systolic function. Overall normal
LVEF (>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**11-22**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: Informed consent was obtained. 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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**11-22**]+) mitral regurgitation is seen.
POSTBYPASS
There is preserved biventricular systolic function. There is a
well seated, well functioning bioprosthesis in the aortic
position. No perivalvular AI is visualized. The MR is now trace.
The study is otherwise unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2146-7-22**] 12:38
Radiology Report CHEST (PORTABLE AP) Study Date of [**2146-7-25**] 8:59
AM
Final Report: There is no evident pneumothorax. Moderate
cardiomegaly is stable. Widened mediastinum is unchanged.
Pulmonary edema has improved, now mild. Bibasilar atelectases
have markedly improved. If any, there is a small left pleural
effusion. Sternal wires are aligned.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
.
[**2146-7-26**] 05:55AM BLOOD WBC-11.0 RBC-2.87* Hgb-9.1* Hct-27.8*
MCV-97 MCH-31.7 MCHC-32.7 RDW-14.2 Plt Ct-196
[**2146-7-25**] 06:05AM BLOOD WBC-10.2 RBC-2.89* Hgb-9.3* Hct-27.8*
MCV-96 MCH-32.2* MCHC-33.5 RDW-14.2 Plt Ct-138*
[**2146-7-26**] 05:55AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-135
K-3.5 Cl-102 HCO3-26 AnGap-11
[**2146-7-25**] 06:05AM BLOOD Glucose-100 UreaN-16 Creat-0.7 Na-137
K-3.7 Cl-104 HCO3-26 AnGap-11
[**2146-7-26**] 05:55AM BLOOD Mg-2.0
Brief Hospital Course:
On [**2146-7-22**] Mr. [**Known lastname 69467**] was taken to the operating room and
underwent a redo sternotomy/Aortic Valve Replacement (#23mm
St.[**Male First Name (un) 923**] Porcine) with Dr.[**Last Name (STitle) **]. Please see opeartive report
for further details. He tolerated the procedure well and was
transferred to the CVICU for invasive monitoring in critical but
stable condition. He awoke neurologically intact and extubated
on the day of surgery. He weaned off pressor support on POD1.
All lines and drains were removed per cardiac surgery protocol
withoout complication. No Beta-blocker were initiated due his
history of sick sinus syndrome and postoperative accelerated
junctional rhythm. Statin/ASA/and diuresis were intiated along
with resuming preoperative meds before transfer from ICU on
POD#1. Physical Therapy was consulted to work on stregnth and
mobility. The remainder of his postop course was essentially
uneventful. He continued to progress and was ready for discharge
to rehabilitation at Clipper [**Hospital1 **] Health in [**Location (un) 12017**], NH on
POD 4.
At the time of discharge he was ambulating with assistance,
incisions are healing well. All follow up appointments were
advised.
Medications on Admission:
CARBIDOPA-LEVODOPA - 25 mg-100 mg tablet - two Tablet(s) by
mouth
4 times per day
CITALOPRAM - 20 mg tablet - one Tablet(s) by mouth once at night
RAMIPRIL [ALTACE] - (Prescribed by Other Provider) - Dosage
uncertain
SIMVASTATIN - (Prescribed by Other Provider) - Dosage uncertain
TAMSULOSIN - 0.4 mg capsule,extended release 24hr - one
Capsule(s) by mouth once per day
ZONISAMIDE - 25 mg capsule - 1 Capsule(s) by mouth twice a day
ZONISAMIDE - 50 mg capsule - 1 Capsule(s) by mouth twice per day
increase to twice a day after 1 week
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - Dosage uncertain
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Carbidopa-Levodopa (25-100) 2 TAB PO QID
3. Citalopram 20 mg PO DAILY
4. Simvastatin 40 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Zonisamide 100 mg PO DAILY
7. Acetaminophen 650 mg PO Q4H:PRN fever, pain
8. Docusate Sodium 100 mg PO BID
9. Milk of Magnesia 30 ml PO HS:PRN constipation
10. Oxycodone-Acetaminophen (5mg-325mg) [**11-22**] TAB PO Q4H:PRN pain
11. Ranitidine 150 mg PO BID Duration: 1 Months
12. Furosemide 40 mg PO DAILY Duration: 10 Days
13. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
Discharge Disposition:
Extended Care
Facility:
clipper [**Hospital1 **] of [**Location (un) **] care and rehabilitation center
Discharge Diagnosis:
aortic stenosis
-redo sternotomy/AVR(#23mm St.[**Male First Name (un) 923**] porcine) on [**2146-7-22**]
-CAD, s/p CABG x 3 ([**2137**])
-hyperlipidemia
-sick sinus syndrome
-Parkinson's (rt hand tremors, RLE weakness, speech hesitancy)
-[**Year (4 digits) 499**] Ca s/p [**Year (4 digits) 499**] resection
- exlap for twisted bowel
-vein ligation
-vertebral fracture T5-6-7 secondary to fall, s/p fusion
-right arm fracture
-tonsillectomy
-left ankle fracture
-varicella zoster rt torso [**6-2**]
Previous Cardiac Surgery?: [**2137**] CAGGx3- LIMA-LAD, SV-PDA,SV-OM1
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema -trace bilat LE 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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 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**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Last Name (LF) **], [**First Name3 (LF) **] [**Telephone/Fax (1) 1504**] on [**8-17**] @1:30PM
Cardiologist: [**Last Name (LF) **], [**Name8 (MD) **] MD ([**Location (un) 34004**] cardiology, ME)on [**9-30**]
@11:20AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 35326**] in [**11-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2146-7-26**]
|
[
"V45.4",
"V15.88",
"414.00",
"V15.51",
"276.2",
"332.0",
"V15.82",
"V45.81",
"424.1",
"272.4",
"V58.66",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"35.21",
"88.49",
"37.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10350, 10456
|
7887, 9114
|
333, 423
|
11071, 11311
|
3080, 3080
|
12044, 12685
|
1901, 2087
|
9782, 10327
|
10477, 11050
|
9140, 9759
|
11335, 12021
|
3724, 5709
|
5753, 7864
|
2102, 2802
|
2818, 3061
|
270, 295
|
451, 1154
|
3096, 3708
|
1176, 1658
|
1674, 1885
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,092
| 103,810
|
44484
|
Discharge summary
|
report
|
Admission Date: [**2157-1-10**] Discharge Date: [**2157-2-1**]
Date of Birth: [**2090-12-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2157-1-24**] Aortic valve replacement (23mm St. [**Male First Name (un) 923**] mechanical) and
coronary artery bypass grafting x3 (LIMA-LAD, SVG-OM1-OM2)
[**2157-1-24**]
Left heart catheterization, coronary angiography [**1-18**]
History of Present Illness:
Mr. [**Known lastname 33733**] is a 66 year old gentleman who was admitted with a
non-healing ulcer on his heel. He subsequently underwent a
right below the knee amputation ([**8-30**]) with a prolonged
post-operative course. He was readmitted now with CHF and
catheterization was done to demonstrate left main and diffuse
three vessel disease. Echocardiography has demonstrated
critical AS as well. he was referred for surgical evaluation for
AVR/CABG.
Past Medical History:
insulin dependent diabetes mellitus
coronary artery disease -s/p MI
chroinc systolic CHF
atrial fibrillation
polyarthritis rheumatica,predisone dependent
peripheral vascular disease
s/p right BKA
s/p AICD implant
Social History:
Pt and wife live at home in [**Name (NI) 8117**], [**Name (NI) **]. Pt retired in [**11-28**]
from
his work as a manager in auto sales. He states he hopes to
return to his previous work part-time in the future. He has a
close family.
ETOH:denies
Tobacco: former use
Family History:
N/C
Physical Exam:
Admission:
VS: 96.2 68 137/67 18 99RA
Gen: NAD, pleasant
HEENT: EOMI, pupils reactive to light, R pupil slightly larger
than the left
CV: irreg irreg, no m/g/r
Pulm: CTA in upper fields b/l, crackles in bases
Abd: +BS, nt/nd, obese
Ext: R BKA; L foot digits [**12-26**] with dry gangrene on distal joints
top part of toes, similar ulcer on right heal.
Pulses
Rad Fem [**Doctor Last Name **] PT DP
R P P dop
L P P dop dop dop
Pertinent Results:
TTE (Complete) Done [**2157-1-12**] at 9:32:13 AM FINAL
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (LVEF = 20 %). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricle has moderate
global free wall hypokinesis. There is severe aortic valve
stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Carotid U/S - [**2157-1-18**]
IMPRESSION:
1. Antegrade flow in both vertebral arteries.
2. Occluded left ICA.
Cardiac Cath - [**2157-1-20**]
FINAL DIAGNOSIS:
1. Moderate left main and diffuse three vessel coronary artery
disease.
2. Moderate to severe aortic stenosis.
3. Low cardiac output/index.
4. Left ventricular systolic and diastolic dysfunction.
5. Severe pulmonary hypertension.
[**2157-1-31**] 04:03AM BLOOD WBC-13.3* RBC-2.86* Hgb-8.5*
[**Known lastname **],[**Known firstname **] [**Initial (NamePattern1) **] [**Known lastname **]. [**Age over 90 95331**] M 66 [**2090-12-8**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2157-2-1**] 10:52 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2157-2-1**] 10:52 AM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip #
[**Clip Number (Radiology) 95332**]
Reason: r/o cva
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with ? L visual field cut.
REASON FOR THIS EXAMINATION:
r/o cva
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: DBH TUE [**2157-2-1**] 3:14 PM
PFI: 1. Left posterior temporal lesion likely old ischemia.
2. Left internal carotid artery completely occluded at its
origin.
Preliminary Report !! PFI !!
PFI: 1. Left posterior temporal lesion likely old ischemia.
2. Left internal carotid artery completely occluded at its
origin.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
PFI entered: TUE [**2157-2-1**] 3:14 PM
Imaging Lab
Hct-26.4* MCV-92 MCH-29.6 MCHC-32.1 RDW-16.8* Plt Ct-336
[**2157-1-31**] 04:03AM BLOOD Glucose-51* UreaN-21* Creat-0.8 Na-136
K-4.0 Cl-101 HCO3-33* AnGap-6*
Brief Hospital Course:
Mr [**Known lastname 33733**] is a 66 year old male with known severe PVD, DM,
severe AS, CHF, who was admitted with LLE gangrene. He
underwent a right below the knee amputation. During this
admission the patient developed acute CHF and ARF. He was found
to have severe AS and multivessel CAD and on [**2157-1-24**] he underwent
an aortic valve replacement (#23mm St.[**Male First Name (un) 923**] Mechanical) and
coronary artery bypass grafting times three
(Lima->LAD/SVG->OM1-OM2sequential). Please refer to Dr. [**Doctor Last Name 95333**] operative report for further details. He
tolerated the procedure well and was transferred in critical but
stable condition to the surgical intensive care unit. He awoke
neurologically intact, pressors were weaned and he was extubated
on post-operative day one. Mr.[**Known lastname 33733**] was placed on stress dose
steroids for his polymyalgia rheumatica and was seen in
consultation by [**Last Name (un) **] for elevated blood sugars. He required
aggressive diuresis with a lasix drip. Electrophysiology
interrogated his internal pacemaker and his epicardial wires
were removed. Coumadin and heparin were started for the
mechanical aortic valve and atrial fibrillation. On POD#4
Mr.[**Known lastname 33733**] was transferred to the surgical step down floor. The
lasix drip was weaned to off. [**1-30**] Mr.[**Known lastname 33733**] complained of poor
visual focus in the mornings. An Ophthalmology consult was done
and he was found to have a normal exam. Neurology was also
consulted and felt it was likely due to fluctuating blood
sugars. [**2-1**] a Head CTA was done which confirmed a previous
ischemic event. No new changes.Neurology cleared Mr.[**Known lastname 33733**] for
discharge to rehab. He also experienced diarrhea toward the end
of his stay and tested positive for clostridium difficile. He
was placed on flagyl. The steroid taper was completed and he
was placed on his home maintenance dose of hydrocortisone. By
post operative day #8, [**2-1**] he was ready for transfer to a rehab
facility for increase in strength, endurance and daily
activities.All follow up appointments were advised.
Medications on Admission:
#. Warfarin stopped on [**2157-1-7**], unclear reason
#. Carvedilol 12.5'
#. Spironolactone 12.5'
#. Captopril 12.5"
#. Rosuvastatin 5'
#. Furosmide 80'
#. Digoxin 0.125mg QOD
#. K-DUR 20'
#. Magnesium oxide
#. Hydrocortisone 10' for PMR,
#. Insulin glargine 32 QHS
#. Novolog SS
#. Citalopram 20'
#. Pantoprazole 40"
#. Oxycodone
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. Warfarin 1 mg Tablet Sig: 7.5 Tablets PO DAILY (Daily):
titrate for an INR goal of 2.5-3.5 for an aortic mechanical
valve.
17. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous at bedtime.
Disp:*qs units* Refills:*2*
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous four times a day: per sliding scale.
19. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days: dc on [**2-8**].
22. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
x 1 week.
23. 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.
24. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
s/p aortic valve replacement & coronary artery bypass grafts
coronary artery disease
peripheral vascular disease
Acute on chronic heart failure- LVEF 20%
Severe Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation
history of perpherial vascular disease with left foot gangrenous
changes,s/p rt. BKA
s/p AICD [**11/2156**] ([**Company 2267**])
insulin dependent diabetes mellitus
atrial fibrillatiion
h/o polymyalgia rheumatica- prednisone dependent
clostridium difficile colitis
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 100.5
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 one month and off all narcotics
No lifting more than 10 pounds for 10 weeks
take all medications as directed
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] ([**Telephone/Fax (1) 14585**] for left lower extremity
vasculature in 1 month.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95334**] PCP ([**Telephone/Fax (1) 95335**] in [**12-24**] weeks.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14715**] Cardiology([**Telephone/Fax (1) 95336**] in [**12-24**] weeks.
Dr. [**Last Name (STitle) **] Cardiac Surgeon([**Telephone/Fax (1) 11763**] in [**3-28**] weeks.
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2157-2-1**]
|
[
"424.1",
"707.15",
"357.2",
"V45.02",
"440.24",
"V49.75",
"725",
"428.0",
"414.2",
"424.2",
"584.9",
"427.31",
"250.60",
"285.9",
"412",
"272.4",
"440.4",
"V45.82",
"008.45",
"428.23",
"414.01",
"V58.67",
"276.1",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.42",
"35.22",
"36.12",
"88.56",
"36.15",
"39.61",
"88.48",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
9454, 9484
|
4739, 6902
|
327, 561
|
10015, 10022
|
2094, 3138
|
10576, 11273
|
1586, 1591
|
7284, 9431
|
3911, 3954
|
9505, 9994
|
6928, 7261
|
3155, 3871
|
10046, 10553
|
1606, 2075
|
280, 289
|
3986, 4716
|
589, 1047
|
1069, 1283
|
1299, 1570
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,282
| 112,078
|
42929
|
Discharge summary
|
report
|
Admission Date: [**2130-3-20**] Discharge Date: [**2130-3-31**]
Date of Birth: [**2080-6-9**] Sex: F
Service: SURGERY
Allergies:
Tegretol
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Coffee Ground Emesis
Urinary Tract Infection
Fever
Hypotension
Major Surgical or Invasive Procedure:
Right subclavian central line
History of Present Illness:
49 F with developmental delay, RA, paraplegia [**2-10**] L1-L2
compression fx, anasarca [**2-10**] FSGS, s/p recent prolonged
hospitalization from [**2130-1-25**] to [**2130-3-15**]. The discharge summary
was reviewed, and is briefly summarized below.
.
She initially presented with diffuse edema involving the entire
body, that had worsened over the past 2-3 months. She was found
to have FSGS by renal biopsy. Her hospitalization was also
significant for an L1-L2 vertebral compression fracture with
near paralysis of her lower extremities. She underwent T10-L4
posterior fusion that was complicated by wound infection and VRE
bacteremia. She underwent wound exploration with incision and
debridement on [**3-10**]. She was discharged to [**Hospital1 **] on
[**3-15**] to complete a course of linezolid.
.
At [**Hospital1 **], she was found to have a UTI and was
started on Amikacin on [**3-19**]. Also had multiple episodes of
emesis o/n. Febrile to 102.7 at 01:00 on [**3-20**]. Then on am of
[**3-20**], had approx 200 cc of coffee ground emesis. Sent to [**Hospital1 18**]
for further management.
.
In [**Hospital1 18**] ED, NG lavage with return of blood that did not clear
after 500 cc saline. Received 2L NS for BP 84/64, and levoflox /
Flagyl. Also received 2 units FFP for INR 1.4.
.
Admitted to MICU where bedside EGD showed grade 3 esophagitis
without active bleed.
Past Medical History:
1. Osteoarthritis.
2. Rheumatoid arthritis.
3. Osteoporosis with vertebral compression fractures - normal
BMD at the femoral neck, osteopenia at the trochanter, and
osteoporosis at the total hip ([**2129**])
4. Developmental delay.
6. Sleep apnea; since [**2116**] on nocturnal ventilation with BiPAP
at 18/12 cm H20 plus 4 liters of nasal cannular oxygen titrated
in, else will desaturate to 45%
7. Obesity.
8. History of leg ulcers.
9. Leg swelling - since [**2116**], followed by podiatry and vascular
surgery (Dr. [**Last Name (STitle) **]
10. Pilonidal cyst removal - [**2117**], complicated by wound
dehiscence
11. R knee replacement - [**2126**]
12. SLE - dx [**2120**], diagnosis not documented well
Social History:
Developmentally delayed. Had been living with mother and sister
until recent hospitalization, now at [**Hospital1 **].
Family History:
Non-contributory
Physical Exam:
Vitals - T 98.1, BP 119/66, HR 99, RR 29, O2 sat 100% on 2L NC,
wt 87.6 kg
General - obese female, appears comfortable, in NAD, speeking
full sentences
HEENT - PERRL, OP clr, MM sl dry
Chest - CTAB
CV - RRR, nl s1, s2, no m/r/g
Abdomen - NABS, soft, mild tenderness to palpation in RLQ, no
g/r
Extremities - diffuse 3+ bilat edema
Back - incision intact, with serous drainage from inferior
aspect; min surrounding erythema at inferior; ~4cm R gluteal
stage II decub with serousanguinous drainage with min
surrounding erythema
Pertinent Results:
Admission Labs:
[**2130-3-20**] 12:30PM BLOOD WBC-25.1*# RBC-3.28* Hgb-9.4* Hct-29.7*
MCV-91 MCH-28.8 MCHC-31.8 RDW-15.8* Plt Ct-281
[**2130-3-20**] 12:30PM BLOOD PT-15.7* PTT-33.4 INR(PT)-1.4*
.
Labs at Transfer From MICU to Floor
[**2130-3-25**] 05:36AM BLOOD WBC-12.6* RBC-3.22* Hgb-9.5* Hct-28.4*
MCV-88 MCH-29.4 MCHC-33.3 RDW-16.6* Plt Ct-173
[**2130-3-25**] 05:36AM BLOOD Neuts-89.8* Lymphs-7.2* Monos-2.2 Eos-0.7
Baso-0.2
[**2130-3-25**] 05:36AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
[**2130-3-25**] 05:36AM BLOOD PT-15.5* PTT-37.3* INR(PT)-1.4*
[**2130-3-25**] 05:36AM BLOOD Glucose-101 UreaN-3* Creat-0.2* Na-141
K-4.1 Cl-112* HCO3-25 AnGap-8
[**2130-3-25**] 05:36AM BLOOD ALT-7 AST-5 LD(LDH)-213 AlkPhos-92
TotBili-0.3
[**2130-3-25**] 05:36AM BLOOD Albumin-1.6* Calcium-8.1* Phos-2.7 Mg-2.2
.
CHEST (PORTABLE AP) [**2130-3-20**] 12:52 PM
AP CXR: Nasogastric tube has been placed, coiling in the
proximal stomach. Cardiac and mediastinal contours are stable
allowing for marked patient rotation. No focal areas of
consolidation within the lungs, and there are no definite
pleural effusions. Right costophrenic angle has been excluded
from the study and cannot be assessed. Mild elevation of right
hemidiaphragm is noted.
.
CHEST (PORTABLE AP) [**2130-3-25**] 5:55 AM
1. Slightly increased right pleural effusion, unchnaged left
pleural effusion.
2. Mild interstitial pulmonary edema, stable.
.
CT L-SPINE W/ CONTRAST [**2130-3-21**] 12:02 PM
IMPRESSION: While no abnormal enhancement is noted, significant
metallic streak artifact and subcutaneous soft tissue stranding
extending down to the spinal canal is present. It is
indeterminate how much of this represents postoperative change
vs. possible infection/phlegmon.
.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2130-3-21**] 11:43 AM
1. Acute cholecystitis.
2. Bilateral small pleural effusions and adjacent atelectasis.
3. Right adrenal mass, unchanged.
4. Abdominal rectus sheath hematoma and left-sided abdominal
wall fluid collection, unchanged.
5. Status post posterior fusion of multiple thoracolumbar
vertebrae,
unchanged in construct from [**2130-3-2**].
.
ECG (MICU admission [**3-20**]):
Sinus tach @ 114; baseline artifact; diffuse TWF across
precordium; aside from tachycardia, no change from [**2130-2-9**]
.
EGD (MICU admission [**3-20**]):
Impression: Grade 3 esophagitis in the lower third of the
esophagus and middle third of the esophagus. Otherwise normal
EGD to second part of the duodenum.
.
[**2130-3-23**] 8:24 am STOOL
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2130-3-23**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2130-3-21**] 6:12 pm SWAB Source: sacral.
Staphylococcus aureus and beta streptococcus).
PROBABLE ENTEROCOCCUS. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
YEAST. RARE GROWTH.
.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
.
ANAEROBIC CULTURE (Final [**2130-3-25**]): NO ANAEROBES ISOLATED.
.
Brief Hospital Course:
She was admitted to MICU under the care of the Medicine Service.
A bedside EGD was performed which showed grade 3 esophagitis
without active bleed, and UGI bleed resolved with PPI's. Her
Hct was stable at 28 after receiving 2units of FFP (in ED) and
2units of PRBC (on the floor). Her hypotension was persistent
thought secondary to her cholecystitis seen on her abdominal CT
as well as her MDR-resistant pseudomonal UTI. A CVL was placed
and she was started on Levophed for blood pressure support. She
was continued on Amikacin for her pseudomonal UTI and started on
Zosyn for her cholecystitis. Her linezolid from a previous VRE
bacteremia was continued until [**3-24**]. General Surgery was
consulted and initially felt that she did not require surgical
intervention at the time and she was planned for percutaneous
cholecystotomy.
She managed to defervesce without percutaneous drainage and was
weaned off pressors on [**3-23**] and her blood pressure normalized.
Foley was changed and repeat UA improved. A one week course of
Amikacin was completed for her pseudomonal UTI, her course of
Linezolid completed on [**3-24**], and she was transferred to the
floor on Zosyn.
She was re-evaluated by General Surgery on [**3-26**], the decision to
proceed with a lap chole on [**3-27**] was made. She was taken to the
operating room where the laporascopic chole was converted into
an open cholecystectomy secondary to a gangrenous gallbladder.
Postoperatively her care was transferred to the General Surgery
service.
Her staples were removed on day of discharge; she will require
follow up with Dr. [**Last Name (STitle) **] mid [**Month (only) 547**].
On HD#10 she was given a clear diet, this was slowly advanced.
Her nutritional status will require close monitoring; it is
being recommended that calorie counts be initiated once at
rehab. She had been on Megace prior to hospitalization, this was
restarted prior to her discharge. Boost Plus supplements have
also been added to her diet. She previously had a rectal tube
that was placed while on the Medicine service; this was
discontinued.
She was hypernatremic with a Na of 148 during her early
hospitalization while on the Medicine service; it was felt
iatrogenic secondary to IV fluid. Her last Na on [**3-30**] was 143.
She did require intermittent IV Lasix for diuresis and was
continued on 20 mg IV BID. Her Lasix was changed to 20 mg po
daily; she was not on this medication prior to her
hospitalization. It is being continued as she still has some
volume overload issues; continued use should be re-evaluated
once her volume status stabilizes.
Physical and Occupational therapy consults were placed and they
have recommended rehab stay after her acute hospitalization.
Medications on Admission:
Cyanocobalamin 1000 mcg SQ Q30d
Aranesp 0.06 mg SQ QTh
fondaparinox 2.5 mg SQ QD
Zofran 8 mg IV Q8h PRN
Amikacin 250 IV Q12h
Lipitor 80 QD
Iron 300 QD
Vit D 50000Qsu
Megace 400 QD
Linezolid 600 [**Hospital1 **]
Calcium 500 TID
Reglan 10 Q6h prn
Senna [**Hospital1 **]
Colace 100 [**Hospital1 **]
Bisacodyl 5 QD
Calcitriol 0.25 QD
Lisinopril 5 QD
MVI QD
Vit C 500 [**Hospital1 **]
Tylenol prn
Calcitonin 200 IU QD
Dilaudid [**2-12**] PO Q4h prn
Ketoconazole 2% cream
Ketoconazole 2% shampoo
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per insulin sliding
scale.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Erythromycin 5 mg/g Ointment Sig: One (1) dose Ophthalmic QID
(4 times a day): administer OS.
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
10. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
11. Megace Oral 40 mg/mL Suspension Sig: Ten (10) ML's PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Upper GI Bleed
MDR-psuedomonal Urinary Tract Infection (sensitive to amikacin)
VRE Wound Infection
Sepsis
Acute Cholecystitis
Discharge Condition:
Stable
Followup Instructions:
Follow up next with Dr. [**Last Name (STitle) **] in General Surgery Clinic; call
[**Telephone/Fax (1) 92654**] to schedule a time for this appointment for
sometime in [**Month (only) 547**].
Previous scheduled appointments:
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2130-3-28**] 11:30
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 16624**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2130-5-1**] 2:00
.
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2130-5-22**] 3:00
Completed by:[**2130-3-31**]
|
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icd9cm
|
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10841, 10913
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2527, 2647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,345
| 140,097
|
55152
|
Discharge summary
|
report
|
Admission Date: [**2107-10-11**] Discharge Date: [**2107-10-19**]
Date of Birth: [**2025-1-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Pacemaker pocket infection
Major Surgical or Invasive Procedure:
Pacemaker explantation [**2107-10-13**]
Cardiopulmonary resuscitation (CPR), intubation
History of Present Illness:
82 y/o male with permanent afib with h/o stroke currently on
warfarin, [**Month/Day/Year **] sinus syndrome s/p single-chamber pacemaker
implantation [**2-/2105**], heart failure, presents with swelling
around site of single chamber st. [**Male First Name (un) **] pm, referred by Dr. [**Last Name (STitle) **]
with concern for pocket infection & plans to explant device.
Pacemaker was placed in [**2105-2-23**] by Dr. [**Last Name (STitle) 1140**] at [**Hospital3 19345**] for atrial fibrillation w/ [**Hospital3 **] sinus syndrome. Had
bleeding but no infection. No recent manipulations. A few
weeks ago developed swelling and redness at pacemaker site.
Mode of pacer set to VVIR with lower pacing rate of 60 bpm.
Pacing only 11% of the time mostly at night. Takes warfarin due
to afib with hx of TIA.
[**2107-8-30**] presented to office feeling tired and having dyspnea with
moderate exertion. Ordered for Lexiscan and Echo.
[**2107-10-5**] echo: LVEF is 42%, mild concentric LVH, left and right
atrium mild mildly dilated. Mild MR. Mild septal hypokinesis.
Changed from [**11-3**] echo: LVEF normal 56% with mild concentric
LVH
[**2107-9-27**]: Lexiscan: Normal perfusion, normal systolic function,
negative ECG.
Blood cultures drawn [**9-28**] were negative, ESR 20. Denies fevers,
chills, rash, decreased appetite, weight loss.
Also complains of orthopnea, edema, PND. Started on lasix on
[**10-5**] with some improvement in symptoms. Referred by Dr.
[**Last Name (STitle) 5017**] for device explantation.
On arrival to the floor, patient denies any acute complaints.
Mild pacemaker pain.
REVIEW OF SYSTEMS
ROS: negative for fevers, chills, chest pain, palpitations,
weight loss, rash, joint pains, lower extremity cramping or pain
when walking
positive for orthopnea, PND, lower extremity edema, weight gain,
worsening cough for the past 2 weeks
Past Medical History:
# Congestive heart failure - LVEF 42% on [**2107-10-5**], mild
concentric LVH, mild septal hypokinesis, changed from [**11-3**]
echo: normal LVEF 56%
# permanent Afib on warfarin
# h/o stroke [**2-/2105**] - persistent memory problems and swallowing
problems
# [**Name2 (NI) **] sinus syndrome s/p St. [**Male First Name (un) 923**] single chamber pacemaker
# Hypertension
# Hyperlipidemia
# HX-PROSTATIC MALIGNANCY, s/p TURP, suprapubic catheter
# HX OF IRRADIATION
# JOINT DIS NEC-PELVIS
# OSTEITIS DEFORMANS NOS
# MITRAL VALVE disorder
Social History:
Lives with wife, uses [**Name2 (NI) **] to ambulate outside the house,
independent inside the house
-Tobacco history: Smoked 0.5 ppd for 20 years, quit at age 37.
-ETOH: none
-Illicit drugs: none
Family History:
Mother died of heart failure
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS- T 97.6 BP 150/91 P 79, R 20, O2 100%RA
GENERAL- WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with JVP of [**9-2**] cm.
CARDIAC- normal s1, s2, irregularly irregular rate. no m/r/g
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- trace bilateral edema
soft tissue swelling palpated over entire surface of pacemaker,
mild erythema on skin surface, mildly tender to palpation. no
distinct fluid collection. no drainage.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ PT 2+
Left: Carotid 2+ PT 2+
GU: suprapubic catheter
DISCHARGE PHYSICAL EXAMINATION
Pertinent Results:
ADMISSION LABS
[**2107-10-11**] 04:15PM BLOOD WBC-5.0 RBC-5.10 Hgb-14.8 Hct-45.5 MCV-89
MCH-29.0 MCHC-32.6 RDW-14.8 Plt Ct-182
[**2107-10-11**] 04:15PM BLOOD Neuts-71.2* Lymphs-19.7 Monos-7.2 Eos-1.2
Baso-0.8
[**2107-10-11**] 04:15PM BLOOD PT-33.9* PTT-47.3* INR(PT)-3.3*
[**2107-10-11**] 04:15PM BLOOD Glucose-142* UreaN-27* Creat-1.2 Na-139
K-3.8 Cl-102 HCO3-27 AnGap-14
[**2107-10-11**] 04:15PM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0
CARDIAC ENZYMES
[**2107-10-11**] 04:15PM BLOOD cTropnT-0.07*
[**2107-10-12**] 06:19AM BLOOD cTropnT-0.07*
[**2107-10-13**] 11:50AM BLOOD cTropnT-0.05* proBNP-2460*
[**2107-10-13**] 10:20PM BLOOD CK-MB-4 cTropnT-0.06*
[**2107-10-14**] 03:59AM BLOOD CK-MB-5 cTropnT-0.06*
BLOOD GASES
[**2107-10-13**] 11:03AM BLOOD Type-ART pO2-70* pCO2-83* pH-7.16*
calTCO2-31* Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2107-10-13**] 11:55AM BLOOD Type-ART pO2-126* pCO2-48* pH-7.26*
calTCO2-23 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED
[**2107-10-13**] 12:47PM BLOOD Type-ART Temp-36.4 Rates-/18 Tidal V-460
FiO2-100 pO2-233* pCO2-35 pH-7.42 calTCO2-23 Base XS-0 AADO2-454
REQ O2-77 Intubat-INTUBATED Vent-CONTROLLED
[**2107-10-13**] 11:03AM BLOOD Glucose-165* Lactate-1.7 Na-135 K-4.0
Cl-101 calHCO3-29
[**2107-10-13**] 12:47PM BLOOD Lactate-1.0
[**2107-10-13**] 11:50AM BLOOD Fibrino-315
DISCHARGE LABS:
IMAGING
[**2107-10-11**] CHEST X-RAY
IMPRESSION: PA and lateral chest reviewed in the absence of any
prior chest imaging studies.
Transvenous right ventricular pacer lead terminates along the
anterior wall of the right ventricle. Heart is moderately
enlarged, predominantly left atrial. Mild interstitial
abnormality could be chronic. There is no appreciable vascular
congestion or any pleural effusion to suggest that it is acute
edema. Right upper costal pleural thickening could be
asbestos-related plaque, but there are no other findings to
suggest asbestos-related diseases.
[**2107-10-13**] CHEST X-RAY
IMPRESSION: New endotracheal tube in appropriate position. New
hilar and juxta patchy opacities, compatible with pulmonary
edema.
[**2107-10-13**] TTE
Preoperative:
The left atrial appendage emptying velocity is depressed
(<0.2m/s). No thrombus is seen in the left atrial appendage.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened with fusion between the left and
noncoronary cusps. There is mild aortic valve stenosis (valve
area 1.5 cm2). Trace aortic regurgitation is seen. Mild to
moderate ([**1-24**]+) mitral regurgitation is seen with vena contracta
of 0.6 cm. Estimated Ejection Fraction is 40% with moderate
global hypokinesis. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2107-10-13**] at
1000.
Post operative:
There is no pericardial effusion post lead extraction. There is
no evidence of new or worsened tricuspid insufficiency.
[**2107-10-15**] CHEST X-RAY
REASON FOR EXAMINATION: Flash pulmonary edema clinically.
Portable AP radiograph of the chest was compared to [**10-14**], [**10-13**], [**2107**].
Cardiomegaly is unchanged. Mediastinum is stable. Minimal
interstitial edema is seen, but no overt alveolar pulmonary
edema is present. Atelectasis in the left perihilar area has
improved. No interval increase in pleural effusion or
development of pneumothorax is present.
DISCHARGE LABS
[**2107-10-17**] 06:27AM BLOOD WBC-7.2 RBC-5.09 Hgb-14.6 Hct-45.1 MCV-89
MCH-28.7 MCHC-32.4 RDW-14.8 Plt Ct-211
[**2107-10-17**] 06:27AM BLOOD PT-23.0* PTT-39.6* INR(PT)-2.2*
[**2107-10-17**] 06:27AM BLOOD Glucose-101* UreaN-37* Creat-1.1 Na-136
K-4.3 Cl-97 HCO3-30 AnGap-13
[**2107-10-17**] 06:27AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
MICROBIOLOGY:
[**2107-10-13**] 11:40 am
SWAB LEFT PACER: Per ID = consistent with skin flora
GRAM STAIN (Final [**2107-10-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
IDENTIFICATION AND SENSITIVITY TESTING PER DR. [**Last Name (STitle) **]
([**Numeric Identifier **]).
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SECOND MORPHOLOGY.
GRAM POSITIVE RODS. SPARSE GROWTH. UNABLE TO IDENTIFY
FURTHER.
ANAEROBIC CULTURE (Final [**2107-10-17**]): NO ANAEROBES ISOLATED.
FINAL NEGATIVE:
[**2107-10-13**] MRSA SCREEN MRSA SCREEN-FINAL
[**2107-10-13**] FOREIGN BODY WOUND CULTURE-FINAL
[**2107-10-12**] SWAB R/O VANCOMYCIN RESISTANT
ENTEROCOCCUS-FINAL
[**2107-10-11**] BLOOD CULTURE Blood Culture, FINAL
[**2107-10-11**] BLOOD CULTURE Blood Culture, FINAL
Brief Hospital Course:
82 y/o male with permanent afib with h/o stroke/TIA currently on
warfarin, [**Numeric Identifier **] sinus syndrome s/p single-chamber pacemaker
implantation [**2-/2105**], recently diagnosed heart failure (EF 44%),
presents with swelling around site of single chamber st. [**Male First Name (un) **]
pm, referred by Dr. [**Last Name (STitle) **] with concern for pocket infection with
plan to explant device.
# PACEMAKER POCKET SWELLING / INFECTION: Pt had [**Last Name (STitle) **] sinus
syndrome s/p single-chamber pacemaker implantation 2/[**2105**].
Onset of swelling several weeks prior to admission. Seemed to
be isolated pocket infection given no systemic signs/symptoms,
leukocytosis or fevers, negative blood cultures, duration and
indolence. Blood cultures on [**9-28**] negative. Blood cultures on
[**10-11**] negative. Consulted ID, who recommended no antibiotics
given as this is likely chronic infection without systemic
spread. Successful pacemaker explantation [**2107-10-13**], but after
extubation, had cardiopulmonary arrest (detailed below). No
frank pus in pocket on explantation. Culture of pacemaker
showed sparse growth of coag-negative staph, consistent with
skin flora. Got 1 dose IV vancomycin after explantation but no
further antibiotics; did not spike fevers or develop
leukocytosis, so infection is unlikely; unclear why he developed
swelling, warmth, and erythema at site, so perhaps he had an
indolent infection. The device has been removed so source
control achieved. Normally, would cover for skin flora, however,
the risk of antibiotics seems to outweigh the benefits,
especially since suspicion for persistent infection is low.
Bactrim is associated with severe increased risk of bleeding
when given with warfarin, doxycycline is associated with
moderate risk. If patient develops fever or signs/symptoms of
infection, would empirically treat with doxycycline 100mg q12h
for 7-10 days, and monitor INR daily because of moderate
increased risk of bleeding while concurrently on warfarin.
# Hematoma - developed hematoma post-op; expanded on POD3; dc'ed
heparin gtt, applied pressure & applied pressure dressing;
stabilized, no need to evacuate. Continue wound care and
application of pressure as needed.
# Afib with slow ventricular response ([**Month/Day/Year **] sinus syndrome, s/p
pacemaker placement in [**2105**]), h/o stroke/TIA. On warfarin at
home, supratherapeutic on admission, held warfarin and bridged
with hep gtt for procedure. After the procedure, heparin gtt &
warfarin were initially held given rib fracture but restarted on
[**10-14**], heparin gtt discontinued [**10-16**] once therapeutic on
coumadin. Prior to explantation, pacemaker settings adjusted,
rate reduced to 30bpm to evaluate for pacemaker dependence. On
interrogation, he was pacemaker dependent only 11% of the time.
Discharged with [**Doctor Last Name **] of Hearts monitor to evaluate need to
replace pacemaker. Pt will follow-up with EP Dr. [**Last Name (STitle) **] to decide
whether he will need replacement of pacemaker 2 weeks after
discharge.
# CARDIOPULMONARY ARREST: After explantation of device without
complications, in the PACU, after extubation, pt was alert,
interactive. Pt developed progressive dyspnea, then respiratory
failure, CXR confirmed pulmonary edema. Reintubated. Went into
PEA arrest, coded, CPR performed for 15 sec, with return of
pulse, ribs were broken. Bedside TTE done, no gross
abnormalities. SBP in 80s. Transferred to CCU for further
management. Likely etiology is flash pulmonary edema in the
setting of peri-operative catecholaminergic surge, hypertensive
with SBP to 190s leading to respiratory failure and subsequent
PEA arrest.
CCU Course:
The patient was admitted to CCU from [**Hospital1 1516**] on [**10-13**] and was
transferred back to [**Hospital1 1516**] on [**10-15**]. Given risk of infection and
poor utilization, EP planned for extraction on [**10-13**]. During the
procedure, lead removal was uncomplicated, and no pus was noted
around pacer. He received vancomycin and cefazolin during the
procedure. After the procedure, patient became hypertensive to
200s systolic. This was followed by hypoxemic respiratory
distress (likely due to flash pulmonary edema), PEA Arrest with
ROSC after 15s with compressions, no shock, and intubation. His
BP dropped to the 60s systolic. After intubation, pt was given
Lasix 20 mg x 1 dose, and started on phenylephrine. On arrival
to the CCU, the patient's BP was 118/69. Overnight, he was
weaned off the pressor. He was further diuresed in the CCU, and
he was net over 2 L negative on [**10-13**]. On the morning of [**10-14**],
he was weaned off sedation and was successfully extubated. His
warfarin was restarted. He was given oxycodone for rib pain.
On [**10-15**], we put him back on his home dose of Lasix 20mg PO daily
and also started lisinopril 2.5mg daily. He was transferred
back to [**Hospital1 1516**] in stable condition for further management.
# MIXED SYSTOLIC/DIASTOLIC CONGESTIVE HEART FAILURE - acute on
chronic systolic and diastolic congestive heart failure. 1.5
weeks prior to admission, developed heart failure symptoms,
started on PO lasix with improvement of sx. [**2107-10-5**] TTE showed
new depressed systolic function LVEF 44% (compared to 55%
10/[**2106**]). DDx: ischemia (no chest pain, EKG stable, stable
cardiac enzymes), progression of hypertensive cardiomyopathy.
Pt had recent regadenoson stress test in early [**Month (only) **] which
was read as normal, normal EF and no signs of ischemia. This
makes ischemia less likely. Per discussion with outpatient
cardiologist, the recent TTE may have been overread, and he does
not think there is new systolic dysfunction. Patient does have
concentric LVH. Most likely, pt has mixed sys/[**Last Name (un) **] heart
failure [**2-24**] to hypertensive cardiomyopathy. [**2107-10-13**] TTE showed
Ejection Fraction is 40% with moderate global hypokinesis.
Developed flash pulm edema post-procedure as above. Diuresed a
total 3L, restarted home lasix. STARTED lisinopril 5mg daily.
# Ventricular tachycardia: intermittent runs of VT on tele (17
beat run of VT on [**10-12**]) asymptomatic. Monitored on tele and
repleted electrolytes prn.
TRANSITION OF CARE ISSUES
- You will have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor until you can be seen
by Dr. [**Last Name (STitle) **] to evaluate whether you will need a new pacemaker.
- Continue anticoagulation with warfarin and follow-up with Dr.
[**Last Name (STitle) 40797**] once discharged from rehab.
- If patient develops fever or signs/symptoms of infection,
would empirically treat with doxycycline 100mg q12h for [**8-2**]
days, and monitor INR daily because of moderate increased risk
of bleeding while concurrently on warfarin.
- If concerned for expanding hematoma, apply pressure, inform
Dr. [**Last Name (STitle) **]
- Please make sure patient has suprapubic catheter changed at
appointment listed on discharge planning on [**2107-10-24**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Multivitamins 1 TAB PO DAILY
2. Vitamin D 4000 UNIT PO DAILY
3. Warfarin 2.5 mg PO DAILY16
4. Simvastatin 20 mg PO DAILY Start: in pm
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Alendronate Sodium 70 mg PO QMON
7. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
8. Furosemide 20 mg PO DAILY
Hold for SBP<90
Discharge Medications:
1. Alendronate Sodium 70 mg PO QMON
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Furosemide 20 mg PO DAILY
Hold for SBP<90
4. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
5. Multivitamins 1 TAB PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Vitamin D 4000 UNIT PO DAILY
8. Psyllium Wafer 1 WAF PO DAILY
9. Warfarin 2.5 mg PO DAILY16
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 1 TAB PO BID:PRN constipation
15. Lisinopril 2.5 mg PO DAILY
hold for SBP <90
Discharge Disposition:
Extended Care
Facility:
Nevins Nursing and Rehabilitation Center
Discharge Diagnosis:
Pacemaker pocket infection
Cardiopulmonary arrest due to flash pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or [**Name (NI) **]).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure being involved in your care during your
hospitalization for pacemaker pocket infection. You had your
pacemaker taken out for concern of infection. Luckily there were
no signs of infection during or after the procedure.
After the procedure, you developed respiratory distress from
fluid going into your lungs and had a short period where your
heart stopped. You were intubated until you were able to
breathe well on your own. You went to the coronary care unit
where you received lasix to help with the fluid in the lungs and
were able to be extubated without issue.
TRANSITION OF CARE ISSUES
- Your rehab facility will set you up with an appointment to see
your primary care physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] will have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor until you can be seen
by Dr. [**Last Name (STitle) **] to evaluate whether you will need a new pacemaker.
- Continue anticoagulation with warfarin and follow-up with Dr.
[**Last Name (STitle) 40797**] once discharged from rehab.
- If concerned for increased swelling at surgical site, apply
pressure and inform Dr. [**Last Name (STitle) **]
The following changes were made to your medications:
START lisinopril for high blood pressure, diabetes
START oxycodone as needed for pain
Followup Instructions:
Please go to the following appointment to have your suprapubic
catheter changed:
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], NP
Location: [**University/College 5130**] Urology
Address: [**Location (un) 112504**], [**Location 9583**], MA
Phone: [**Telephone/Fax (1) 112505**]
Appointment: Monday, [**10-24**] at 10:20am
Please also follow up with your doctors at the following
appointments:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY
Address: [**Last Name (un) 39144**], STE#404, [**Hospital1 **],[**Numeric Identifier 39146**]
Phone: [**Telephone/Fax (1) 5424**]
Appointment: Tuesday [**2107-10-25**] 1:00pm
Department: CARDIAC SERVICES
When: FRIDAY [**2107-11-4**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: STUPNYTSKYI,OLEKSANDR
Address: [**Last Name (un) 39144**] [**Apartment Address(1) 75552**], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 83705**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Completed by:[**2107-10-20**]
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32,796
| 107,859
|
32774
|
Discharge summary
|
report
|
Admission Date: [**2133-1-29**] Discharge Date: [**2133-2-10**]
Date of Birth: [**2064-4-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
[**2133-1-30**] small bowel enteroscopy
[**2133-1-30**] mesenteric angiography, embolization of splenic artery
aneurysm
[**2133-2-2**] EGD, injection and fulguration of bleeding duodenal
ulcer
[**2133-2-4**] EGD, injection and fulguration of bleeding duodenal
ulcer
History of Present Illness:
Ms. [**Known lastname **] is a 68 y/o female who presented to an outside
hospital on [**2133-1-19**] complaining of abdominal and back pain, and
was found to have a large diverticular abscess. She underwent
CT guided drainage of the abscess, but continued to have
increased abd pain and elevated white count, so went to the OR
for sigmoid colectomy/hartmanns. She began to have stool output
from the ostomy on POD2, but on POD3 began putting out large
amounts of bloody stool. Hct was 15, so she was transferred to
the ICU, where she received multiple units of PRBC and FFP.
Multiple endoscopies were done which revealed only nonbleeding
gastric ulcers. Tagged RBC scan was negative. In total she
received 13 units of PRBC and 6 units of FFP before being
transfered to [**Hospital1 18**].
Past Medical History:
Sciatica, back pain
history of appendectomy.
Social History:
Pt lives alone, ambulates and drives independently. Pt quit
smoking in [**2105**], denies regular EtOH
Family History:
Noncontributory
Physical Exam:
On admission:
VS T 98.8; HR 89; BP 122/61; RR 15; O2 100% on 2L NC
Gen: Well appearing, NAD, A&Ox3
CV: RRR, No R/G/M
RESP: CTAB
ABD: Obese, soft, appropriately tender, midline infraumbilical
surgical incision with staples, no sign of wound infection,
minimal reaction around staples. LLQ ostomy device with melenic
output, RLQ JP with serosanguinous drainage
EXT: No edema
Pertinent Results:
[**2133-1-29**] 07:26PM WBC-16.2* RBC-2.76* HGB-8.3* HCT-23.8* MCV-86
MCH-30.0 MCHC-34.9 RDW-15.6*
[**2133-1-29**] 07:26PM PLT COUNT-277
[**2133-1-29**] 07:26PM PT-12.7 PTT-26.5 INR(PT)-1.1
[**2133-1-29**] 07:26PM GLUCOSE-203* UREA N-11 CREAT-0.6 SODIUM-137
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-33* ANION GAP-6*
[**2133-1-29**] 07:26PM ALT(SGPT)-13 AST(SGOT)-19 LD(LDH)-134 ALK
PHOS-36* AMYLASE-90 TOT BILI-0.3
[**2133-1-29**] 07:26PM LIPASE-208*
[**2133-1-29**] 07:26PM ALBUMIN-2.2* CALCIUM-7.5* PHOSPHATE-1.8*
MAGNESIUM-2.1
[**2133-1-29**] 07:26PM TRIGLYCER-84
***** [**1-30**] MESENTERIC ANGIOGRAM:
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman with upper GI bleed. Uppper endoscopy
demonstrates copious blood comming from the ampulla.
REASON FOR THIS EXAMINATION:
Please identify the source of bleeding into the biliary tree and
embolize as appropriate.
MESENTERIC ANGIO AND EMBOLIZATION
INDICATION: Upper GI bleeding from the ampulla by endoscopy from
the outside institution.
Details of the procedure and possible complications were
explained to the patient and her daughter and informed consent
was obtained.
RADIOLOGISTS: Dr. [**Last Name (STitle) 380**] and Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) 380**], staff
radiologist, was present for the entire procedure.
TECHNIQUE AND FINDINGS: Using sterile technique and local
anesthesia, the right common femoral artery was punctured and a
5 French sheath introduced over a guidewire using Seldinger
technique. A 5 French C2 glide catheter was then advanced over
the wire through the sheath and its tip engaged into the origin
of the celiac trunk. Arteriogram was then performed in different
projections. With the help of a glidewire, the catheter was then
advanced into the right hepatic artery and another arteriogram
was performed. The catheter was then repositioned into the left
hepatic artery and another arteriogram was performed in several
projections. The catheter was then repositioned into the
gastroduodenal artery and arteriogram was performed. The
catheter was then repositioned into the splenic artery and
arteriogram was performed in multiple different projections.
There was no evidence of active bleeding, pseudoaneurysm or
neovascularity in the right hepatic artery, left hepatic artery
and gastroduodenal artery. There is a small broad-based
pseudoaneurysm in the mid portion of the splenic artery without
evidence of active extravasation.
The findings were discussed with Dr. [**First Name (STitle) 2819**] and it was decided to
perform embolization of the splenic artery since no other
potential source of bleeding was detected. C2 glide catheter was
then advance with the help of a glidewire just distal to the
pseudoaneurysm. Multiple 8-mm and 6-mm coils were then
sequentially deployed into the splenic artery starting just
distal to the pseudoaneurysm with the last few coils placed
proximal to the pseudoaneurysm.
Followup arteriogram demonstrated occlusion of the splenic
artery and no opacification of the pseudoaneurysm or distal
splenic artery.
The catheter was then repositioned into the superior mesenteric
artery and arteriogram was performed. No abnormalities, active
extravasation, or aberrant/accessory vessels were identified in
the SMA territory.
The catheter was removed and the sheath was left in place with
side arm flush.
The patient tolerated the procedure well. There were no
immediate complications.
Moderate sedation was provided by administering divided doses of
200 mcg of Fentanyl and 3 mg of Versed throughout the
intraservice time of 3 hours during which the patient's
hemodynamic parameters were continuously monitored.
IMPRESSION: Small pseudoaneurysm without evidence of active
bleeding in the mid portion of the splenic artery, embolized
with multiple coils after discussion of the findings with Dr.
[**First Name (STitle) 2819**].
***** [**2-2**] CTA ABDOMEN/PELVIS
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman with GIB s/p splenic artery coiling
REASON FOR THIS EXAMINATION:
? abscess
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 68-year-old female with coil embolization of a splenic
artery aneurysm, for reassessment.
TECHNIQUE: CT of the abdomen and pelvis was performed without
intravenous contrast followed by CT of the abdomen and pelvis
post-administration of intravenous contrast, reconstructions
were performed in the axial, sagittal, and coronal planes.
COMPARISON: With angiogram of [**2133-1-30**].
FINDINGS:
CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST:
There is a left basal effusion with atelectasis of the left
lower lobe. There is a small pericardial effusion.
There are multiple coils present in the splenic artery, and on
the post- contrast examination, there are multiple
low-attenuation foci within the spleen one of them in anterior
portion of the spleen with a convex outer margin, suggestive a
combination of cysts and splenic infarcts. The gallbladder
contains multiple calculi as well as sludge. The liver, pancreas
appear unremarkable.
Bilateral left more than right diffuse thickening of the adrenal
glans most likely represents hyperthrophy. There is a
subcentimeter low- attenuation focus in the upper pole of the
left kidney. There are scattered subcentimeter upper abdominal
lymph nodes. There is a left-sided ileostomy.
CT PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST:
There is a drain present within the pelvis, traversing the right
lower pelvic wall. There is small amount of free fluid in the
pelvis. There are scattered bilateral inguinal lymph nodes,
mildly enlarged but with preserved fatty hilus.
MUSCULOSKELETAL:
Bilateral subcutaneous fat stranding of the right and the left
lateral abdominal and pelvic walls might represent areas of
dependent edema or inflamation. There are degenerative changes
present in the spine.
CONCLUSION:
1. Multiple metallic coils within the splenic artery with
scattered low- attenuation foci within the spleen, most likely a
combination of cysts and focal areas of splenic infarction
post-coil embolization.
2. Left basal effusion with atelectasis at the left lower lobe
and inflammatory changes in the mesentery of the upper abdomen
are consistent with post-procedure sequelae.
3. Extensive sludge and calculi in an otherwise unremarkable
gallbladder.
4. Bilateral adrenal gland thickening, most likely representing
hyperplasia.
Brief Hospital Course:
Ms. [**Known lastname **] was transferred from [**Hospital3 7571**]Hospital on
[**2133-1-29**] and admitted to the SICU. She received 2 units of blood
that evening. On [**1-30**] she underwent mesenteric angiography
which revealed no active bleeding, but did reveal a splenic
artery aneurysm. After discussion with Dr. [**First Name (STitle) 2819**], the decision
was made to coil the aneurysm. However her hematocrit continued
to drop and she was given 2 more units of PRBC on [**1-30**]. Her
hematocrit dropped again on [**2-2**] so an additional 2 units of
PRBC were given and EGD was performed. This revealed a bleeding
ulcer in the second part of the duodenum, which was injected and
fulgurated. Endoscopy was repeated on [**2-4**] and the same ulcer
was injected and fulgurated once again. Subsequently her
hematocrit remained stable so she was transferred to the floor.
She also complained of back and L leg pain during her ICU stay
so pain service was consulted and she was started on her home
oxycodone/celexa.
On the floor, Mrs.[**Doctor Last Name 21128**] hematocrit continued to be stable.
She complained of nausea with eating solid foods, but was able
to obtain adequate nutrition by supplementing her meals with
Ensure. She continued to have low back and left leg pain
consistent with her preexisting diagnosis of sciatica. Chronic
pain service was consulted and she was started on Neurontin,
dilaudid, and standing tylenol. her bowl movements were no
longer bloody. Physical therapy consult was called and
recommended rehab upon discharge. As she was tolerating regular
diet, ambulating, and her hematocrit was stable, she was
discharged to rehab on ***********
Medications on Admission:
Oxycodone, Timolol, Xalatan, Ambien, Celexa.
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Acute pain.
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Bleeding duodenal ulcer
Nonbleeding multiple gastric ulcers
Sciatica
Chronic back pain
s/p sigmoid colectomy/Hartmanns
Discharge Condition:
Good
Discharge Instructions:
Please call or return to the hospital if you have any of the
following:
* Dizziness/lightheadedness
* Bloody or black output from your ostomy
* Persistent tachycardia or hypotension
* Persistent Nausea/vomiting
* Inability to tolerate food or liquids by mouth
* any other symptoms that are concerning to you
Resume your regular diet with Ensure shakes with each meal
Resume your normal activity as tolerated.
Followup Instructions:
SURGERY: Please call Dr.[**Name (NI) 11471**] office ([**Telephone/Fax (1) 2359**]) to
schedule a followup appointment for 2-3 weeks from now.
PAIN MANAGEMENT: Call the pain management clinic ([**Telephone/Fax (1) 1091**])
to schedule an appointment for your low back and sciatica pain.
You may also ask your primary care physician to refer you to a
neurologist.
Completed by:[**2133-2-10**]
|
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|
1498, 1602
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,974
| 195,954
|
26756
|
Discharge summary
|
report
|
Admission Date: [**2128-2-9**] Discharge Date: [**2128-2-14**]
Date of Birth: [**2079-12-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Asymptomatic with CAD
Major Surgical or Invasive Procedure:
[**2128-2-9**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag1, SVG to Diag2, SVG to PDA)
History of Present Illness:
47 y/o male with extensive PMH, currently asymptomatic but being
worked up for possible kidney transplant. Underwent cardiac cath
which revealed severe two-vessel coronary artery disease and was
referred for surgical revascularization.
Past Medical History:
Coronary Artery Disease s/p LAD stent, Congestive Heart Failure,
Myocardial Infarction, Stroke [**12-15**], Hypercholesterolemia,
Hypertension, Diabetes Mellitus, Cardiomyopathy, Hepatitis C -
Stage II liver fibrosis, Chronic Renal Insufficiency (on
Dialysis), Anemia, s/p RUE A-V fistula, s/p Tonsillectomy, s/p
Pilonidal cyst removal
Social History:
IVDA and illicit drug use (heroin, oxycontin, and cocaine) up
until day of surgery. Currently unemployed, awaiting disability.
Smokes 1ppd and has done so for approximately 30 years. No etoh
use for 2 years.
Family History:
One brother died from complications related to DM and CAD, and
unknown (to pt) metastatic CA. Another brother with dm. Father
died at 83 from a complication of CABG surgery, but began having
manifestations of CAD in early 60's.
Physical Exam:
VS: 68 140/76 6'1" 200#
General: NAD with "cigarette" smell
Skin: Multiple tattoos on chest and extremities
HEENT: PERRL, EOMI, Anicteric, poor dentition
Neck: Supple, FROM, -JVD, +Carotid Bruits
Chest: CTAB -w/r/r
Heart: RRR 2/6 SEM
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, RUE A-V fistula (inc
well-healed)
Neuro: MAE, A&O x 3, non-focal
Pertinent Results:
[**2128-2-9**] Echo: PRE-BYPASS: The left atrium is moderately dilated.
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 mildly depressed. LV apex is mildly depressed. Right
ventricular chamber size and free wall motion are normal. The
descending thoracic aorta is mildly dilated. There are three
aortic valve leaflets. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
POST-BYPASS: Left ventricular function appears improved. RV
function is preserved. Aorta is intact post decannulation.
Mitral regurgitation is unchanged. Other findings are unchanged
[**2128-2-13**] 05:17AM BLOOD WBC-7.6 RBC-2.73* Hgb-8.4* Hct-24.6*
MCV-90 MCH-30.9 MCHC-34.3 RDW-15.3 Plt Ct-128*
[**2128-2-13**] 05:17AM BLOOD Plt Ct-128*
[**2128-2-13**] 05:17AM BLOOD Glucose-88 UreaN-51* Creat-4.5* Na-135
K-4.5 Cl-101 HCO3-25 AnGap-14
[**2128-2-12**] 04:54AM BLOOD Glucose-114* UreaN-65* Creat-4.8* Na-134
K-5.0 Cl-103 HCO3-21* AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 15716**] was admitted same day to operating room where he
underwent a coronary artery bypass graft x 4. Please see
operative report for surgical details. He tolerated the
procedure well and was transferred to the CSRU for invasive
monitoring in stable condition. Later on op day he was weaned
from sedation, awoke neurologically intact and was extubated.
Renal service was consulted due to preop renal failure. On
post-op day one he started on beta blocker, antihypertensives,
and weaned from vasodilators. He continued to do well and was
transferred to the floor. Chest tubes were removed on post-op
day two. He started on hemodialysis on postoperative day 2 and
was continued to be receive HD managed by renal service.
Epicardial pacing wires on post-op day three. Physical followed
patient during entire post-op course for strength and mobility.
He continued to make steady process and was discharged home with
VNA services on post-op day 4.
Medications on Admission:
Clonidine 0.2mg TID
Iron 325mg [**Hospital1 **]
Minoxidil 10mg TID
ASA 81mg daily
Calcitrol
Metoprolol 50mg [**Hospital1 **]
Terazosin 5mg [**Hospital1 **]
Lisinopril 5mg daily
Lipitor 10mg
70/30 insulin 10 units [**Hospital1 **]
Procrit qMonthly
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Terazosin 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
Disp:*60 Capsule(s)* Refills:*1*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*1*
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. Hytrin 5 mg Capsule Sig: One (1) Capsule PO once a day.
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTUES (every Tuesday).
Disp:*QS 1 month* Refills:*0*
12. Insulin
70/30 5 units QAM, 5 units QPM
Regular Insuilin sliding scale
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Congestive Heart Failure, Myocardial Infarction, s/p LAD
stent, Stroke [**12-15**], Hypercholesterolemia, Hypertension,
Diabetes Mellitus, Cardiomyopathy, Hepatitis C - Stage II liver
fibrosis, Chronic Renal Insufficiency (on Dialysis), Anemia, s/p
RUE A-V fistula, s/p Tonsillectomy, s/p Pilonidal cyst removal
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) 1016**] in [**2-14**] weeks
Dr. [**Last Name (STitle) 65906**] in [**1-13**] weeks
Completed by:[**2128-2-13**]
|
[
"428.0",
"414.01",
"250.00",
"070.54",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"39.95",
"38.93",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
5765, 5828
|
3118, 4089
|
342, 445
|
6249, 6255
|
1928, 3095
|
6573, 6756
|
1310, 1539
|
4386, 5742
|
5849, 6228
|
4115, 4363
|
6279, 6550
|
1554, 1909
|
281, 304
|
473, 710
|
732, 1069
|
1085, 1294
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,806
| 101,065
|
42492+58533
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-1-4**] Discharge Date: [**2162-1-8**]
Date of Birth: [**2091-4-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Orthostatic lightheadedness
Major Surgical or Invasive Procedure:
[**2162-1-4**] Aortic Valve Replacement(#21 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue)
History of Present Illness:
70 year old female with reports of occasional orthostatic
lightheadedness. An echo [**2161-11-24**] revealed moderate to severe
aortic stenosis with peak gradient 85 mmHg, mean 48, [**Location (un) 109**] 0.6
cm2, and good LV function with an EF of 55%. She was referred
for a diagnostic right and left heart catheterization. She was
found to have severe aortic stenosis and is now being referred
to cardiac surgery for evaluation of an aortic valve
replacement.
Past Medical History:
Aortic stenosis s/p Aortic valve replacement
Hypertension
Dyslipidemia
MVC with right leg/ankle fracture
History of anemia
Anxiety
Depression
Early glaucoma
Hemorrhoids
Appendectomy
Hysterectomy
Social History:
Race:Hispanic
Last Dental Exam:1 months ago
Lives with:son
Contact:[**Name (NI) **] [**Name (NI) 91967**], [**First Name3 (LF) **]. C: [**Telephone/Fax (1) 91968**]
[**Name2 (NI) **]ation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**2-2**] drinks/week [x] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Father had heart disease,
died at age 85; one brother died of heart attack at age 62;
Another brother with heart disease and emphysema died at 70;
Sister with heart attack at age 72.
Physical Exam:
Pulse:79 Resp:13 O2 sat:97/RA
B/P Right:162/82 Left:156/74
Height:5'3" Weight:204 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 [x] grade 3-4/6 SEM to neck
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]well healed scars from hysterectomy & appy
Extremities: Warm [x], well-perfused [x] Edema [n] _____
Varicosities: None [x]
Neuro: Grossly intact []
Pulses:
Femoral Right:2 Left:2
DP Right: 1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Right: n Left:n transmitted cardiac murmur
Pertinent Results:
[**2162-1-8**] 06:45AM BLOOD WBC-10.0 RBC-3.24* Hgb-9.4* Hct-27.9*
MCV-86 MCH-29.0 MCHC-33.7 RDW-13.7 Plt Ct-282
[**2162-1-8**] 06:45AM BLOOD Plt Ct-282
[**2162-1-8**] 06:45AM BLOOD PT-13.5* INR(PT)-1.3*
[**2162-1-8**] 06:45AM BLOOD UreaN-13 Creat-0.5 Na-138 K-4.4 Cl-101
[**2162-1-8**] 06:45AM BLOOD Mg-2.2
TEE [**2162-1-4**]:PRE-CPB:
The left atrium is moderately dilated. No thrombus is seen in
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. No thoracic
aortic dissection is seen.
The three aortic valve leaflets are severely thickened/deformed.
A small, filamentous, mobile mass is seen on the aortic side of
the non-coronary cusp. Significant aortic stenosis is present
(not quantified). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POST-CPB:
A bioprostheticvalve is seen in the aortic position. The valve
appears to be well seated with normal leaflet mobility. There
are no paravalvular leaks. There is no AI. The peak gradient
across the aortic valve is 23mmHg, and the mean gradient is
11mmHg with CO of 3.2L/min.
The LV chamber size is small, consistent with hypovolemic state.
The LV systolic function remains normal, EF>55%.
There is no evidence of aortic dissection.
Dr. [**Last Name (STitle) **] was notified in person of the results at time of
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2162-1-6**] 17:18
Brief Hospital Course:
Mrs. [**Known lastname 91969**] was a same day admission to the operating room for
aortic valve replacement with Dr [**Last Name (STitle) **]. Prior to admission she
underwent pre-operative work-up including cardiac
catheterization. On [**1-4**] she was brought to the operating room
please see operative report for details, in summary she had:
aortic valve replacement with #21 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve. Her
bypass time was 79 minutes with a crossclamp time of 62 minutes.
She tolerated the operation well and following surgery she was
transferred to the CVICU in stable condition for invasive
monitoring. In the immediate post-op period she remained
hemodynamically stable, was weaned from sedation, awoke
neurologically intact and extubated. On POD1 she continued to be
hemodynamically stable and was transferred to stepdown floor for
continued post-op care. All tubes lines and drains were removed
according to cardiac surgery protocol without complication. She
went into a rapid atrial fibrillation on POD 1 night and was
given increased dose of Lopressor, IV amiodarone/ po Amiodarone
and converted to sinus rhythm at 3 AM on POD2. She remained
hemodynamically stable throughout remainder of hospital course.
She was diuresed with Lasix toward preoperative weight. Once on
the stepdown floor she worked with nursing and physical therapy
to improve strength and mobility. The remainder of her hospital
course was uneventful. On POD #4 she was tolerating a full oral
diet, her incision was healing well and she was ambulating with
assistance. She was cleared for discharge to [**Location (un) **] House
rehab. All follow up appointments were advised. Target INR
2.0-2.5 for A Fib. First INR check tomorrow at rehab.
Medications on Admission:
AMLODIPINE 10 mg Daily
BENAZEPRIL 20 mg Daily
FLUTICASONE 50 mcg Spray, two sprays via both nostrils at
bedtime
HYDROCHLOROTHIAZIDE 25 mg PRN
LATANOPROST 0.005 % Drops - one drop each eye at bedtime
LORAZEPAM 0.5 mg PRN
METOPROLOL SUCCINATE 100 mg Daily
PRAVASTATIN 80 mg daily
TRAMADOL 50 mg PRN
ASPIRIN 81 mg Daily
IBUPROFEN 200-600 mg PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for SBP < 100.
6. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: 400 mg [**Hospital1 **] through [**1-12**].
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: 200 mg [**Hospital1 **] [**1-13**] through [**1-20**].
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
200 mg daily starting [**1-21**] ongoing.
11. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily): NU daily.
12. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): both eyes.
13. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
15. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 2 weeks.
16. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 days: dose for today [**1-8**] is 2.5 mg; all further daily
dosing per rehab provider;target INR 2.0-2.5 for A Fib.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Aortic stenosis s/p Aortic valve replacement
postop A Fib
Past medical history:
Hypertension
Dyslipidemia
MVC with right leg/ankle fracture
History of anemia
Anxiety
Depression
Early glaucoma
Hemorrhoids
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
1+ 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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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 A Fib
Goal INR 2.0-2.5
First draw tomorrow [**1-9**]
****please arrange for coumadin/INR f/u prior to discharge from
rehab
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2162-2-3**] at 1:00 PM
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7526**] on [**2162-1-26**] at 11:30 AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22235**] in [**4-1**] 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 A Fib
Goal INR 2.0-2.5
First draw tomorrow [**1-9**]
****please arrange for coumadin/INR f/u prior to discharge from
rehab
Completed by:[**2162-1-8**] Name: [**Known lastname 14470**],[**Known firstname 14471**] R Unit No: [**Numeric Identifier 14472**]
Admission Date: [**2162-1-4**] Discharge Date: [**2162-1-8**]
Date of Birth: [**2091-4-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
morphine
Attending:[**First Name3 (LF) 741**]
Addendum:
Expected length of stay at rehab is less than 30 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 12660**] Nursing & Rehabilitation Center - [**Location (un) 12660**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2162-1-8**]
|
[
"300.00",
"272.4",
"427.31",
"365.9",
"401.9",
"E878.1",
"997.1",
"424.1",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11103, 11337
|
4484, 6262
|
301, 420
|
8668, 8835
|
2479, 4461
|
9894, 11080
|
1511, 1730
|
6654, 8296
|
8442, 8500
|
6288, 6631
|
8859, 9871
|
1745, 2460
|
234, 263
|
448, 912
|
8522, 8647
|
1146, 1495
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,899
| 110,759
|
43573
|
Discharge summary
|
report
|
Admission Date: [**2186-3-9**] Discharge Date: [**2186-3-11**]
Date of Birth: [**2109-9-23**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Called by Emergency Department to evaluate
left leg numbness and weakness s/p IV tPA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 39318**] is a 76-year-old right-handed woman with a
history of cardiac arrhythmia s/p PPM on Coumadin who presents
with acute onset left leg numbness and weakness. This morning
she
was in her USOH standing at the kitchen sink. She tried to turn
to use the microwave, and felt that her left leg was heavy and
did not turn as quickly as she wanted. She walked to the bedroom
and lay down on the couch. She felt heart palpitations and a
general feeling of weakness, and said to her husband, "I need to
go to the hospital." They called 911, and EMS brought her to
[**Location (un) 620**].
There, her initial NIHSS score was 4, as recorded by the ED
physicians. This included 2 for weakness in her left leg and 2
for what they felt was subtle ataxia in her left arm and leg.
The
decision was made to thrombolyse, and IV tPA was begun at 9:05.
After tPA was delivered, the Stroke team at [**Hospital1 18**] was then
called, who agreed with transfer to [**Hospital1 18**]. She now feels that
her
leg is better, but still not back to normal. She had no other
weakness and no speech or language difficulty.
Of note, she was scheduled for a colonoscopy and thus had
stopped
her Coumadin 1 week ago. The colonoscopy got delayed and she
restarted her Coumadin 2 days ago. She reports pitch black stool
this morning, but was Guaiac negative in the [**Location (un) 620**] ED prior to
tPA. INR was 1.3 at [**Location (un) 620**].
On neuro ROS, Ms. [**Known lastname 39318**] reports a mild bifrontal headache.
She
denies loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal numbness, parasthesiae. No bowel or
bladder incontinence or retention. Denies difficulty with gait.
On general review of systems, she denies recent fever or chills.
No night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain or tightness. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
Paryoxysmal atrial fibrillation on Coumadin
Sinus node dysfunction s/p PPM
Hyperlipidemia
RUQ breast mass
Lightheadedness in the past, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 46062**] in
neurology and evaluated by EEG, which was normal, and symptoms
have been attributed to a fib.
Social History:
Denies history of smoking. Drinks wine with dinner.
Lives with husband at home in [**Name (NI) 620**] and volunteers at
[**Hospital1 **].
Family History:
Father died of MI at age 57. Sister died of emphysema
and PE at age 50. Mother died of cancer at advanced age.
Physical Exam:
Vitals: T: 98.0 P: 79 R: 16 BP: 119/74 SaO2: 97%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Contracture of right elbow with scar on medial
aspect.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. The pt. had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: 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 protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5- 5- 5 5 5 5 5- 5 4 5- 5 5 5
R 5- 5- 5 5 5 5 4+ 5 4+ 5 5 5 4+
-Sensory: Decreased pinprick over small strip of lateral left
foot. Decreased vibration at left great toe. No deficits to
light
touch, cold sensation, proprioception throughout. No extinction
to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
(Subcutaneous tissue at the knees interferes with reflex
testing)
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem with some difficulty. Romberg
absent.
Pertinent Results:
[**2186-3-10**] 09:55AM BLOOD WBC-6.6 RBC-4.15* Hgb-13.8 Hct-38.0
MCV-92 MCH-33.3* MCHC-36.3* RDW-13.0 Plt Ct-193
[**2186-3-9**] 12:10PM BLOOD WBC-8.7 RBC-4.25 Hgb-13.6 Hct-38.9 MCV-91
MCH-32.0 MCHC-35.0 RDW-13.6 Plt Ct-194
[**2186-3-9**] 12:10PM BLOOD Neuts-79.5* Lymphs-16.0* Monos-3.0
Eos-1.2 Baso-0.3
[**2186-3-10**] 09:55AM BLOOD PT-17.2* PTT-24.4 INR(PT)-1.6*
[**2186-3-9**] 12:10PM BLOOD PT-18.9* PTT-26.8 INR(PT)-1.7*
[**2186-3-10**] 09:55AM BLOOD Glucose-152* UreaN-12 Creat-0.6 Na-141
K-3.9 Cl-109* HCO3-24 AnGap-12
[**2186-3-9**] 12:10PM BLOOD Glucose-118* UreaN-16 Creat-0.7 Na-142
K-4.8 Cl-108 HCO3-25 AnGap-14
[**2186-3-10**] 09:55AM BLOOD CK(CPK)-47
[**2186-3-9**] 12:10PM BLOOD CK(CPK)-69
[**2186-3-10**] 09:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2186-3-9**] 12:10PM BLOOD cTropnT-<0.01
[**2186-3-10**] 09:55AM BLOOD Calcium-9.3 Phos-2.8 Mg-1.9 Cholest-PND
NCHCT [**2186-3-10**]: (prelim)
no intracranial hemorrhage
[**2186-3-11**] 07:05AM BLOOD PT-16.1* PTT-29.8 INR(PT)-1.4*
Brief Hospital Course:
This 76 yo F was transferred from [**Hospital1 **] [**Location (un) 620**] after IV tPA for a
suspected stroke presenting as LLE weakness/heaviness as
described in the HPI. Twenty four hours after the onset of her
symptoms, she felt that her LLE strength had returned to
baseline. Her NCHCT post tPA showed no hemorrhage and she was
restarted on her coumadin, with a lovenox bridge. She was
transferred to the neurology floor. She did well on the floor
and was discharged with home services to help with Lovenox while
coumadin becomes therapeutic.
Medications on Admission:
Coumadin 2.5 mg po Sun/Wed; 5 mg po other days
Clonazepam 0.5 mg po daily
Digoxin 250 mcg po daily
Omeprazoel 20 mg po bid
Sotalol 80 mg po bid
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for temp > 100.4 or pain.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day).
Disp:*14 syringe* Refills:*2*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Stroke v. TIA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of some weakness in your leg. This
may have been due to a stroke. We did not see any evidence on
the CT of an acute stroke. You should return to the ER if you
have any new weakness, nubmness, dizziness or slurred speech.
You will need to take coumadin to prevent future strokes
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2186-5-19**] 2:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2040**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**]
Date/Time:[**2186-5-19**] 3:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2040**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**]
Date/Time:[**2186-8-21**] 11:20
F/U with Dr. [**Last Name (STitle) **] - please call
You will need to follow-up with your PMD on monday for INR
checks
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"V58.61",
"427.81",
"272.4",
"434.91",
"355.8",
"V45.01",
"427.31",
"781.3",
"V45.88"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8285, 8343
|
6930, 7479
|
400, 406
|
8401, 8410
|
5909, 6907
|
8766, 9416
|
3131, 3244
|
7674, 8262
|
8364, 8380
|
7505, 7651
|
8434, 8743
|
4382, 5890
|
3259, 3823
|
275, 362
|
434, 2616
|
3838, 4365
|
2638, 2959
|
2975, 3115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,292
| 113,876
|
33334
|
Discharge summary
|
report
|
Admission Date: [**2199-2-26**] Discharge Date: [**2199-3-8**]
Date of Birth: [**2123-1-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
VT storm, unable to extubate after VT ablation
Major Surgical or Invasive Procedure:
VT ablation
History of Present Illness:
The patient is a 76-year-old man with coronary artery disease
status post single vessel CABG with previous critical aortic
stenosis status post-aortic valve repair in [**2196**], status post
AICD, history of PEA arrest, history of VT, who presented to [**Hospital1 **] with VT storm [**2-25**] with 40 ICD shocks and was transferred
to [**Hospital1 18**] for VT ablation. Pt. with VT initially post CABG/AVR,
and was started on amiodarone and mexelitine which he did not
tolerate.
.
The patient reports sitting at home watching TV, then went to
the bathroom and felt ICD fire. The patient denies prior
palpitations, chest pain, shortness of breath or dizziness. ICD
fired several times.
.
At [**Hospital3 **], pt. continued ot have VT in the ED, and the
patient was was started on lidocaine and amiodarone drips and
admitted to the Intensive Care Unit. He was started on p.o.
Amiodarone load and lidocaine drip was discontinued without any
further episodes of VT. The patient had a cardiac cath which is
unchanged from [**3-10**]. He has LAD 40% ostial lesion, left
circumflex, 70% ostial lesion, RCA 40% mid lesion with patent
left circ. He also had an TTE demonstrating reduced EF (30-35%)
compared to 1 year ago (40%).
.
Transferred here for VT ablation. In EP lab, intubated and
found to have 2 separate foci near mitral valve annulus. [**12-5**] VT
foci were able to be ablated. In addition, had pacer adjusted
such that when VT was induced burst pacing extinguished 2nd site
of VT. He was initially extubated, but was somewhat somnolent,
and given a h/o hypoxia-induced PEA arrest s/p extubation from
inguinal repair last year, pt. was re-intubated easily and
transferred to PACU for further monitoring. Of note, pt. was
positive 1L during procedure.
.
In PACU, had CXR demonstrating likely reflecting left pleural
effusion and fluid overload. Currently, pt. is intubated,
sedated on propofol, L arterial sheath pulled at 7PM.
.
Review of symptoms unable to be obtained [**1-5**] sedation. Review
of PMH shows recent MCA stroke, with need for walker at
baseline. No report of deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. Per [**Hospital1 **] notes, he denied recent fevers, chills or rigors.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CAD status post 1v CABG (SVG-->OM).
2. AS status post AVR in [**2196**] which is a tissue valve.
3. Status post AICD in [**2196**].
4. Diabetes.
5. Hypertension.
6. Hypercholesterolemia.
7. Spinal stenosis.
8. PEA arrest in [**2197**] s/p hernia repair with prolonged
intubation.
9. History of VT.
10. Pulmonary hypertension.
11. Diverticulosis.
12. Thalassemia.
13. Right MCA infarct [**12/2198**]
14. Left internal carotid artery stenosis. ([**12/2198**])
15. Lumbar stenosis
16. sternal nonunion after CABG
[**07**]. Systolic and diastolic dysfunction presumed to be secondary
to hypertensive diabetic and valvular heart disease.
18. Charcot joints.
19. Chronic renal failure, BL 1.2-1.3
Social History:
The patient currently lives in [**Location 4288**] with his wife. [**Name (NI) **] is a
retired owner of a printing center franchise. He quit work
approximately 8-9 years ago. He does not smoke. He does not
use illicit drugs and he very infrequently drinks alcohol.
Family History:
NC
Physical Exam:
VS: T afebrile, BP 107/35, HR 61, RR 12, O2 100% on AC 50%/Tv
500/RR 12/PEEP 5
Gen: obese man, intubated, sedated. Per EP fellow, Oriented x3,
but sleepy prior to procedure.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI with doll's.
Neck: very large with excess tissue, JVP not assessed as pt.
flat post-procedure. no carotid bruits
CV: RR, normal S1, soft s2, loud harsh early systolic murmur
best heard at LUSB
Chest: Large anterior chest wall deformity with unstable
sternum, large incision from CABG/valve repair well-healed.
Decreased BS on left anteriorly. No crackles, wheeze, rhonchi
noted
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. L scar medial to arterial
puncture site, sl. indurated, well healed
Skin: + mild stasis dermatitis, R shin ulcers 1.5mm X 2 mm, oval
marked, with no crepitus, mild erythema. 1+ pitting edema to
knees
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP and PTs
Left: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP and PTs
Pertinent Results:
CXR on admission: Lung volumes are low with opacification of the
left lower lobe, likely reflecting left pleural effusion and
atelectasis. Consolidation can't be excluded. Vascular
redistribution in the right upper lobe suggests fluid overload.
.
CXR at [**Hospital3 **] ([**2-25**]):
The diaphragms are markedly elevated with low lung volumes.
This makes evaluation of the lung bases impossible. There is
suggestion of increasing interstitial opacities of the upper
lung zones which could be a function of the high diaphragms or
some superimposed edema.
.
2D-ECHOCARDIOGRAM performed on [**2199-2-25**] demonstrated (per [**Hospital1 **] ECHO report):
Technically difficult study. LV dimensions mildly dilated.
Global LV systolic function is moderately to severely reduced
with an estimated EF of 30-35%. There is global hypokinesis with
abnormal septal motion. RV is mildly dilated with moderate
hypokinesis. There is moderate biatrial enlargement. Aortic
valve bioprosthesis appears to be well seated with appropriate
gradients for this valve. Trace AR. Mitral leaflets are mildly
thickened with mild MR. [**First Name (Titles) **] [**Last Name (Titles) **] with moderate PHTN. Estimated
PASP is 43 mmHg + CVP. A minimal pericardial effusion is seen.
Pacer wire is noted in right heart [**Doctor Last Name 1754**]. Compared to prior
study dated [**2198-6-30**], LV systolic function appears somewhat lower
on the current study.
.
ETT performed on [**11-8**] demonstrated:
A Dobutamine stress echo was carried out during which time peak
HR of 127bpm was obtained (86% of maximum predicted HR). At
rest, LVEF estimated 25%. Evidence of LVH as well as LAE. Global
LV systolic dysfunction. Aortic valve moderately calcified with
40mmHg peak gradient and 20mmHg mean valve gradient. This
represents no significant change from prior study of [**2196-11-8**].
With Dobutamine, LVEF increased to 35-40%. Again, global
hypokinesis was seen. Peak gradient increased to 65mmHg with
mean gradient of 26 mmHg. Unfortunately, LVOT velocity could
not be obtained either at rest or at peak dose Dobutamine,
therefore aortic valve area could not be calculated. These
findings however appear to be most consistent with a
cardiomyopathy with moderate AS rather than hemodynamic
insignificant AS. Suggest clinical correlation.
.
CARDIAC CATH performed on [**2199-2-25**] demonstrated:
The patient had a cardiac cath which is unchanged from [**3-10**].
He is LAV 40% ostial lesion, left circumflex, 70% ostial lesion,
RCA 40% mid lesion and he describes to us left circumflex is
patent.
LABORATORY DATA: notable for BL Cr 1.2, 1.5 on admission to [**Hospital1 **] with hct 34 on admission and 30 upon transfer.
Discharge labs:
[**2199-3-8**] 07:10AM BLOOD WBC-7.2 RBC-4.05* Hgb-8.2* Hct-27.6*
MCV-68* MCH-20.4* MCHC-29.9* RDW-16.6* Plt Ct-268
[**2199-3-8**] 07:10AM BLOOD Plt Ct-268
[**2199-3-8**] 07:10AM BLOOD PT-14.3* PTT-30.6 INR(PT)-1.2*
[**2199-3-8**] 07:10AM BLOOD Glucose-60* UreaN-19 Creat-1.4* Na-140
K-5.0 Cl-101 HCO3-31 AnGap-13
[**2199-3-8**] 07:10AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.1
Brief Hospital Course:
76yo with h/o VT, CABG, PEA arrest s/p extubation and h/o
difficulty weaning, who underwent VT ablation procedure for VT
storm, and who had difficult weaning of endotracheal tube after
VT ablation procedure and was started on antiarrythmics for
control of VT.
Rhythm: He found to have 2 automatic foci which were the cause
of his VT storm on presentation. He was reduced to 200 mg
Amiodarone sometime prior to admission for unclear reasons. His
TSH and LFTs are wnl. On the day of presentation, he underwent
successful ablation of 1 of the 2 VT foci with other focus
easily controlled in lab with burst pacing after pacer
adjustment. He continued to have periods of ventricular rhythms
which were paced out, though s/p VT on [**3-1**] which was too slow
to burst pace per pacer settings, likely because of amio. On
morning of [**3-2**], patient triggered for VT at 116-126 bpm SBP
90-110s. No benefit with vagal maneuver, carotid massage so IV
lidocaine was given, amiodarone and mexiletine were discontinued
and patient was switched to quinidine. Patient had his lower
pacing rate increased to 75bpm and subsequently, patient had no
more episodes of VT. His mexiletine was titrated up to 648mg TID
with QT of 560 which was corrected for wide QRS to 480ms which
was minimally changed from his pre-quinidine QT. However, he
developed diarreah on the quinidine so he was switched back to
amiodarone and mexiletine. His pacer was also adjusted to have a
lowered VT detection zone from 130 down to 115bpm. He had no
episodes of VT on this regimen and was discharged on telemetry
monitoring with paced HR ranging in 70s. He will also need
Q6month CBC, TFTs, LFTs on discharge.
CAD/Ischemia: Cath showed unchanged disease from previous. CP
free prior to cath.
Patient continued on statin, zetia, receiving aspirin via
aggrenox. LDL 117 at OSH. Atorvastatin was increased to 80mg
daily. He was also continued on his beta blocker and ACEi.
Pump: Depressed EF to 30-35% compared to ECHO last year, with
CXR e/o pleural effusion and pulmonary edema. On 80 mg po lasix
qdaily at home. Pt. with limited BL activity [**1-5**] previous
stroke, so unsure if class II or III NYHA CHF, though some
evidence for benefit in both. Initially lasix and lisinopril
were held in setting of ARF, but patient continued to improved
and by discharge, patient was restarted on lisinopril and
titrated up to his home dosage. He was also started on low dose
lasix of 40mg PO daily.
Respiratory failure: Given patient's history of difficult course
post-extubation from prior procedure, he was watched closely
after extubation from his EP procedure. He did well
post-extubation with incentive spirometry, oxygen, and was
discharged with sats of 94% on RA.
Microcytic anemia: Decreased Hct likely due to Fe deficiency +
known thalassemia trait. Hct 34->30 at [**Hospital3 **] and then
->25, now improved to 28.4. Patient's Hct remained stable
throughout his hospital course with no indication of acute
bleeding.
Acute on chronic renal failure: CR 1.3 at baseline,
hyperphosphatemic initially so added phos-binder which improved
this. Creatinine peaked at 2.0, and on discharge was 1.2-1.3. Cr
bump likely pre-renal given significant diuresis and dry
appearance on exam vs. contrast nephropathy from recent cath at
[**Hospital3 **]. Restarted low dose lisinopril and lasix -
titrated as Cr and BP allow.
Urinary obstruction: Patient was unable to void after foley
removed on [**3-3**] and had residuals above 300cc. Started on
tamsulosin on [**3-2**]. Patient was discharged to rehab with foley
in, and to continue on tamsulosin for 1 week. Plan to remove
foley on [**2199-3-9**] with trial void.
Valves: bioprosthetic Aortic valve, no longer anticoagulated
HTN: beta blocker was increased to metoprolol 75mg PO TID. ACEi
as above. BP well controlled on this
DM: restarted home NPH with sliding scale. He was discharged
back on home metformin and NPH dosing. He can restart his home
regimen of regular insulin 4 units before dinner at rehab as
needed.
Chronic pain: continue neurontin
s/p stroke: continue aggrenox. No changes in neuroexam post
procedure.
FEN: regular diabetic cardiac diet
Prophylaxis: hep SC, home PPI
Code: FULL CODE
Medications on Admission:
1. Prilosec 20 mg p.o. daily.
2. Aggrenox 1 capsule p.o. b.i.d.
3. Colace 200 mg p.o. daily.
4. Amiodarone 200 mg p.o. daily.
5. Trazodone 50 mg p.o. q.h.s.
6. Iron 325 mg p.o. daily.
7. Lasix 80 mg p.o. daily.
8. Lopressor 50 mg p.o. b.i.d.
9. Lipitor 40 mg p.o. daily
10. Multivitamin 1 tablet p.o. daily.
11. Neurontin 300 mg p.o. t.i.d.
12. Lisinopril 20 mg p.o. b.i.d.
13. Senna p.r.n.
14. Zetia 10 mg p.o. daily.
15. Ativan 0.5 mg p.r.n.
16. Insulin NPH 25 units before breakfast and insulin NPH 25
units q.h.s.
17. Regular insulin 4 units before dinner.
18. Glucophage 1000 mg p.o. b.i.d.
19. Lactulose p.r.n.
Discharge Medications:
1. Outpatient Lab Work
Lab draws of LFTs, TFTs, CBC every 6 months. Please have results
faxed in to PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at (F) [**Telephone/Fax (1) 77387**]
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QIDACHS (4 times a day (before meals and at
bedtime)).
14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
15. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
17. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
20. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
22. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
Five (25) units subcutaneous Subcutaneous QAM before breakfast.
23. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
Five (25) units subcutaneous Subcutaneous at bedtime.
24. Insulin Aspart 100 unit/mL Solution Sig: Give per insulin
sliding scale Subcutaneous four times a day.
25. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Final diagnosis
Recurrent ventricular tachycardia
Secondary diagnosis
Coronary artery disease
Systolic congestive heart failure
Acute on chronic renal fialure
Hypertension
Urinary retention
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for a procedure to deactivate areas of your
heart which were firing irregularly. You had two areas of
irregular activity and one of the two areas were deactivated.
Your pacemaker was also adjusted to better control the rate of
your heart. You were observed after the breathing tube was
removed after the procedure. You were also started on a
medication called mexiletine in addition to your amiodarone
which will help control your heart rhythm. You will need to take
200mg every 8 hours of mexiletine daily.
Other medication changes are as follows:
- your lipitor was increased to 80mg daily
- your lasix was decreased to 40mg daily
- your metoprolol was increased to 75mg 3 times a day
Followup Instructions:
Your follow up appointment with the electrophysiology team is as
follows: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2199-3-18**] 9:40am on the [**Location (un) 436**] of [**Hospital Ward Name 23**] Building,
[**Hospital1 18**].
You also have an appointment with your cardiologist, Dr. [**Last Name (STitle) 10220**]
at [**Hospital3 2568**] ([**Telephone/Fax (1) 77388**]. Your appointment is on Tuesday
[**3-19**] at 1:45pm.
You have an appointment with your primary care provider, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Location (un) **]. T ([**Telephone/Fax (1) 77389**]. Your appointment
is on [**Last Name (LF) 2974**], [**3-15**] at 1pm. You will also need lab draws to
check your CBC, LFTs every 6 months.
|
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30,408
| 133,833
|
47475
|
Discharge summary
|
report
|
Admission Date: [**2149-11-17**] Discharge Date: [**2149-12-5**]
Date of Birth: [**2084-9-29**] Sex: M
Service: NEUROLOGY
Allergies:
Isovue-370
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Headache, neck pain
Major Surgical or Invasive Procedure:
Cerebral angiography
Intubation/Extubation
History of Present Illness:
65 year-old right-handed man with a history of atrial
fibrillation and pulmonary embolism ([**2148-4-21**]) on warfarin,
hypertension, dyslipidemia, with a left MCA infarct in [**Month (only) 359**]
[**2148**], and renal cell carcinoma, who presents with headache and
neck pain since yesterday. History obtained primarily from wife
given aphasia and dysarthria.
The patient was apparently in his usual state of health until
Sunday. On the day prior, he had been doing some yard work at
his home, though was primarily supervising others who were
assisting. On Sunday, his wife reports that he awoke with a
severe headache, that began to involve his neck, as the day
progressed. He reports that the discomfort has worse on the
left. His wife was a bit alarmed, given that she could
onlyremember him with only one prior headache. The pain only
worsened over the course of the day, and he wore a collar to
attend a dinner last evening in an effort to gain some relief.
However, the pain became so severe that he left the dinner
early. His concerned wife spoke by phone with a physician friend
in [**Name (NI) 5622**] who suggested some analgesic medication, as it
sounded musculoskeletal by description. However, when the pain
persisted this morning, his wife called his primary care
physician, [**Name10 (NameIs) 1023**] referred him to the emergency room.
Of note, the patient's INR was 3.2 yesterday, according to his
wife. [**Name (NI) **] received his scheduled dose of baby aspirin this
morning for cardiovascular protection, but had not received his
warfarin. In the emergency room, he was emergently sent to CT
scan. A non-contrast image of the head and neck suggested a
"likely subdural spinal hematoma" extending from the
cerebellopontine angle "to the C2-C3 level with cord compression
and edema." There was no fracture or malalignment. Neurology
and neurosurgery were emergently consulted.
Review of Systems: Dysarthria and aphasia prevented gathering a
coherent review from the patient, though his wife reports that
he complained of some chest pain in the morning yesterday.
Other than that symptom, she has only noted that his speech has
been increasingly dysarthric.
Past Medical History:
-Left MCA infarct, thought to be cardioembolic secondary to his
atrial fibrillation, [**2148-10-21**]. He received IA tPA and MERCI
clot retrieval at that time. He had a mixed aphasia with
dysarthria, and right face, arm, and leg hemiplegia and sensory
loss. His course was complicated by intermittent confusional
episodes. With extensive physical and speech rehabilitation
since that time, the patient has made great progress and was
fully strong and fairly independent. He worked closely with Dr.
[**Last Name (STitle) **] to improve his aphasic deficits.
-Atrial fibrillation on warfarin
-Hypertension
-Dyslipidemia
-Left cerebellopontine mass, likely Schwannoma
-Pulmonary embolism, [**2148-4-21**]
-Papillary renal cell carcinoma of the right kidney. His stroke
occurred in the setting of his anticoagulation being held for a
renal biopsy. This has reportedly been watched closely with no
growth on repeated imaging.
-Sciatica
-Gout
The patient also reports that he was in an automobile accident
on [**10-25**]. He was the seat-belted driver of a Suburban and
was rear-ended. He apparently suffered no known ill effects
from the accident.
Social History:
Married and lives with wife. [**Name (NI) 1403**] in the oil industry. Smokes
cigars and occasional cigarette. Has two alcoholic drinks per
night.
Family History:
Father and mother- passed away from strokes in their 70's
Physical Exam:
Vitals: T 98.1 F BP 167/92 P 64 RR 17 SaO2 95 RA
General: NAD, well-nourished
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: no bruits appreciated, deferred assessment of ROM
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes
Neurologic Examination:
Mental Status:
Awake and alert, unable to relay fully coherent history in part
due to aphasia and dysarthria, cooperative with exam where able;
appears to know he is in the emergency room, but cannot tell me
the date; language is non-fluent, with dysarthric speech,
follows comprehension of basic examination commands bilaterally
Cranial Nerves:
Optic disc margins sharp; visual fields are full to blink
bilaterally. Pupils equally round and reactive to light, 4 to
3.5 mm bilaterally. Extraocular movements intact, no nystagmus.
Facial sensation reduced on right side, V1-V3. Facial movement
normal and symmetric. Hearing reduced to finger rub on right.
Palate elevates midline, though cough response to gag is absent.
Tongue protrudes midline, no fasciculations. Trapezii full
strength bilaterally.
Motor:
Normal bulk and tone throughout. Subtle right pronator drift.
No tremor.
D T B WE FiF [**Last Name (un) **] IP Q H TA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] EDB
Right 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Light touch and pin prick reduced throughout to the
right arm and leg. Position sensation to skin is intact in all
four extremities.
Reflexes: B T Br Pa Pl
Right 3 3 3 3 0
Left 3 3 3 3 0
Toes were downgoing bilaterally.
Coordination: No intention tremor noted. Slight dysmetria on
right finger-nose-finger, preserved on left. No dysmetria on
HKS bilaterally. FFM slowed and clumsy on the right.
Gait: Deferred given acuity of hemorrhage
Pertinent Results:
LABS:
MICRO:
Urine Cx ([**11-17**]): <10,000 organisms/ml.
Urine Cx ([**11-21**], [**11-25**]): No growth
Urine Cx ([**11-22**]): ENTEROCOCCUS >100,000 ORGANISMS/ML;
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML
Blood Cx ([**11-21**], [**11-22**] x3, [**11-23**] x2, [**11-25**] x2): No growth
IMAGING:
ECG ([**11-17**]): Sinus rhythm at a rate of 62. RSR' pattern in lead
V1.
CT Head ([**11-17**]): IMPRESSION:
1. Acute extra-axial hematoma along the lower brainstem and
upper cervical spinal cord with associated mass effect and
edema. Possible etiologies include vascular malformation or
aneurysm or bleeding from the patients known left CP angle
schwannoma.
2. Hypodensity in the left cerebellopontine angle likely
acoustic schwannoma previously diagnosed by MRI.
3. Large territory of hyperdensity and encephalomalacia in the
area of the left MCA consistent with prior left MCA infarction.
CT C-Spine ([**11-17**]): IMPRESSION:
1. Acute extra-axial hematoma (likely SDH) extending from the
medulla along the cervical spinal cord to approximately the C3
vertebral level. There is resultant mass effect on the cord with
rightward and posterior cord displacment and compression, as
well as probable cord edema. Recommend CTA to further evaluate
for vascular abnormality or tumoral bleeding.
2. No fracture or malalignment.
3. Degenerative changes with mild canal narrowing extending from
C4 through C7.
CTA Head ([**11-17**]): IMPRESSION: No evidence of AVM, aneurysm
formation, or other vascular abnormality. Enhancing lesion
within the left cerebellopontine angle consistent with
previously described schwannoma on prior MR. [**Name13 (STitle) 227**] the location
of the schwannoma, it is likely the source of bleeding. MR or
catheter angiogram may be helpful for more definitive proof.
CXR ([**11-17**]): IMPRESSION: No acute intrathoracic process.
MR [**Name13 (STitle) **] ([**11-17**]): IMPRESSION:
1. Area of acute hemorrhage seen within left cerebellopontine
angle mass, the source of the patient's extra-axial hematoma
compressing the cervical spinal cord.
2. Deviation of the cervical spinal cord to the right with
severe edema within the cord.
MR [**Name13 (STitle) 430**]/MR [**Last Name (Titles) **] ([**11-19**]): IMPRESSION:
1. Mild increase in the size of the left CP angle mass lesion
felt to represent vestibular schwannoma, with blood products
within.
2. Areas of blood products in the CP angle region, anterior to
the medulla, and in the posterior fossa relate to the recently
noted subdural/subarachnoid hemorrhage.
3. Left MCA chronic infarct with hemosiderosis, related to
evolution of the chronic infarct.
4. Patent major intracranial arteries without focal
flow-limiting stenosis, occlusion, or aneurysm more than 3 mm
within the resolution of MR angiogram. Short segment stenosis of
M1 segment of the left Middle cerebral artery without flow
limitation related to prior ischemic event.
Conventional angiogram can be considered to confirm the source
of hemorrhage after discussion with the interventional
neuroradiologist, if there is continued cocern.
MR [**Name13 (STitle) **] ([**11-19**]): IMPRESSION:
1. Continued evolution of the blood products, noted in the CSF
space, anterior and to the left side of the medulla and in the
upper cervical canal with mild decrease in the anteroposterior
extent of the blood products as seen on the sagittal images;
improvemed but persistent compression on the upper cervical cord
and the left side of the medulla compared to the prior study
(but persistent).
2. Multilevel degenerative changes in the cervical spine as
described above.
Cerebral Angiography ([**11-20**]): IMPRESSION:
1. Prominent venous/vascular structures in the region of the
proximal V4 segment of the left vertebral artery may represent a
developmental venous anomaly/venous angioma. Hypervascular tumor
cannot be excluded.
2. Mild narrowing of the intradural V4 segments of the vertebral
arteries more on the left than on the right may represent spasm
versus hypoplastic intradural V4 segment of the vertebral
arteries.
ECG ([**11-22**]): Atrial fibrillation at a rate of 140. Moderate
artifact. Incomplete right bundle-branch block. Non-specific ST
segment changes in leads V4-V6.
ECG ([**11-22**]): Atrial fibrillation at a rate of 98. Incomplete
right bundle-branch block. The previously described ST segment
changes are less prominent.
Bilateral LENIs ([**11-22**]): IMPRESSION: No DVT in the bilateral
lower extremities.
CT Head ([**11-22**]): IMPRESSION:
1. Improving extra-axial hemorrhage. No new focus of
intraparenchymal hemorrhage is identified.
2. Stable left MCA infarct. No new major vascular territorial
infarction is detected.
CXR PA/Lateral ([**11-23**]): The cardiomediastinal silhouette is
unremarkable. The lungs are essentially clear except for minimal
atelectasis at the left base. There is small right pleural
effusion, part of it can be seen at the left apex. No
pneumothorax is demonstrated.
CT Torso ([**11-24**]): IMPRESSION:
1. No evidence of abscess and no explanation for the patient's
fever.
2. Cholelithiasis without cholecystitis.
3. Multiple renal cysts including two hyperattenuating, likely
hemorrhagic, cysts in the right kidney. These cysts could be
further evaluated by ultrasound on a non-emergent basis.
4. Moderately extensive diverticulosis without diverticulitis.
TTE ([**11-25**]): The left atrium is normal in size. 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>60%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The aortic valve leaflets are
mildly thickened. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
No vegetation seen (cannot definitively exclude).
MR [**Name13 (STitle) 430**]/IAC ([**11-29**]): IMPRESSION:
1. No evidence of acute infarct.
2. Chronic left MCA infarct is identified.
3. Small tentorial subdural is identified extending into the
retrocerebellar region indicating a small posterior fossa
subdural. No significant mass effect on the cerebellum seen.
4. Left-sided cerebellopontine angle mass consistent with
vestibular
schwannoma is identified which demonstrates intrinsic area of
blood products as seen on the previous CT. Limited comparison
with the previous MRI demonstrate no significant change in size
when comparing the differences in technique.
5. No evidence of midline shift or hydrocephalus.
PFTs ([**12-1**]):
SPIROMETRY 11:11 AM Pre drug
Actual Pred %Pred
FVC 4.90 5.68 86
FEV1 3.52 3.83 92
MMF 2.68 3.25 82
FEV1/FVC 72 67 107
LUNG VOLUMES 11:11 AM Pre drug
Actual Pred %Pred
TLC 7.48 8.69 86
FRC 4.61 4.98 92
RV 3.04 3.01 101
VC 4.54 5.68 80
IC 2.87 3.71 77
ERV 1.56 1.98 79
RV/TLC 41 35 118
He Mix Time 3.13
DLCO 11:11 AM
Actual Pred %Pred
DSB 30.62 27.92 110
VA(sb) 7.12 8.69 82
HB 13.90
DSB(HB) 31.25 27.92 112
DL/VA 4.39 3.21 137
Brief Hospital Course:
1. Extra-axial hematoma extending from the medulla along the
cervical spinal cord, likely due to bleeding around schwannoma:
The patient was admitted with new headache and neck pain, and
was found to have acute extra-axial hematoma extending from the
medulla along the cervical spinal cord to approximately the C3
vertebral level, with resultant mass effect on the cord with
rightward and posterior cord displacment and compression, as
well as probable cord edema. CTA head showed no evidence of AVM,
aneurysm formation, or other vascular abnormality. Cerebral
angiography showed prominent venous/vascular structures in the
region of the proximal V4 segment of the left vertebral artery
may represent a developmental venous anomaly/venous angioma, but
hypervascular tumor cannot be excluded. It was thought that the
cause of his bleeding was from the schwannoma.
His INR was 3.6 on admission, and he was given Prophylnine 2
vials, Vitamin K 10 mg IV x1, and 2 U FFP. His Coumadin and ASA
were discontinued, but his Aspirin was added back at 81 mg daily
at the time of discharge. Neurosurgery was consulted on
admission and recommneded reversing INR to 1.3. He was initially
admitted to the NeuroICU, where he returned to his baseline
aphasia and dysarthria. Hypercoaguable work up showed Lupus AC
neg, ATIII nl, Prot C nl, Prot S nl ACA IgG/IgM nl, homocysteine
nl, FVL no mutation, MTHFR Heterozygous, prothrombin no
mutation. He will follow up with Dr. [**Last Name (STitle) **] in Neurology as an
outpatient.
2. Atrial fibrillation with rapid ventricular response: The
patient has a history of atrial fibrillation on Coumadin. During
this admission, his Coumadin and ASA were discontinued given his
extra-axial hematoma around his schwannoma. His ASA 81 mg daily
was added back at the time of discharge. His outpatient
cardiologist, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 112**] was [**Hospital1 653**] about this
medication change. He went into atrial fibrillation with RVR
requiring a diltiazem gtt. Given that it was too risky to put
him back on Coumadin, EP was consulted for possible ablation and
initiation of antiarrythmic. He was started on Amiodarone 200 mg
tid which should be continued for 1 month, then changed to 200
mg daily. Baseline PFTs were obtained. He will be sent out with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor for the next 2 weeks, so monitor his
QTc and heart rate while starting Amiodarone. His QTc at the
time of discharge was 462. His Ditiazem was changed to Diltiazem
SR 240 mg daily. He will follow up with Dr. [**Last Name (STitle) 914**] in Cardiac
Surgery to consider Minimaze procedure with surgical PVI and [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 94279**]. He will follow up with Dr. [**Last Name (STitle) **] in
Cardiology/Electrophysiology.
3. Fevers: The patient spiked temperatures during his hospital
stay. WBC was 14.1 on admission with 88% neutrophils, and peaked
at 18.7 Urine Cx ([**11-17**]): <10,000 organisms/ml, ([**11-21**], [**11-25**]):
No growth, and ([**11-22**]): ENTEROCOCCUS >100,000 ORGANISMS/ML;
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.
ID thought the enterococcus was likely a contaminent. Blood Cx
([**11-21**], [**11-22**] x3, [**11-23**] x2, [**11-25**] x2): No growth. The team was
unable to do an LP given his posterior fossa mass. CXR and LFTs
were normal, ANCA was negative, and TTE did not show any
vegetations. CT Torso showed no evidence of abscess and no
explanation for the patient;s fever. LENIs showed no DVT in the
bilateral lower extremities. ID was consulted and recommended
starting Vancomycin 1 gm IV q12 hr and Meropenem 500 mg q6 hr to
cover for nosocomial organisms. He completed a 7 day course of
these antibiotics.
4. Hypertension: His bp was 167/92 on admission. His Nadolol was
discontinued, and he was started on Diltiazem SR 240 mg daily
and Amiodarone 200 mg tid, to be changed to 200 mg daily in 1
month.
5. Dyslipidemia: He was continued on Simvastatin 40 daily.
6. Papillary renal cell carcinoma: CT Torso showed multiple
renal cysts including two hyperattenuating, likely hemorrhagic,
cysts in the right kidney. He had recently had an MRI Abdomen at
[**Hospital1 112**] ([**2149-10-1**]) which showed:
-Stable in size partially exophytic solid mass in the lower pole
of the right kidney, consistent with known papillary renal cell
carcinoma, unchanged in size and appearance since comparison
study from [**2149-5-23**]
-Multiple stable in size bilateral renal cysts. The cyst in the
lower pole of the right kidney with slighly thickened walls is
also unchanged.
-Bilateral adrenal nodules likely representing adenoma
-Cholelithiasis
-Linear scarring in the parenchyma of the spleen, likely sequela
of prior infarcts.
7. Gout: He was continued on Allopurinol 300 mg daily.
8. Urology: The patient failed bladder trains and voiding trials
during this admission. He was started on Flomax daily, and will
be discharged to rehab with a Foley in place. The Foley can be
attempted to be removed at rehab.
Medications on Admission:
-Warfarin 7.5 mg on Mondays, 10 mg daily on other days
-ASA 81 mg on Monday, Wednesday, and Friday
-Corgard 20 mg daily
-Simvastatin 40 mg daily
-Allopurinol 300 mg daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): ***200 mg tid for 1 month, then change to 200 mg
daily***.
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-22**] Sprays Nasal
QID (4 times a day) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain or fever.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection TID (3 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO TID
(3 times a day) as needed for constipation.
12. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
PRIMARY:
Extra-axial hematoma extending from the medulla along the
cervical spinal cord, likely due to bleeding around schwannoma
Schwannoma
Atrial fibrillation with rapid ventricular response
SECONDARY:
Chronic left MCA infarct
Hypertension
Dyslipidemia
History of Pulmonary embolism
Papillary renal cell carcinoma
Gout
Discharge Condition:
Aphasia, dysarthria. Full strength, decreased sensation on right
face and RUE, slightly increased reflexes on the right
Discharge Instructions:
You were admitted to the hospital with headache and neck pain,
and were found to have a hematoma around your medulla to the
cervical spinal cord which was likely due to bleeding around
your schwannoma. Your Coumadin was discontinued, but you were
continued on Aspirin 81 mg daily. You were started on Amiodarone
200 mg three times a day and Diltiazem SR 240 mg daily to help
control your atrial fibrillation. In one month, you should
increase the Amiodarone to 200 mg daily. You will follow up with
Dr. [**Last Name (STitle) 914**] in Cardiac Surgery as an outpatient for
consideration of procedures to control your atrial fibrillation.
You were discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor for the next 2
weeks while you are starting the Amidodarone. The information
from this monitor should be sent to Dr.[**Name (NI) 7914**] office. You
spiked fevers while hospitalized, but no infectious source of
the fevers was found.
The following changes were made to your medications: Your
Coumadin was discontinued given the bleeding around your
schwannoma. Your Nadolol was discontinued. You were started on
Amiodarone 200 mg three times a day, which should be changed to
Amiodarone 200 mg daily in 1 month. You were started on
Diltiazem SR 240 mg daily. You were started on Flomax daily as
we were unable to successfully remove your Foley catheter. In a
week while in rehab, they can attempt to remove the Foley.
If you develop increased headache or neck pain, new weakness or
numbness, increased difficulty speaking or swallowing, decreased
vision or blurry vision, fevers/chills, cough, chest pain,
diarrhea, pain or burning on urination, or any other symptoms
that conern you, call your PCP or return to the ED.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 914**] in Cardiac
Surgery ([**Telephone/Fax (1) 170**]) on [**2149-12-30**] at 1:00 pm in the [**Hospital Unit Name 3269**], [**Location (un) 551**].
You have a follow up appointment with Dr. [**Last Name (STitle) **] in Neurology
([**Telephone/Fax (1) 2574**]) on [**2150-1-6**] at 2:00 pm in the [**Hospital Ward Name 23**] Center, [**Location (un) 6749**].
You have a follow up appointment with Dr. [**Last Name (STitle) **] in
Cardiology/Electrophysiology ([**Telephone/Fax (1) 62**]) [**2150-1-14**] at 1:00 pm
in the [**Hospital Ward Name 23**] Building, [**Location (un) **].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
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"225.1",
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"189.0",
"V12.51",
"348.4",
"788.20",
"336.1",
"401.9",
"438.11",
"E878.8",
"322.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
19853, 19930
|
13234, 18358
|
292, 337
|
20296, 20418
|
6010, 13211
|
22230, 22974
|
3916, 3976
|
18580, 19830
|
19951, 20275
|
18384, 18557
|
20442, 22207
|
3991, 4389
|
2296, 2558
|
233, 254
|
365, 2277
|
4760, 5991
|
4428, 4744
|
4413, 4413
|
2580, 3734
|
3750, 3900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,849
| 139,472
|
37472
|
Discharge summary
|
report
|
Admission Date: [**2130-2-17**] Discharge Date: [**2130-2-22**]
Date of Birth: [**2105-8-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Tylenol OD
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 58665**] is a 24F with a PMH s/f substance abuse, who ingested
150 500mg tables of Tylenol at 1pm on [**2129-2-17**]. She was taken to
an OSH ED where her Tylenol level was noted to be 424 at approx
2pm. She was started on NAC but infused at the incorrect dose.
She was transferred to [**Hospital1 18**] ED where her Tylenol level was 450
at 7:30pm. It is unclear if she recieved charcol in the first
four hours s/p ingestion.
.
In the ED, initial vs were: VS 87 112/62 20 98% RA. Patient was
reloaded with NAC at 150mg/kg over 1 hr, then continued on
50mg/kg over 4 hours. She was initially admitted to the floor,
but given concerns for her impending liver failure she was
admitted to the ICU. She endorses N/V.
Past Medical History:
1. Migraine headaches
2. Substance abuse- Narcotics
Social History:
The patient lives in [**Hospital3 **] with her boyfriend and 5-year-old
son. She reports that her relationship with her boyfriend is
supportive, and denies domestic violence. Her son is healthy.
Her mother also lives nearby and provides social support. She
is currently unemployed. She smokes 1/2ppd, rare ETOH, and has
a history of narcotic dependence.
Family History:
NC
Physical Exam:
Vitals - T:99.1 BP:116/65 HR:97 RR:24 02 sat:97% RA
GENERAL: Young, healthy appearing young woman, cooperative and
pleasant.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM. Abdominal striae.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses. Multiple tattoos.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Listens and responds to questions appropriately,
pleasant. Occasionally tearful.
Pertinent Results:
Peak ALT/AST on admission ([**2130-2-17**])- 101/67, trended down to
48/16 on [**2130-2-21**].
.
Total bilirubin remained within normal limits
.
Peak acetaminophen level on [**2130-2-17**] was 450, cleared by
[**2130-2-20**]
.
INR peaked at 1.4 on [**2130-2-17**], and normalized to 1.0 on
[**2130-2-20**]
Brief Hospital Course:
Ms. [**Known lastname 58665**] was initially admitted to the Medical ICU out of
concern for possible liver failure after ingesting ~75g of
acetaminophen in an attempt to commit suicide. She was started
on the appropriate dose of N-acetylcysteine, using an
intravenous protocol secondary to nausea and vomiting. She
tolerated this well, and her transaminases, acetaminophen
levels, and coagulation parameters normalized by hospital day
#4, at which point the NAC was discontinued. She was maintained
on a 1:1 sitter, and was co-managed with psychiatric
consultation. She agreed to the plan of care recommended by
both the medicine and psychiatric teams, which was inpatient
psychiatric care.
She developed menstrual cramps during her hospital stay, which
was managed with ibuprophen. For anxiety and insomnia, she was
written for 0.5mg lorazepam as needed at bedtime.
Medications on Admission:
Oral contraceptive pills
Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Acetaminophen overdose- medically cleared for inpatient
psychiatric care
Discharge Condition:
Normal mental status, stable vital signs, ambulatory.
Discharge Instructions:
You were admitted after a tylenol overdose. You tolerated
treatment with a medication called "N-acetylcysteine" very well
with no complications. Your liver function improved, as you
cleared the tylenol. We are recommending inpatient psychiatric
care to help initiate management of your anxiety.
Followup Instructions:
To be set up on discharge from your psychiatric hospitalization
|
[
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"305.1",
"787.01",
"304.90",
"965.4"
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4067, 4112
|
2730, 3605
|
327, 333
|
4229, 4285
|
2400, 2707
|
4631, 4698
|
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3680, 4044
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4133, 4208
|
3631, 3657
|
4309, 4608
|
1582, 2381
|
276, 289
|
361, 1097
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1119, 1172
|
1188, 1547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,296
| 185,194
|
27863
|
Discharge summary
|
report
|
Admission Date: [**2134-6-5**] Discharge Date: [**2134-6-18**]
Date of Birth: [**2054-1-26**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
worsening lower quadrant pain
Major Surgical or Invasive Procedure:
exploratory laparotomy, sigmoid resection, [**Doctor Last Name 3379**] pouch,
repair of epigastric hernia, liver biopsy for perforated
diverticulitis
History of Present Illness:
Patient is an 80-year-old female on high-dose steroids for Bell
palsy who presents with a 1- week history of lower quadrant pain
that became progressively
worse in the last 3 days. She presented to an outside hospital
on the 14th with abdominal pain and was found to have free air
on CT scan. In addition to this, she also had a thickened
sigmoid colon with diverticuli; however, the
etiology of the perforation was not clear. She was transferred
here for further care and was diagnosed here again with a
perforated viscus likely from perforated diverticulitis. She was
consented for an exploratory
laparotomy, abdominal washout, possible bowel resection,
possible colostomy.
Past Medical History:
Bell's palsy on hig dose steriods for 3-4 weeks (120-50mg/day),
h/o Zoster, hyperchol
Social History:
no tobacco, EtOH, drugs
Family History:
n/c
Physical Exam:
97.2 87 116/70 18 96%on RA
NAD
R ptosis, facial droop
rrr, no m/r/g
CTAB
abd. soft, obese, diffuse tenderness, +rebound, +guarding in
BLQs
rectal guaiac -
On discharge:
stoma functioning well, wound open and granulating with vac in
place.
Pertinent Results:
[**2134-6-5**] 12:36AM PT-10.9 PTT-22.1 INR(PT)-0.9
[**2134-6-5**] 06:22AM PLT COUNT-241
[**2134-6-5**] 06:22AM WBC-3.9*# RBC-4.36 HGB-12.6 HCT-38.8 MCV-89
MCH-29.0 MCHC-32.5 RDW-19.4*
[**2134-6-5**] 06:22AM CALCIUM-8.0* PHOSPHATE-5.8*# MAGNESIUM-1.8
[**2134-6-5**] 06:22AM GLUCOSE-151* UREA N-32* CREAT-1.3* SODIUM-142
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14
[**2134-6-5**] 12:36AM PT-10.9 PTT-22.1 INR(PT)-0.9
[**2134-6-5**] 06:22AM PLT COUNT-241
[**2134-6-5**] 06:22AM WBC-3.9*# RBC-4.36 HGB-12.6 HCT-38.8 MCV-89
MCH-29.0 MCHC-32.5 RDW-19.4*
Brief Hospital Course:
Patient was transferred to [**Hospital1 18**] and brought to the OR for
exploratory laparotomy. The patient wad transferred from the
PACU to SICU. She remained hemodynamically stable with stable
vitals and good urine production. On POD2 she went into a. fib.
her rate was controlled on beta blocker and she returned to
[**Location 213**] sinus rhythm. She remained in nsr for the remainder of
her hospital stay. She remained in the SICU until POD3 she was
transfered to the regular floor.
On POD4 her liver biopsy path came back showing adenocarcinoma.
Oncology service was consulted and sent the path samples for
further staining to determine the primary site. CT abd/pelvis
done on [**6-14**] showed a possible pelvic mass and a pelvic US
showed a complex mass at the right/posterior aspect of the
uterus. Gyn was consulted and they agreed to follow the patient
on an outpatient basis for a possible gyn primary. An MRI was
done and showed the uterine mass to be consistent with a
fibroid. She was scheduled for Gyn and Onc followup on an
outpatient basis.
She was started on TPN. Her stoma was functioning well. On
POD5 her diet was advanced to sips to clears with aspiration
precautions. On POD6 her FS was running high to 300s and
insulin sliding scale was adjusted and TPN was held. Glucose
stayed within normal limits afterwards. On POD 7 she was
restarted on [**11-23**] TPN.
Her wound had to be opened and was packed wet to dry and her
wound was cultured. A wound vac was later placed and set up to
be changed q3 days.
On discharge, she was ambulating with physical therapy. She was
to maintain a soft diet with supervision. She was restarted on
her steroid taper as per PCP.
Medications on Admission:
Pred 50'
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: [**11-23**] PO Q4-6H (every
4 to 6 hours) as needed.
2. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
TID (3 times a day).
3. Prednisone 20 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily):
please decrease to 45mg in 1 week. Decrease by 5mg every 2
weeks.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
7. Chewable multivitamin q1day
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
perforated diverticulitis
Discharge Condition:
stable
Discharge Instructions:
Please have staples taken out in one week.
Please have wound vacuum changed every 3 days.
Please [**Name8 (MD) 138**] MD or come to the ER if you notice redness,
swelling, purulent discharge around the wound site or for
fever>101.5.
Please resume taking all medications as taken prior to this
surgery and pain medications and stool softener as prescribed.
Please follow-up as directed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9899**], M.D. Phone:[**Telephone/Fax (1) 558**]
Date/Time:[**2134-7-5**] 1:00
Please call [**Telephone/Fax (1) 5777**] to set up an appointment with
[**Hospital 67897**] clinic.
Please call [**Telephone/Fax (1) 22**] to set up an appointment with oncology
clinic.
Please call [**Telephone/Fax (1) 2998**] to set up an appointment with Dr.
[**Last Name (STitle) 6633**].
Completed by:[**2134-6-18**]
|
[
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] |
icd9cm
|
[
[
[]
]
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[
"45.76",
"50.12",
"46.10",
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icd9pcs
|
[
[
[]
]
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4617, 4703
|
2244, 3948
|
343, 494
|
4773, 4782
|
1646, 2221
|
5221, 5699
|
1366, 1371
|
4007, 4594
|
4724, 4752
|
3974, 3984
|
4806, 5198
|
1386, 1542
|
1556, 1627
|
274, 305
|
522, 1200
|
1222, 1309
|
1325, 1350
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,624
| 118,997
|
43360
|
Discharge summary
|
report
|
Admission Date: [**2105-10-28**] Discharge Date: [**2105-11-7**]
Date of Birth: [**2032-9-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
pericardial effusion, uremia
Major Surgical or Invasive Procedure:
insertion of tunneled hemodialysis catheter
History of Present Illness:
73 yo F with DM2, CKD stage 4, hypertension, hyperlipidemia,
CAD, and ITP presenting from nephrology office generalized
weakness. She has complained of gradually worsening fatigue and
weakness for the last 5 days. She has never received dialysis,
but she has an AV fistula in place for about a year due to her
nephrologist's concern for a dialysis need in the near future.
There was a plan for her to start dialysis on Monday anyway. She
was sent to the ED from her nephrologist's office when he saw
how weak she was.
.
She was admitted very recently with similar chronic weakness,
and chest pain. She was found to have a 90% stenosis of the
mid-LAD and received a bare metal stent.
.
In the [**Last Name (LF) **], [**First Name3 (LF) **] ultrasound was performed showing a circumferential
pericardial effusion with question of RV mattressing. She
remained hemodynamically stable with relative hypotension.
Vitals on transfer were 98.0 78 20 98 101/72.
.
On arrival to the MICU, she is still feeling weak. She is also
complaining of chest pain under her left breast that started
after her echo this morning. She feels the pain is worse with
pressure and worse with inspiration as well.
Past Medical History:
# Unstable angina s/p BMS to the LAD [**10/2105**]
# Diabetes Mellitus Type 2 -- last HgbA1c 5.6% ([**2105-2-9**])
# CKD Stage 4 -- baseline creatinine 3.9-4.2
-- Left AV fistula in place but not on HD
# Anemia of CKD -- on Procrit
# Hyperlipidemia -- LDL 124 ([**2105-9-21**])
# DVT -- following airline flight many years ago
# Hypothyroidism
# Thyroid nodules
# ITP -- severe thrombocytopenia in [**2097**], now stable
# Sjogrens Syndrome
# Sarcoidosis
# Obesity -- BMI ~32
# Carpal Tunnel Syndrome -- prior surgery
# Gout
Social History:
She is originally from [**Male First Name (un) 1056**]. She is widowed for several
years and 2 adult children who live in the area. She lives by
herself but has been staying with a sister recently. She is
mostly independent in her ADLs.
- Alcohol: None
- Tobacco: Never smoked
- Drugs: None
Family History:
# Father -- MI, died at age 64
# Mother -- DM2, died at age 78
# Brother -- renal cell cancer
# Sister -- DM2, asthma
Physical Exam:
ADMISSION EXAM
Vitals: T 97.8, BP 128/63, HR 79, RR 16, O2 98%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, reproducible tenderness of left chest
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mildly tender LUQ, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ edema
.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP is flat. Pulsus is 10
CV: Regular rate and rhythm, II/VI systolic murmur, normal S1 +
S2,rubs, gallops
Lungs: CTAB
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly
Ext: warm, well perfused, 2+ pulses, 1+ edema b/l; L AV fistula
w/ thrill
Neuro: AOx3
Pertinent Results:
ADMISSION LABS:
[**2105-10-28**] 11:55AM BLOOD WBC-10.3# RBC-3.32* Hgb-9.9* Hct-28.8*
MCV-87 MCH-29.9 MCHC-34.5 RDW-16.2* Plt Ct-201#
[**2105-10-28**] 11:55AM BLOOD Neuts-84.4* Lymphs-9.6* Monos-3.6 Eos-1.8
Baso-0.5
[**2105-10-28**] 11:55AM BLOOD Glucose-184* UreaN-96* Creat-5.0*#
Na-132* K-5.1 Cl-97 HCO3-19* AnGap-21*
PERTINENT INTERVAL LABS:
[**2105-10-31**] 07:31AM BLOOD WBC-8.8 RBC-2.94* Hgb-8.4* Hct-25.2*
MCV-86 MCH-28.5 MCHC-33.2 RDW-16.4* Plt Ct-203
[**2105-11-1**] 08:22AM BLOOD Ret Aut-2.3
[**2105-10-30**] 05:00PM BLOOD Glucose-167* UreaN-115* Creat-5.6*
Na-132* K-4.9 Cl-98 HCO3-19* AnGap-20
[**2105-11-1**] 08:22AM BLOOD Glucose-193* UreaN-75* Creat-4.5*# Na-135
K-3.8 Cl-97 HCO3-25 AnGap-17
[**2105-10-30**] 05:00PM BLOOD Calcium-8.8 Phos-5.5* Mg-1.9
[**2105-11-1**] 08:22AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.0 Iron-20*
[**2105-11-1**] 08:22AM BLOOD calTIBC-169* VitB12-1532* Folate-GREATER
TH Hapto-382* Ferritn-874* TRF-130*
[**2105-10-29**] 02:31AM BLOOD Osmolal-304
[**2105-10-31**] 07:11AM BLOOD PTH-300*
URINE:
[**2105-10-28**] 06:21PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2105-10-28**] 06:21PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2105-10-28**] 06:21PM URINE RBC-<1 WBC-6* Bacteri-MOD Yeast-NONE
Epi-7
[**2105-10-29**] 05:17AM URINE Hours-RANDOM Na-28 K-31 Cl-20
[**2105-10-29**] 05:17AM URINE Osmolal-310
MICRO:
MRSA Negative screen
ECHO (Atrius) [**2105-10-28**]
1. The left ventricle size is normal. There is mild concentric
left ventricular hypertrophy. There are no regional wall motion
abnormalities. Overall left ventricular ejection fraction is
normal, with an estimated LVEF of 60-65%.
2. The left atrial volume is mildly increased.
3. The right atrium is normal in size. There is end-diastolic
indentation of the RA free wall, suggesting some elevation of
pericardial pressure.
4. PA systolic pressure, estimated at 19 mmHg above RA
pressure.
5. There is a moderate concentric pericardial effusion present,
measuring 1.0 cm in diameter anteriorly and posteriorly at
end-diastole in the parasternal long-axis view. There is
fibrinous material adherent to the visceral pericardium along
the RV free wall.
There is no evidence of cardiac tamponade.
6. No significant valvular heart disease visualized on this
study.
7. Compared with the findings of the prior report of [**2105-10-18**]
from [**Hospital1 18**], the presence of a pericardial effusion is new. Dr.
[**Name (NI) 93351**] (Renal) notified and he is arranging admission to
hospital for early
institution of dialysis.
.
ECHO ([**Hospital1 18**]) [**2105-10-28**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). A mid-cavitary gradient is identified.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. There is abnormal septal
motion/position. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a moderate sized pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. No right ventricular diastolic collapse
is seen. There is brief right atrial diastolic invagination is
seen c/w elevated intrapericardial pressure.
Compared with the prior study (images reviewed) of [**2105-10-18**], a
pericardial effusion is now seen with evidence of elevated
intrapericardial pressure but no overt tamponade.
.
EKG [**2105-10-28**]: NSR rate of 80, low voltage in all leads, old T
wave inversions in lateral leads
CXR ([**10-28**]):
FINDINGS: Single AP upright portable view of the chest was
obtained. No
focal consolidation, large pleural effusion, or evidence of
pneumothorax is
seen. Enlarged cardiac silhouette persists. The aorta is
calcified and
tortuous. Hilar contours are unremarkable.
IMPRESSION: Persistent enlargement of the cardiac silhouette
without overt
pulmonary edema.
AV Fistulogram ([**10-30**]): PENDING
CXR ([**11-1**]):
FINDINGS: In comparison with the study of [**10-28**], the patient has
taken a
better inspiration. Central catheter extends to the lower
portion of the SVC.
There is continued enlargement of the cardiac silhouette,
especially
considering that this is a PA rather than AP view. Opacification
in the
retrocardiac area most likely represents volume loss in the
lower lobe and
effusion. However, in the appropriate clinical setting, a
supervening
pneumonia would have to be seriously considered. No evidence of
pulmonary
vascular congestion..
.
[**2105-11-6**] 07:06AM BLOOD WBC-7.1 RBC-2.85* Hgb-8.1* Hct-25.6*
MCV-90 MCH-28.5 MCHC-31.8 RDW-15.9* Plt Ct-148*
[**2105-11-6**] 07:06AM BLOOD Plt Ct-148*
[**2105-11-6**] 07:06AM BLOOD Glucose-139* UreaN-28* Creat-2.9* Na-138
K-4.0 Cl-97 HCO3-30 AnGap-15
[**2105-11-6**] 07:06AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9
Brief Hospital Course:
=================
BRIEF HOSPITAL SUMMARY
=================
73 yo F with DM2, CKD stage 4, hypertension, hyperlipidemia, CAD
s/p NSTEMI, and ITP presenting with pericardial effusion without
tamponade physiology, with worsening uremia.
Uremia, CKD stage 5: Pt was initiated on dialysis through a CVL.
Outpatient dialysis was arranged at [**Hospital **] Health Center
TuThSat.
Pericardial effusion: No evidence of tamponade physiology during
the admission. A repeat ECHO showed improvement of the
pericardial effusions.
AVF malfunction: The patient was also found to have a
non-functioning fistula. She was set up with transplant
outpatient vascular service to plasty the fistula.
Medications on Admission:
Actos 15 mg PO twice weekly: on Sunday and Wednesday
Levothyroxine 75 mcg daily
Calcitriol 0.25 mcg 1 tab every other day alternating with 2 tab
every other day
Allopurinol 100 mg Tablet every other day
Ferrous sulfate 325 mg (65 mg iron) daily
Vitamin C 500 mg daily
Vitamin D 400 mg daily
Procrit 20,000 unit/mL injection every other week
Aspirin 325 mg daily for 30 days.
Clopidogrel 75 mg daily
Atorvastatin 40 mg [**Hospital 5910**]
Metoprolol succinate 25 mg daily
Glipizide 5 mg QID
Calcium acetate 667 mg TID
Lasix 20 mg daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
primary diagnosis: uremia, end-stage renal disease
pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Completed by:[**2105-11-7**]
|
[
"710.2",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"88.49",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
10303, 10360
|
9034, 9717
|
336, 382
|
10475, 10475
|
3542, 3542
|
2470, 2589
|
10381, 10381
|
9743, 10280
|
3151, 3523
|
268, 298
|
410, 1598
|
3558, 9011
|
10400, 10454
|
10490, 10631
|
1620, 2146
|
2162, 2454
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,806
| 115,484
|
2211+55360
|
Discharge summary
|
report+addendum
|
Admission Date: [**2122-11-2**] Discharge Date: [**2122-11-14**]
Date of Birth: [**2052-4-9**] Sex: F
Service: MEDICINE
Allergies:
Meperidine / Erythromycin Base / Oxycodone / Fentanyl / Levaquin
/ Cephalosporins
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
mid sternal chest pressure associated with SOB at rest, relieved
with NTG
Major Surgical or Invasive Procedure:
[**2122-11-3**] - CABGx3 (LIMA-->LAD, SVG-->OM, SVG-->RCA), AVR (21mm
CE pericardial model 2800)
[**2122-11-2**] - Cardiac Catheterization
History of Present Illness:
70 year old white female with extensive cardiac history, EF
<20%, past MI's, several RCA PCI's, including rotational
atherectomy/PTCA/stenting of proximal and mid RCA in [**2-21**], HTN,
hyperlipidemia, PVD, Type II DM, presented to osh ER on [**2122-10-30**]
with c/o recurrent angina. States had mid-sternal chest "heavy
pressure" associated with SOB at rest. Took NTG SL and pain
resloved however recurred and she went to ER. Denies
diaphoresis, N/V, palpitations, lightheadedness, PND, orthopnea.
Patient ruled out for MI by enzymes. ECG showed anterolateral
ST depression. She was placed on NTG gtt primarily for BP
control. She was then transferred to [**Hospital1 18**] for cardiac
cath(results below).Referred to Dr. [**Last Name (STitle) **] for AVR/CABG.
Past Medical History:
1. CAD. Cardiac cath in [**2117**] with 80% proximal RCA lesion,
50-60% distal RCA lesion, 50% OM and a 40% distal LM/PLAD
lesion. S/p PTCA and stent placement to the proximal RCA.
Cardiac cath [**2118**]: RCA had an ostial 30-40% stenosis and mild
30-40% diffuse in-stent restenosis. EF of 60%. Cardiac cath
[**2121-12-26**], with 30% instent restenosis in the previously placed
RCA stent, and 95% mid vessel stenosis. PTCA with Cypher stent
placement performed, with 10% residual stenosis.
2. CHF, last EF 60% in [**2118**]. Recent ECHO showed her EF to be
40%.
3. Hypothyroidism
4. Diabetes mellitus type 2
5. COPD
6. mild CRI
7. elev. chol
8. prior GI bleed on ASA/plavix
Past Surgical History:
1. Aorto-bifem bypass [**2111**]
2. Pseudoaneurysm repair '[**17**]
3. Bilateral cataract surgery
Social History:
She lives with her sister, no etOH. Ex-smoker, stopped smoking 9
years ago (smoked [**12-21**] ppd X 35 yrs).
Family History:
noncontributory
Physical Exam:
BP right arm 111/41 left arm 156/52
HEENT: Bliateral carotid bruits present
Chest: CTA, RRR no m/r/g
ABD: S/NT/ND/BS+
EXT: multiple varicosities
Pulses:
right radial + brachial + femoral + DP + PT +
left radial + brachial + femoral + Dp + PT +
Pertinent Results:
[**2122-11-10**] 12:35PM BLOOD WBC-7.6 RBC-4.51 Hgb-13.2 Hct-38.3 MCV-85
MCH-29.3 MCHC-34.5 RDW-14.5 Plt Ct-259
[**2122-11-10**] 12:35PM BLOOD Plt Ct-259
[**2122-11-10**] 12:35PM BLOOD Glucose-184* UreaN-42* Creat-1.5* Na-136
K-4.6 Cl-93* HCO3-30 AnGap-18
[**2122-11-10**] 12:35PM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1
[**2122-11-5**] 06:14PM BLOOD Hapto-217*
[**2122-11-2**] Cardiac Catheterization
1. Selective coronary angiography of this right dominant
system demonstrated severe two (2) vessel coronary artery
disease.
Specifically the left main was heavily calcified and
demonstrated
diffuse disease with a 80% ostial lesion that extended into the
Aorta.
The Left circumflex demonstrated mild illuminal irregularites
throughout
the vessel with no flow limiting lesions. The LAD also
demonstrated
only minor illuminal irregularities. The RCA was diffusely
diseased
throughout the vessel with extensive in-stent restenosis with an
80%
ostial lesion and a 90% mid vessel lesion.
2. LV ventriculography was deferred.
3. Limited resting hemodynamics demonstrated an elevated
central aortic
pressure.
[**2122-11-10**] CXR
Moderate bilateral pleural effusions are increasing in size. In
addition, there is moderate-to-severe bilateral atelectasis.
Pneumonia as an explanation for increasing left lower lobe
opacity cannot be excluded. The heart is normal size, the
mediastinal caliber is within normal limits, and there is no
evidence for pulmonary edema. Right IJ catheter tip projects
over the SVC and pacemaker leads course their anticipated paths.
Median sternotomy wires identified. No pneumothoraces.
[**2122-11-3**] Carotid Series
Moderate plaque with bilateral 40%-59% carotid stenosis. Of
note, on the left vertebral artery, there is increase in
velocity, which is consistent with some intrinsic disease.
[**2122-11-2**] ECHO
The left atrium is normal in size. The left ventricular cavity
size is normal. LV systolic function appears mildly to
moderately depressed. Resting regional wall motion abnormalities
include inferior and inferolateral akinesis/hypokinesis. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is mild
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
There is an anterior space which most likely represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
Compared with the prior study (tape reviewed) of [**2122-2-27**], the
left ventricle now appears less dilated and left vnetricualr
systolic function appears less depressed. Mitral regurgitation
is now less prominent.
[**2122-11-13**] 07:15AM BLOOD Hct-33.4*
[**2122-11-13**] 07:15AM BLOOD UreaN-59* Creat-2.0*
[**2122-11-12**] 06:55AM BLOOD UreaN-53* Creat-1.8* K-4.2
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2122-11-2**] for further
management of her chest pain. She was taken to the
catheterization lab where she was found to have an 80% stenosed
left main coronary artery and a 90% in-stent stenosed right
coronary artery. Given the severity of her disease, the cardiac
surgical service was consulted for surgical revascularization.
She was worked-up in the usual preoperative manner including a
carotid duplex ultrasound which revealed moderate plaque with
bilateral 40%-59% carotid stenosis. An echocardiogram was
performed which revealed 1+ aortic regurgitation, 1+ mitral
regurgitation and an ejection fraction of 40-45%.
On [**2122-11-3**], Ms. [**Known lastname **] was taken to the operating room. An
intraoperative transesophageal echocardiogram revealed severe
aortic stenosis and EF 30-35% thus she underwent coronary artery
bypass grafting to three vessels and an aortic valve replacement
using a 21mm [**Last Name (un) **] [**Doctor Last Name **] pericardial model 2800
bioprosthesis. Postoperatively she was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, she awoke neurologically intact and was extubated. The
electrophysiology service was consulted for interrogation of her
internal cardiac defibrillator and some changes were made to the
atrial and ventricular output. Beta blockade and aspirin were
resumed. She was gently diuresed towards his preoperative
weight. As she was anemic postoperatively, she was transfused
with packed red blood cells. Her oxygen requirements remained
high given her COPD however slowly improved over time. On
postoperative day seven, she was transferred to the step down
unit for further recovery. The physical therapy service was
consulted to assist with her postoperative strength and
mobility. Her oxygen saturations improved to 93% on a nasal
canula. Her creatinine rose to 2.0 on POD #10 and her lasix was
decreased to 20 mg qd. She continued to be monitored on the
floor and awaits tranfer to rehab. (stopped [**11-13**]).
Medications on Admission:
Toprol XL 100mg QAM and 200mg QPM
Aldactone 25mg QD
Aspirin 81mg daily
Zocor 40mg daily
Iron
Synthroid 100mcg daily
Glucophage 1000mg twice daily
aldactone 25 mg daily
Imdur 30mg twice daily
Norvasc 5mg daily
Protonix 40mg twice daily
Prednisone for rash ( completed wean off on [**11-1**])
betamethasone ointment to back rash [**Hospital1 **]
Discharge Medications:
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
CHF
HTN
DM, type II
Hypercholesteremia
CAD
PVD
CRI
COPD
Anemia, past GIB on plavix/ASA
Colon polyps
C. Diff [**1-24**]
PCI
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
one week.
3) No lotions, creams or powders to wounds
4) Report any fevers greater then 100.5
5) no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in four weeks ([**Telephone/Fax (1) 11763**]
Follow up with Dr. [**Last Name (STitle) 11493**] in [**12-21**] weeks ([**Telephone/Fax (1) 11764**]
Completed by:[**2122-11-14**] Name: [**Known lastname 400**],[**Known firstname 1617**] E Unit No: [**Numeric Identifier 1618**]
Admission Date: [**2122-11-2**] Discharge Date: [**2122-11-14**]
Date of Birth: [**2052-4-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Meperidine / Erythromycin Base / Oxycodone / Fentanyl / Levaquin
/ Cephalosporins
Attending:[**First Name3 (LF) 741**]
Addendum:
[**2122-11-14**] Creatinine level came down from 2 to 1.7. Pt discharged
to rehab facility in stable condition.
Major Surgical or Invasive Procedure:
[**2122-11-3**] - CABGx3, (LIMA-->LAD, SVG-->OM, SVG-->RCA)
AVR (21mm CE pericardial model 2800)
[**2122-11-2**] - Cardiac Catheterization
Past Medical History:
1. CAD. Cardiac cath in [**2117**] with 80% proximal RCA lesion,
50-60% distal RCA lesion, 50% OM and a 40% distal LM/PLAD
lesion. S/p PTCA and stent placement to the proximal RCA.
Cardiac cath [**2118**]: RCA had an ostial 30-40% stenosis and mild
30-40% diffuse in-stent restenosis. EF of 60%. Cardiac cath
[**2121-12-26**], with 30% instent restenosis in the previously placed
RCA stent, and 95% mid vessel stenosis. PTCA with Cypher stent
placement performed, with 10% residual stenosis.
2. CHF, last EF 60% in [**2118**]. Recent ECHO showed her EF to be
40%.
3. Hypothyroidism
4. Diabetes mellitus type 2
5. COPD
6. mild CRI
7. elev. chol
8. prior GI bleed on ASA/plavix
Past Surgical History:
1. Aorto-bifem bypass [**2111**]
2. Pseudoaneurysm repair '[**17**]
3. Bilateral cataract surgery
Social History:
She lives with her sister, no etOH. Ex-smoker, stopped smoking 9
years ago (smoked [**12-21**] ppd X 35 yrs).
Family History:
noncontributory
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-21**]
Drops Ophthalmic PRN (as needed).
Disp:*qs one month * Refills:*2*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs one month * Refills:*2*
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for ritchy rash on back.
Disp:*qs month * Refills:*0*
9. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
Disp:*qs month * Refills:*2*
11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-21**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*qs one month * Refills:*0*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every
2 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs one month * Refills:*0*
15. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 5 days.
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1620**] - [**Location (un) 1621**]
Discharge Diagnosis:
CHF
HTN
DM, type II
Hypercholesteremia
CAD
PVD
CRI
COPD
Anemia, past GIB on plavix/ASA
Colon polyps
C. Diff [**1-24**]
PCI
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
one week.
3) No lotions, creams or powders to wounds
4) Report any fevers greater then 100.5
5) no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in four weeks [**Telephone/Fax (1) 1477**]
Follow up with Dr. [**Last Name (STitle) 1653**] in [**12-21**] weeks([**Telephone/Fax (1) 1654**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2122-11-14**]
|
[
"401.9",
"593.9",
"428.0",
"285.9",
"272.4",
"414.8",
"496",
"250.00",
"V45.02",
"244.1",
"996.72",
"414.01",
"V15.82",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.15",
"99.04",
"37.22",
"88.56",
"39.61",
"36.12",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
12792, 12866
|
5727, 7815
|
9624, 9765
|
13033, 13040
|
2619, 5704
|
13389, 13702
|
10730, 10747
|
10770, 12769
|
12887, 13012
|
7841, 8187
|
13064, 13366
|
10487, 10586
|
2354, 2600
|
302, 377
|
584, 1357
|
9787, 10464
|
10602, 10714
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,707
| 193,605
|
31326
|
Discharge summary
|
report
|
Admission Date: [**2154-4-23**] Discharge Date: [**2154-5-13**]
Date of Birth: [**2104-4-7**] Sex: M
Service: MEDICINE
Allergies:
Sevoflurane / [**Location (un) **] Juice / Reglan / Bactrim
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Fevers, chills, nausea, vomiting, inability to take PO
Major Surgical or Invasive Procedure:
Graft Excision - [**4-26**]
Tunnelled HD Catheter Placement - [**4-29**]
History of Present Illness:
This is a 50 yo M with DM1 c/b nephropathy, ESRD on HD through
AV graft (TTS) and esophagitis who presents with three days of
fevers, chills, nausea, vomiting, and inability to tolerate PO.
The patient was in his USOH until Saturday when he developed
intractable nausea after HD. The patient notes a normal HD
session only complicated by a small amount of bleeding at the
graft site. After HD, the patient had nausea and vomited some
food, bilious material, and what he says is "coffee ground"
color material. The patient did not have any hematemesis. He
vomited 6-8 times and was unable to eat or drink. The patient
denied any other GI symptoms including diarrhea, melena, or
hematochezia. He endorsed constipation, with no stool x 3 days.
With the vomiting, he had mild RLQ tenderness. He says that this
occurred intermittently on Saturday and Sunday, but has resolved
completely. Along with these symptoms, the patient noted fevers
and shaking chills. He had slight, nonproductive cough without
SOB, wheezing, or chest pain. He noted more nocturnal cough and
reflux symptoms with supine positioning. He denied sore throat,
rhinorrhea, sick contacts, recent travel, no IV drug use, or
other exposures. He has diabetic neuropathy, but [**Month/Year (2) **] any
non-healing ulcers. Of note, he did cut his R foot over the
weekend, but did not notice any accompanying skin changes,
redness, or drainage.
In ED, developed fever to 102.9. Patient was given vancomycin.
Guiac negative. CXR normal. CT abdomen performed without acute
process identified. The patient was sent to the HD unit prior to
coming to the floor for workup of fever.
Past Medical History:
- Diabetes mellitus, type I, c/b retinopathy (legally blind
on left), neuropathy and nephropathy, gastroparesis
- CAD, NSTEMI [**2150-8-10**]
- CHF
- Hypertension
- Pulmonary hypertension
- Glaucoma
- s/p surgical debridement of left arm fistula ([**5-25**]) and
ruptured aneurysm repair ([**6-25**])
- History of PEA arrest ([**6-25**])during AV fistula repair
- History of positive PPD, s/p one year of treatment
- Hiccups.
- hx seizure d/o
Social History:
Originally from [**Male First Name (un) 1056**]. Separated, with five healthy
children. Not currently working, but has worked as a security
guard in the past. Moved from [**Location (un) 7349**] recently but lives alone. Has
a sister in the area. He [**Location (un) **] current tobacco use (quit
several years ago). He [**Location (un) **] EtOH or illicit drug use. History
of homelessness, but currently lives alone in apt with visiting
nurse services daily. Has HD in [**Location (un) **] T/Th/Sa in the am.
Family History:
Multiple siblings with hypertension and diabetes. Two sisters
with a "[**Last Name **] problem." No known early coronary disease or
kidney disease.
Physical Exam:
Admission Physical Exam:
VS - Temp 102.7 F, BP 158/67, HR 78, R 20, O2-sat 100% RA
GENERAL - tired appearing gentleman, AOx3
HEENT - anicteric sclera, mild conjunctival injection, legal
blindness of L eye, no tonsilar exudates
NECK - supple, no thyromegaly, no JVD, no LAD
LUNGS - limited by poor effort, no wheezes, crackles,
consolidations. equal breath sounds bilaterally
HEART - RRR, systolic machine like murmur at RUSB, no radiation
to carotids, likely referred from AV graft, no rubs, no extra
heart sounds
ABDOMEN - hypoactive bowel sounds, soft, NT, ND, no rebound,
guarding
EXTREMITIES - warm, [**12-21**]+ pulses bilaterally, small 2cm
laceration on R metatarsal callous, no skin changes
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, nonfocal
Medicine To Cardiology transfer:
VS: Tm 101 Tc 98.4 125/60 HR 70s on RA
Gen: well appearing
Heart: triphasic friction rub
Ext: right UE bandaged, incision with packing, no purulent
drainage
Discharge Exam:
Pertinent Results:
Admission Labs:
[**2154-4-23**] 09:30AM BLOOD WBC-10.5# RBC-4.45* Hgb-13.4*# Hct-40.3
MCV-90 MCH-30.1 MCHC-33.3 RDW-14.8 Plt Ct-71*
[**2154-4-23**] 09:30AM BLOOD Neuts-89.4* Lymphs-6.1* Monos-3.9 Eos-0.3
Baso-0.3
[**2154-4-23**] 09:30AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-OCCASIONAL Burr-OCCASIONAL
[**2154-4-23**] 09:30AM BLOOD PT-13.5* PTT-35.2 INR(PT)-1.3*
[**2154-4-23**] 09:22PM BLOOD Fibrino-288
[**2154-4-23**] 10:40PM BLOOD FDP-10-40*
[**2154-4-23**] 09:30AM BLOOD Glucose-123* UreaN-89* Creat-13.4*#
Na-135 K-6.4* Cl-92* HCO3-19* AnGap-30*
[**2154-4-23**] 09:30AM BLOOD ALT-33 AST-55* LD(LDH)-789* CK(CPK)-260
AlkPhos-97 TotBili-0.4
[**2154-4-23**] 09:30AM BLOOD cTropnT-0.15*
[**2154-4-23**] 10:40PM BLOOD Albumin-4.3 Calcium-8.6 Phos-5.4* Mg-2.0
Medicine to Cardiology Transfer Labs:
[**2154-5-1**] 06:15AM BLOOD WBC-8.0 RBC-3.90* Hgb-11.4* Hct-36.0*
MCV-92 MCH-29.3 MCHC-31.8 RDW-14.7 Plt Ct-226
[**2154-5-1**] 06:15AM BLOOD Glucose-152* UreaN-31* Creat-8.6*# Na-135
K-4.1 Cl-96 HCO3-27 AnGap-16
[**2154-5-1**] 06:15AM BLOOD ALT-2 AST-15 LD(LDH)-260* CK(CPK)-52
AlkPhos-92 TotBili-0.3
[**2154-5-1**] 06:15AM BLOOD Calcium-9.5 Phos-5.5* Mg-2.3
Cardiac Enzymes:
[**2154-4-23**] 09:30AM BLOOD cTropnT-0.15*
[**2154-4-29**] 06:00AM BLOOD CK-MB-2 cTropnT-0.09*
[**2154-4-30**] 07:25AM BLOOD CK-MB-2 cTropnT-0.12*
[**2154-5-1**] 06:15AM BLOOD CK-MB-1 cTropnT-0.12*
MICRO:
[**2154-4-23**] 9:30 am BLOOD CULTURE
**FINAL REPORT [**2154-4-26**]**
Blood Culture, Routine (Final [**2154-4-26**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final [**2154-4-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 73863**] PAGER#
[**Serial Number 73864**] @ 0132 ON
[**2154-4-24**].
Anaerobic Bottle Gram Stain (Final [**2154-4-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2154-4-23**] 12:00 pm BLOOD CULTURE
**FINAL REPORT [**2154-4-26**]**
Blood Culture, Routine (Final [**2154-4-26**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # 348-2165P [**2154-4-23**].
Aerobic Bottle Gram Stain (Final [**2154-4-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 73863**] PAGER #
[**Numeric Identifier 73864**] @ 0255
ON [**2154-4-24**].
Anaerobic Bottle Gram Stain (Final [**2154-4-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2154-4-25**] 8:37 pm FOREIGN BODY Site: ARM
RIGHT UPPER ARM AV GRAFT.
**FINAL REPORT [**2154-4-28**]**
WOUND CULTURE (Final [**2154-4-28**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 73865**] [**2154-4-25**]
[**2154-4-25**] 7:48 pm SWAB RIGHT AV GRAFT ABSCESS.
GRAM STAIN (Final [**2154-4-25**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
WOUND CULTURE (Final [**2154-4-28**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2154-4-29**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
[**2154-4-26**] 2:00 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2154-4-27**]**
C. difficile DNA amplification assay (Final [**2154-4-27**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Imaging:
CT Abdomen/Pelvis:
1. No evidence of intra-abdominal process to explain fevers.
2. 1.1-cm perifissural nodule in the right lower lobe. This is
not clearly identified on prior studies. Most likely, this is
simply a subpleural lymph node; however, given its size,
followup scan in three months would be recommended.
3. Atrophic kidneys in keeping with the patient's history of
end-stage renal disease.
Ultrasound RUE: [**4-24**]
IMPRESSION:
1. Three hematomas surrounding the graft, possibly related to
graft access. No evidence of abscess.
2. Small, eccentric intraluminal vegetation or thrombus within
the superior-to-mid portion of the graft.
Ultrasound RUE: [**4-30**]
In comparison to [**2154-4-24**] exam, two heterogeneous collections in
the right arm, likely hematomas, have resolved. A single
heterogeneous collection adjacent to the graft persists, likely
a chronic hematoma, unchanged since prior.
Echo: [**4-25**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild global left ventricular hypokinesis (LVEF
= 45 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal. with borderline normal free wall
function. 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. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion. Compared with the findings of the prior
study (images reviewed) of [**2154-3-20**], the left ventricular
ejection fraction is reduced.
IMPRESSION: no vegetations seen
Trans-esophageal echo [**5-2**]:
GENERAL COMMENTS:
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 40 cm from the incisors. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
Tricuspid regurgitation is present but cannot be quantified. No
vegetation/mass is seen on the pulmonic valve. There is a small
to moderate sized circumferential, pericardial effusion with
preferential fluid deposition adjacent to the left ventricular
free wall and inferior walls (maximal dimension of 1.2 cm (clip
[**Clip Number (Radiology) **])). There are no echocardiographic signs of tamponade.
IMPRESSION: No valvular vegetations or abscesses appreciated.
Small to moderate pericardial effusion without echocardiographic
evidence of tamponade. Normal biventricular systolic function.
Echo [**5-8**]
PERICARDIUM: Large pericardial effusion. Effusion
circumferential. Sustained RA diastolic collapse, c/w low
filling pressures or early tamponade. RV diastolic collapse, c/w
impaired fillling/tamponade physiology. Significant, accentuated
respiratory variation in mitral/tricuspid valve inflows, c/w
impaired ventricular filling.
Conclusions
The right ventricular free wall is hypertrophied. The ejection
fraction is low-normal. There is a large 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, seen best in clip [**Clip Number (Radiology) **]. There is significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, consistent with impaired ventricular filling.
Study terminated secondary to patient instability/cardiac
arrest.
IMPRESSION: Suboptimal image quality. Large pericardial
effusion. Sustained right atrial and right ventricular diastolic
collapse consistent with tamponade physiology. At least moderate
pulmonary hypertension.
Compared to the prior study (images reviewed) of [**2154-5-4**], there
are signs of pericardial tamponade physiology and the
pericardial effusion has increased in size.
Brief Hospital Course:
Mr. [**Known lastname 73843**] [**Known lastname **] is a 50 year old male with diabetes mellitus,
type 1 (DM1) complicated by end stage renal disease (ESRD) on
hemodialysis (HD) who initially presented with fevers and was
found to have Staph aureus bacteremia and infected AV Graft. He
underwent graft ligation and excision on [**4-25**]. Hospital course
complicated by continued fevers and sinus arrest on telemetry
prompting transfer to the CCU on HD#8 for pericarditis. He
underwent pericardial drainage and epicardial pacemaker
placement on [**2154-5-8**] after his sinus arrests did not improve
with conservative treatment of pericarditis.
# Methicillin-sensitive staph aureus (MSSA) AV graft infection:
Patient presented with fevers to 104 with rigors and
tachycardia. Blood cultures taken in ED immediately turned
positive for MSSA. He was transitioned from vancomycin to
cefazolin, dosed with HD. Initial TTE was negative for
endocarditis and repeat TEE on [**5-2**] was also negative for
endocarditis or abscess. Ultrasound of graft showed possible
focus of infection. Transplant surgery took patient to OR on [**4-26**]
for graft excision which per report was found to have [**Month/Day (4) **] pus.
Majority of graft was removed however part of it remains. Wound
was packed and no longer drained purulent material. ID was
consulted who suggested 6 weeks of therapy with cefazolin given
retained foreign object from graft. Patient had a line holiday
from [**4-26**] to [**4-29**]. On [**4-29**] (HD#6) patient had tunnelled line
placed by IR. That night, patient spiked a fever to 101 however
was asymptomatic. Repeat ultrasound did not reveal abscess. On
[**4-30**] he continued to spike fevers. On [**5-1**], he was noted to have
a new friction rub. EKG showed new Q waves anterolaterally.
Cardiology was consulted who suggested transfer to cardiology
for further management of pericarditis (see below). He was
treated with cefazolin x 6 weeks dosed for HD on 2gm/2gm/3gm
daily on T/TH/SA. He is set up for ID outpatient follow up and
should have weekly labs: CBCw/diff, CMP, fax to [**Telephone/Fax (1) 1419**].
# Bradycardia with sinus arrest: He developed bradycardia with
HR ranging from the 20s to the 60s resting. Several provocative
vagal maneuvers and administration of atropine failed to improve
the bradycardia, indicating that it was unlikely an AV [**Last Name 73866**]
problem. [**Name (NI) **] had EKGs back to [**2148**] showing prolonged PR interval
never longer than 240. He again went into various sinus node
arrhythmias such as sinus exit block, sinus bradycardia, sinus
Wenckebach block, and sinus arrests with pauses up to 5 seconds.
He did have drops in his blood pressure with these sinus
arrests and occasionally was observed to have seizure activity
by the dialysis nurses.
He was started on a dopamine drip, however, it stopped
working after about 18 hours. Because of concern for
hemodynamic instability with pauses, he was started on
isoproterenol with good response of his heart rate and
improvement in pauses and blood pressures. The EP team felt
that his new arrhythmias may have been related to pericardial
effusion (see below) so he was tried on colchicine and ibuprofen
(renally dosed). This did not improve his arrhythmias. He was
also tried on PO theophylline and glycopyrollate without
improvement in bradycardia or arrhythmias.
On [**5-7**], he complained of intense pruritus and vomiting
with drop in his blood pressure to 70s, despite fluid boluses.
He was started on pressors and a bedside echo showed enlargement
of his pericardial effusion with possible tamponade physiology.
During the echo, he was observed to be bradycardic to the 50s
with myoclonic jerks and then became pulseless. He underwent
chest compressions and received 1 amp of epinephrine which
regained pulse. Also gave 125 solumedrol for possible
anaphylaxis given prurtitus, low BP and vomiting. He went to
the cath lab for emergent temporary transvenous pacemaker
placement through his right IJ. On [**5-8**] cardiac surgery placed
a permanent epicardial pacemaker with pericardial drainage, his
generator is in his abdomen. This was chosen because of the
lower risk for infection while bacteremic and because he already
had many venous access problems in his upper extremities and
thorax for HD.
# Pericardial effusion: At the same time that he developed the
bradycardias, he also started to become febrile again and had a
new physical exam finding of pericardial rub. An echo showed a
trace effusion, which had developed in the interval from [**4-25**] to
[**5-2**]. Repeat echo on [**2154-5-4**] showed slight interval enlargement
of the pericardial effusion and then on [**5-7**] there was concern
for tamponade as above (pressures during the cath did not
indicate tamponade physiology). He has ESRD and his uremia
worsened to 100 on [**4-29**] so the effusion could have been uremic
pericarditis. However, he also was febrile again with a known
recent blood stream infection so it is possible that the
pericardial fluid was infected. Cultures of the fluid was
negative on discharge.
# DM1: His diabetes was managed with sliding scale insulin and
glargine.
# ESRD on HD: As above, patient had infected graft which was
removed on [**4-26**]. Tunnelled line was placed on [**4-29**]. Patient
continued on regular T/TH/SA schedule.
TRANSITIONAL ISSUES:
- FU with transplant surgery, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7504**], 2 weeks from DC
- COUGH WITH INCIDENTAL PULMONARY NODULE: 1.1-cm perifissural
nodule in the right lower lobe. This is not clearly identified
on prior studies. Most likely, this is simply a subpleural
lymph node; however, given its size, followup scan in three
months would be recommended. He has been coughing.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily
CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
CLONIDINE - 0.1 mg/24 hour Patch Weekly - place on left arm
qWednesday
ISOSORBIDE MONONITRATE - 60 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth Daily
LOSARTAN [COZAAR] - 100 mg Tablet - one Tablet(s) by mouth once
a
day
DOXEPIN - 10 mg/mL Concentrate - 2.5 ml by mouth at bedtime as
needed for insomnia do not drive or use heavy machinery while
taking this [**Last Name (NamePattern1) 4085**]. may repeat once prn
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100
unit/mL Solution - 3units lantus in the morning
INSULIN SYRINGE-NEEDLE U-100 - 28 gauge X [**11-19**]" Syringe - as
directed [**Hospital1 **] and prn
LEVOTHYROXINE - 25 mcg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth every 12 hours
ONDANSETRON HCL - 4 mg Tablet - 1 (One) Tablet(s) by mouth three
times a day as needed for nausea
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 to 2 Tablet(s)
by mouth every six (6) hours as needed for pain
SEVELAMER HCL - 800 mg Tablet - one Tablet(s) by mouth three
times daily with meals
VIT B CPLX #11-FA-C-BIOT-ZINC [DIALYVITE] - 1 mg Tablet - one
Tablet(s) by mouth daily
Discharge Medications:
1. Outpatient Lab Work
Please draw CBC with Differential and Chem 10 panel every
Thursday at Hemodialysis. Please fax results to [**Hospital **] clinic at
[**Telephone/Fax (1) 1419**].
ICD9 790.7
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
12. doxepin 10 mg/mL Concentrate Sig: 2.5 mL PO at bedtime.
13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day.
14. loperamide 2 mg Capsule Sig: One (1) Capsule PO every [**2-22**]
hours as needed for diarrhea.
15. Lantus 100 unit/mL Solution Sig: Three (3) units
Subcutaneous at bedtime.
16. Humalog 100 unit/mL Solution Sig: variable units
Subcutaneous four times a day as needed for hyperglycemia:
Follow sliding scale.
17. cefazolin 1 gram Recon Soln Sig: [**12-21**] grams Intravenous once
a day for 6 weeks: Please give 2 grams after hemodialysis on
Tues, Thurs. Give 3 grams after HD on Saturday. End on [**2154-6-6**] .
18. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
19. diazepam 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed for anxiety or leg pain.
20. heparin (porcine) 1,000 unit/mL Solution Sig: 4,000-11,000
units Injection PRN (as needed) as needed for line flush:
dialysis RN only.
21. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please wean off in [**12-21**] weeks.
23. CefazoLIN 2 g IV POST HD
on Tuesday and Thursday
24. CefazoLIN 3 g IV POST HD
On Saturday
25. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
26. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
27. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **] - [**Location (un) 3786**]
Discharge Diagnosis:
MSSA bacteremia
End stage renal disease on hemodialysis
Diabetes type 1
PEA arrest
Pericardial effusion
Pericarditis
Incidental nodule in lungs.
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. [**Known lastname 73843**] [**Known lastname **],
You were admitted to the hospital because you were having
fevers. You were found to have bacteria in your blood. Your
dialysis graft was cleaned of the infection. Your heart rhythm
was extremely slow so we placed pacemaker wires on the outside
of your heart to keep your heart beating. You will need to have
intravenous antibiotics with dialysis for a total of 6 weeks.
Followup Instructions:
Department: Cardiology, Device Clinic
When: Wednesday [**5-16**] at 11:00am.
Where: [**Hospital Ward Name 23**] Center, [**Hospital Ward Name **], [**Location (un) 436**]
Best parking: [**Hospital Ward Name 23**] garage
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2154-5-20**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: MONDAY [**2154-5-27**] at 9:30 AM
With: EMG LABORATORY [**Telephone/Fax (1) 2846**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: MONDAY [**2154-6-3**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17785**],MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: TRANSPLANT CENTER
When: MONDAY [**2154-5-27**] at 8:45 AM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
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56,502
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Discharge summary
|
report
|
Admission Date: [**2119-6-5**] Discharge Date: [**2119-6-8**]
Date of Birth: [**2080-2-24**] Sex: F
Service: MEDICINE
Allergies:
Wellbutrin / High Dose Steroids
Attending:[**Doctor First Name 2080**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
39 year old woman with asthma and possible hypersensitivity
pneumonitis who presents with shortness of breath. She has had
6-7 years of progressively worsening SOB and has had an
extensive prior workup (please refer to Dr.[**Name (NI) 84946**] notes)
including an open lung biopsy in [**10/2118**] which was initially
thought to show sarcoidosis, but after re-review is more
consistent with a hypersensitivity pneumonitis. She has had
numerous prior ICU admissions for SOB and has been intubated in
the past. She has had worsening SOB for the past several days,
possibly worsened by the heat, and has been using her inhaler
more frequently so came to the ED.
.
In the ED initial VS were: afebrile, HR 115, RR in the 30s, sats
in the mid-80s which improved to 99% after a neb. On exam she
was taking rapid shallow breaths with poor air movement so got 3
back-to-back nebs with some improvement. She initially refused
steroids due to h/o steroid psychosis. She was given 4g
magnesium and 0.3mg 1:1000 subQ epi, and then agreed to take
solumedrol 125mg IV. She also got 2mg lorazepam x3 for anxiety.
VS prior to transfer were HR 134, BP 111/56, RR 27, 98% on a
continuous neb.
.
On arrival to the MICU, patient is tachypneic and speaking in
short sentences. Appears anxious and uncomfortable.
Past Medical History:
1. Asthma
2. Possible inflammatory lung process such as hypersensitivity
pneumonitis. (Had open lung biopsy in [**10/2118**] which was reviewed
by [**Hospital1 18**] pathologists and showed undefined inflammatory process
superimposed on normal lung,and poorly formed granulomas that
seemed to be consistent with a hypersensitivity pneumonitis)
3. History of positive PPD (the patient reports that it was
borderline degree of induration for many years and has not
received INH. She states the reason for no INH was a clear CXR
4. PCOS
5. Postpartum depression requiring psychiatric hospitalization
6. Multiple miscarriages requiring D and C
7. Status post multiple colposcopies and cervical LEEP procedure
8. Meningitis in [**2118-12-11**]
9. Status post tonsillectomy
Social History:
The patient is divorced and lives in a home with her 3 children.
Works as a business analyst. Occasional etoh. Prior 1-1/2 pack
per day smoking for 15 years, quit in [**2106**]. High likelihood of
asbestos exposure according to the patient as she was a
volunteer firefighter in the past. History of positive PPD. Has
a dog, cat, a lizard and a hamster at home.
Family History:
Father alcoholic. [**Name2 (NI) **] family history of lung disease or DVTs.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.5, 147, 113/69, 25, 96% on continuous neb
General: Alert, oriented x3, appears uncomfortable, speaking in
short sentences, but intermittently comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic but regular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: No wheezing, no rales
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
PE: T98.0 HR92 BP139/69 R18 O2sat97% RA
Gen: anxious, well-appearing, speaking in full sentences
CV: tachycardic, regular, no m/r/g
Resp: poor inspiratory effort, clear, no wheezing
Abd: soft, NT/ND
Ext: warm and well-perfused, no c/c/e
Pertinent Results:
ADMISSION LABS:
[**2119-6-5**] 11:00AM BLOOD WBC-8.8 RBC-5.01 Hgb-14.4 Hct-43.6 MCV-87
MCH-28.8 MCHC-33.1 RDW-14.4 Plt Ct-370
[**2119-6-5**] 11:00AM BLOOD Neuts-69.5 Lymphs-24.6 Monos-3.8 Eos-1.4
Baso-0.7
[**2119-6-5**] 11:00AM BLOOD Glucose-93 UreaN-11 Creat-0.9 Na-141
K-4.5 Cl-106 HCO3-23 AnGap-17
[**2119-6-5**] 11:00AM BLOOD Calcium-10.0 Phos-2.3* Mg-2.0
.
DISCHARGE LABS:
[**2119-6-7**] 07:10AM BLOOD WBC-9.5 RBC-4.14* Hgb-11.9* Hct-36.1
MCV-87 MCH-28.8 MCHC-33.0 RDW-14.8 Plt Ct-282
[**2119-6-8**] 07:25AM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-142 K-4.1
Cl-106 HCO3-24 AnGap-16
[**2119-6-8**] 07:25AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8
[**2119-6-7**] 07:10AM BLOOD TSH-2.0
.
IMAGING:
CXR (PA and lateral) [**2119-6-6**]: Lung volumes are improved compared
with prior. There is no focal
consolidation, pleural effusion, or pneumothorax. Cardiac
silhouette and mediastinal contours are normal. Chain suture is
again noted in the right mid lung. IMPRESSION: Improved lung
volumes without acute chest abnormality.
EKG [**2119-6-7**]: Sinus tachycardia. Early R wave transition.
Non-specific ST segment changes
anteriorly. Broderline low voltage. No previous tracing
available for
comparison.
***CT TRACHEA W/O C W/3D REND [**2119-6-7**]:
FINDINGS: The lungs are clear, with evidence of prior wedge
biopsy from the
right upper and lower lobes. A subpleural 2-mm nodule in the
right upper lobe
is unchanged from [**2116**]. The pleural surfaces are normal without
effusion or
pneumothorax.
There is evidence of severe tracheobronchomalacia, with near
complete and, in
places, complete collapse of the trachea and bronchial tree
during dynamic
expiration. At the level of the clavicular heads, the trachea
measures 2.3 cm
AP x 1.6 cm TV (314 mm2), which on dynamic expiration decreases
to 1.1 cm AP x
0.9 cm TV (56 mm2) (6; 9, 5; 14). At the level of the aortic
arch, the
trachea measures 1.8 cm AP x 2.5 cm TV (350 mm2) on inspiration,
which on
dynamic expiration decreases to 0.6 cm AP x 1.2 cm TV (59 mm2).
The right and left bronchi measure 1.3 and 1.4 cm, respectively,
on the
inspiratory phase (2; 27) which progresses to near-complete
collapse,
measuring less than 2 mm on dynamic expiration (5; 24). The
bronchus
intermedius measures 6 mm on inspiration (2; 27) and 3 mm on
expiration (5;
28).
The heart and great vessels are normal in size and
configuration. There is no
pericardial effusion. There is no central lymph node
enlargement.
Though this exam is not tailored for the evaluation of
infradiaphragmatic
structures, no abnormality is seen. The size of the spleen
measures at the
upper limits of normal.
There is a subacute nondisplaced fracture of lateral left sixth
rib, new from
[**2119-3-12**].
IMPRESSION:
1. Severe tracheobronchomalacia with air trapping.
2. No lung parenchymal abnormality to suggest diagnosis of
hypersensitivity
pneumonitis or sarcoid.
3. Subacute fracture of the lateral left sixth rib.
Brief Hospital Course:
39 year old woman with asthma and possible hypersensitivity
pneumonitis who presents with shortness of breath.
Acute issues:
# Tracheobronchomalacia (NEW DIAGNOSIS): Patient states symptoms
are similar to prior asthma exacerbations but no wheezing on
exam and CXR shows no hyperinflation of lungs. Pt initially
admitted to the MICU, but soon transferred to the floor.
Interventional pulmonology (Dr. [**Last Name (STitle) **] and pulmonology (Dr.
[**Last Name (STitle) **] involved as outpatient care and inpatient advice. CT
Trachea performed and showed severe tracheobronchomalacia.
Additional workup to be performed as an outpatient with possible
stenting in a few weeks.
Chronic issues:
# Anxiety/Depression: Continued citalopram, trazodone.
# Sinus tachycardia: Likely related to anxiety. No chest pain.
VSS. EKG unremarkable. Improved over the course of admission.
Transitional issues:
# Tracheobronchomalacia: extensive outpatient workup required
prior to possible treatment. Appreciate excellent coordination
of care by Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], et. [**Doctor Last Name **]. See d/c paperwork for
details.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR
MICU.
1. Albuterol Inhaler [**12-12**] PUFF IH Q4-6HRS PRN shortness of breath
or wheeze
2. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
3. ciclesonide *NF* unknown Inhalation unknown
4. Citalopram 10 mg PO DAILY
5. ipratropium-albuterol *NF* unknown Inhalation unknown PRN
6. Methotrexate 15 mg PO QFRI
7. Terbutaline Sulfate 5 mg PO BID
8. traZODONE 75 mg PO QHS
Discharge Medications:
1. Albuterol Inhaler [**12-12**] PUFF IH Q4-6HRS PRN shortness of breath
or wheeze
2. Citalopram 10 mg PO DAILY
3. Terbutaline Sulfate 5 mg PO BID
4. traZODONE 75 mg PO QHS
5. Methotrexate 15 mg PO QFRI
6. Meds
Please continue all previous medications as prescribed,
including ciclesonide, ipratropium-albuterol PRN. Unknown
dosages.
7. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheobronomalacia
Asthma
Discharge Condition:
Stable. Continued feeling of chest tightness likely due to
tracheobronchomalacia
Discharge Instructions:
Dear Ms. [**Known lastname 92011**],
You were admitted to the hospital with shortness of breath. A
CT scan was performed looking at your breathing tubes. It was
found that you have severe tracheobronchomalacia that may
require stenting. The interventional pulmonologists, who
specialize in problems like this, recommended additional
follow-up and tests to be done outside of the hospital. You
will then see Dr. [**Last Name (STitle) **] again for discussion of treatment and
options for your tracheobronchomalacia.
Followup Instructions:
Department: DIGESTIVE DISEASE CENTER
When: MONDAY [**2119-6-12**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Name: Mallur, [**Last Name (un) **] S. MD
Location: [**Hospital1 18**] OTOLOARYNGOLOGY
Address: [**Doctor First Name **], STE 6E, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 41**]
Appt: [**6-12**] at 1:45pm
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Location (un) 92012**], EAST [**Hospital1 **],[**Numeric Identifier 82263**]
Phone: [**Telephone/Fax (1) 92013**]
Appt: [**6-15**] at 9:45am
Department: RADIOLOGY
When: TUESDAY [**2119-6-20**] at 9:00 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
***PLEASE CALL TO CANCEL THIS APPT - THIS IS FOR THE CT SCAN
THAT YOU HAD WHILE IN THE HOSPITAL - YOU SHOULD NOT HAVE ANOTHER
SCAN
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2119-6-20**] at 10:00 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
****PLEASE CALL DR.[**Doctor Last Name **] OFFICE TO CLARIFY IF YOU NEED THIS
TEST: [**Telephone/Fax (1) 3020**]
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2119-6-20**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2119-6-29**] at 11:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2119-6-29**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"285.9",
"748.3",
"V15.82",
"311",
"300.00",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9062, 9068
|
6865, 7545
|
311, 317
|
9139, 9223
|
3887, 3887
|
9791, 12301
|
2824, 2902
|
8610, 9039
|
9089, 9118
|
8054, 8587
|
9247, 9768
|
4265, 6842
|
2917, 3610
|
3626, 3868
|
7767, 8028
|
252, 273
|
345, 1637
|
3903, 4249
|
7561, 7746
|
1659, 2429
|
2445, 2808
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,375
| 101,053
|
27872
|
Discharge summary
|
report
|
Admission Date: [**2182-5-19**] Discharge Date: [**2182-5-24**]
Date of Birth: [**2132-9-19**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Intubation
Hemodialysis
Central line placement
History of Present Illness:
This is a 49 year-old male with history of diabetes,
hypertension, and end stage renal disease who was transfered
from an outside hospital after a PEA arrest. For the past week,
he has been feeling unwell. One week ago, he underwent
placement of a perotoneal dialysis catheter. At that time, he
required hospital admission for 2 days due to hyperkalemia and
hyperglycemia. He was not dialysed at that time. He had
persistent nausea. The day prior to admission, he was back to
his baseline health, which is severe fatigue with ambulation of
a few yards. The morning of presentation, he began to feel
nauseated. Per report, he fell from his chair and was
unresponsive. He had some jerking movements of his arms that
were similar to his hypoglycemic episodes. Shortly thereafter,
he was responsive but then became unresponsive again. When EMS
arrived, he was found to be bradycardic in PEA arrest. He
received epi and atropine. He subsequently became hypotensive
to the 60s systolic and was asystolic. He was transcutaneously
paced. He was taken to an outside hospital where he continued
to be hypotensive. He received 4 L of IV fluid resuscitation.
A temporary pacer was placed, and he was paced at 80 beats per
minute. Without pacing, he had only rare junctional escape
beats. His labs were notable for hyperkalemia to 6.2,
hyperglycemia to the 700s, and acidemia with a pH of 7.03.
Cardiac enzymes were negative and his BNP was elevated to [**2175**].
An echocardiogram revealed an EF of 15-20% with global
hypokinesis and decreased right ventricular function. He was
transfered to the [**Hospital1 18**] for further management. On transfer,
his vent settings were noted to be incorrect and he was found to
be hypoxic to the 50s on 2 separate gases about 1.5 hours apart.
On arrival he was oxygenating well. He was on 5 mcg of
levophed to maintain his blood pressure. He was intially
unresponsive, with fixed dilated pupils, with an absent corneal
and gag reflex. An initial potassium was 6.4. He received
calcium, bicarb, insulin, and kayexelate. He was admitted to
the CCU.
Past Medical History:
1. Insulin dependant diabetes diagnosed 20 years ago.
2. End stage renal disease for about 1.5 years with plans to
start perironeal dialysis next month. A PD catheter was placed
last week.
3. Hypertension
4. Hyperlipidemia
5. History of lens removal in left eye.
6. History of TIA
Social History:
He is currently not working. He is married and has 2 children.
He smokes 1 pack per day. He doesn't drink alcohol.
Family History:
His mother has a triple bypass in her 60s. She also has
diabetes and hypertension.
Physical Exam:
Vitals: Temperature:34 rectal Blood Pressure:121/72 on levophed
Pulse:80 V-paced Respiratory:16 Rate: Oxygen Saturation:99% on
vent.
General: Intubated in no acute distress.
HEENT: Left pupil surgical fixed at 8mm, right pupil surgical at
6mm, moist mucous membranes.
Cardiac: Regular rhythm, paced, S1, S1, no murmurs, rubs,
gallops.
Pulmonary: Clear to auscultation bilaterally.
Abdomen: Normoactive bowel sounds, soft, nontender,
nondistended, healing surgical incision.
Extremities: Cool to touch, 2+ radilal and dorsalis pedis
pulses. Left cortis dressing intact.
Neuro: Spontaneous eye opening, tracking to voice, moving all 4
extremities.
Pertinent Results:
Outside Hospital:
1. Chest x-ray: Cardiomegally, pacer wires coiled in the right
ventricle, pulmonary edema, widened mediastinum.
2. Head CT: Negative for acute bleed or mass effect.
3. Echocardiogram: EF 15-20% with global hypokinesis. Decreased
right ventricular systolic function.
.
[**Hospital1 18**]:
1. Chest x-ray: Cardiomegally, pacer wires coiled in right
ventricle, widened mediastinum, pulmonary edema.
2. Chest CTA: No pulmonary emboli, no aortic dissection,
pulmonary edema with bilateral pleural effusions, coronary
arteries grossly clean.
.
EKG: Ventricular paced at 80 bpm with left bundle morphology.
EKG with underlying rhythm: narrow complex escape beats at
50-60.
.
TTE [**2182-5-21**]:
Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed. LVEF 40% Distal
anterior, apical, and distal inferior hypokinesis is present.
3. The aortic root is mildly dilated.
4. The mitral valve leaflets are mildly thickened.
5. There is mild pulmonary artery systolic hypertension.
6. There is a small pericardial effusion.
.
.
Exercise stress test: [**2182-5-22**]
The baseline EKG showed prominant voltage, diffuse STT wave
abnormalities and LAE. No additional, significant ST segment
changes
over baseline were observed during the infusion or in recovery.
The
rhythm was sinus with no ectopy. Appropriate blood pressure
response to
the infusion; blunted heart rate response. The dipyridamole was
reversed with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or significant EKG changes
over
baseline. Nuclear report sent separately.
.
PERSANTINE MIBI [**2182-5-22**]
RADIOPHARMECEUTICAL DATA:
3.1 mCi Tl-201 Thallous Chloride;
21.0 mCi Tc-[**Age over 90 **]m Sestamibi;
HISTORY: Diabetes, ESRD, and hypertension, status post
hyperkalemia-related cardiac arrest. CAD evaluation.
SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
milligram/kilogram/min. Two minutes after the cessation of
infusion, Tc-99m
sestamibi was administered IV.
INTERPRETATION:
Image Protocol: Gated SPECT
Resting perfusion images were obtained with thallium.
Tracer was injected 15 minutes prior to obtaining the resting
images.
This study was interpreted using the 17-segment myocardial
perfusion model.
The image quality is adequate.
Left ventricular cavity size is dilated, and more dilated at
stress than at
rest.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the
myocardium.
Gated images reveal diffuse hypokinesis without focal wall
motion abnormalities.The calculated left ventricular ejection
fraction is 48%
IMPRESSION: 1. Normal myocardial perfusion. 2. Transient
dilitation of the left ventricle during dipyridamole (stress)
images compared to rest, with a
baseline dilated left ventricle.
Brief Hospital Course:
49 year-old male with diabetes, end-stage renal disease,
hypertension, hyperlipidemia admitted with cardiac arrest likely
secondary to hyperkalemia and acidemia.
.
1. Cardiac arrest: Patient had an asystolic arrest in the
setting of hyperkalemia to 6.4 and acidemia to 7.0. On arrival,
he was 100% paced with an underlying rhythm of 50-60s junctional
escapes. He was also hypotensive requiring Levophed. He was
treated for hyperkalemia in the emergency department with
calcium gluconate, bicarb, insulin, and Kayexalate. His mental
status improved with treatment of hyperkalemia. His EKG with
back-up pacing at a rate of 40 showed heart block with
occasional conducted beats with AV delay. There was also some
inappropriate pacing spikes. The sensing was decreased with
good effect. He subsequently converted to normal sinus rhythm
without AV delay as his potassium was corrected. His blood
pressure also improved with treatment of his hyperkalemia. He
is currently off of Levophed. Patient had a repeat TTE which
demonstrated an improvement in his EF to 40%. Temporary pacer
was discontinued on [**2182-5-20**]. Patient did not have further
evidence of arrythmia. He will have close follow-up locally and
he will have his PCP refer him to a local cardiologist.
.
2. Chronic renal failure: secondary to diabetes and
hypertension. At the OSH the patient had a catheter placed with
the goal of starting peritoneal dialysis in 1 month. However,
during that hospitalization, he then developed hyperkalemia and
subsequent PEA arrest, which required transfer to [**Hospital1 18**].He was
dialyzed on the night of admission and had two additional
sessions of hemodialysis while in-house. Tunneled dialysis line
placed [**5-22**] and out-pt hemodialysis was coordinated; he has
follow-up with Dr. [**Last Name (STitle) **] his nephrologist on [**2182-5-25**].
.
3. Diabetes: He was hyperglycemic to 700s initially without any
evidence of ketosis. He received insulin and was started on an
insulin drip. He was requiring 1 unit per hour. On hospital
day 2, he was transitioned to NPH and the insulin drip was
weaned off. He was discharged on a regimen of glargine and
lispro.
.
3. Congestive Heart Failure: At the outside hospital, he had an
echocardiogram that showed diffused hypokinesis with an ejection
fraction of 15-20%. It also showed decreased right ventricular
function. According to his wife, he had a normal echocardiogram
on month prior. Repeat ECHO at [**Hospital1 18**] showed at EF of 40%. His
EF may continue to improve following this event. He should have
a repeat ECHO in the next several months.
.
4. Elevation in cardiac enzymes: On admit, he had a troponin
leak that was likely secondary to hypotension in the setting of
his arrest. Also, noted to have elevated CK-MB. Enzymes trended
down during his admission. He did not have a cath while he was
here. He will discuss elective cardiac catheterization at
follow-up with his PCP and primary cardiologist.
.
6. Hypertension: Was briefly on pressors, then as pressure came
up required Nitro for blood pressure control (initially
avoiding nodal blocking agents). Additional agents were slowly
added back and he was discharged on a regimen of Procardia,
labetalol and lisinopril. Blood pressure will be followed by
PCP and [**Name9 (PRE) **] regimen will be titrated up as
necessary.
.
7. Intubation: He was intubated for airway protection at the
OSH. As his electrolyte disturbances resolved, ventilation and
sedation were weaned. He was extubated on hospital day 2. He did
not have any additional respiratory issues.
Medications on Admission:
1. Lantus
2. Novalog
3. Lipitor
4. Labetalol
5. Norvasc
6. Lasix
7. Metolazone
8. Neurontin
9. Thiamine
10. Folate
11. B12
12. Procrit
13. Calcium Carbonate
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. 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*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
6. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous Q am.
7. Insulin Lispro (Human) 100 unit/mL Solution Sig: as dir units
Subcutaneous four times a day: as per sliding scale.
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID PRN ().
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. Epoetin Alfa 10,000 unit/mL Solution Sig: as directed units
Injection ASDIR (AS DIRECTED): at HD.
15. Procardia 10 mg Capsule Sig: One (1) Capsule PO three times
a day.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- PEA arrest
- hyperkalemia
- ESRD with hemodialysis initiation
- CHF
SECONDARY:
- Insulin dependant diabetes
- End stage renal disease
- Hypertension
- Hyperlipidemia
- History of lens removal in left eye.
- History of TIA
Discharge Condition:
- stable to home, with outpatient hemodialysis
Discharge Instructions:
- Take medications as directed.
- Follow up as scheduled.
- Follow up with Dr. [**Last Name (STitle) **]. You have been started on dialysis -
follow up for dialysis as scheduled.
Followup Instructions:
Follow up with your kidney doctor (Dr. [**Last Name (STitle) **] as scheduled.
Follow up for hemodialysis on Saturday, [**5-25**] at the Kidney
Center. Dr.[**Name (NI) 67911**] office should call you on Friday
(tomorrow). Call him if you do not hear from him tomorrow. His
number is [**Telephone/Fax (1) 67912**]. Youi can speak with im or his assistant
[**Doctor First Name **].
Follow up with your PCP [**Name Initial (PRE) 176**] 1 week. Your PCP should follow
your blood pressure as changes have been made to your blood
pressure regimen and further changes may be needed as you
continue with dialysis. You should discuss finding a local
cardiologist with your PCP. [**Name10 (NameIs) **] may need to have a cardiac
catheterization at some point in the future.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"403.91",
"276.7",
"427.5",
"428.0",
"585.6",
"250.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"38.91",
"39.95",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11873, 11879
|
6691, 9332
|
283, 331
|
12156, 12205
|
3687, 3820
|
12433, 13336
|
2918, 3004
|
10497, 11850
|
11900, 12135
|
10316, 10474
|
12229, 12410
|
3019, 3668
|
9349, 10290
|
229, 245
|
359, 2462
|
3829, 6668
|
2484, 2768
|
2784, 2902
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,029
| 152,983
|
44620
|
Discharge summary
|
report
|
Admission Date: [**2181-1-19**] Discharge Date: [**2181-2-9**]
Date of Birth: Sex:
Service:
SERVICE: Gold Surgery
HISTORY OF PRESENT ILLNESS: This is a 60-year-old female who
had been discharged the day previously from the medical
service after having an episode of cholangitis. She was
treated with an ERCP and biliary stenting. During that
hospitalization, she was also found to have a severe COPD and
required significant pulmonary toilet as well as steroids and
inhalers. The patient was actually discharged on home oxygen
with 02 sat in the 80s. After getting home, the patient ate a
snack and immediately developed severe right upper quadrant
pain and the pain was nonradiating and sharp. She did have a
cough and reported a positive sputum which she had been
treated for in the hospital with Levaquin. She also had
significant shortness of breath.
PAST MEDICAL HISTORY:
1. COPD.
2. MRSA pneumonia.
3. Diabetes mellitus.
4. Hypothyroidism.
5. Thrush.
PAST SURGICAL HISTORY: Negative.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS UPON DISCHARGE FROM THE MEDICAL SERVICE:
1. Advair 1 puff b.i.d.
2. Levoxyl 50 micrograms p.o. a day
3. Percocet 1-2 tabs p.o. q.4 h. p.r.n. pain.
4. Protonix 40 mg p.o. a day.
5. Colace 100 mg p.o. b.i.d.
6. Levaquin 500 mg p.o. a day x 4 days.
7. Albuterol nebulizers.
8. Atrovent nebulizers.
9. Lantus.
10. Regular insulin sliding scale.
11. Flagyl 500 mg p.o. t.i.d. x 4 more days.
PHYSICAL EXAMINATION: On physical examination, she was
afebrile. Her heart rate was 82. Blood pressure 126/52,
respiratory rate 12, 02 sat 82% on 2 liters. She was somewhat
somnolent but arousable. She had decreased breath sounds.
There were significant expiratory wheezes. Her heart was a
regular rate. The abdomen was soft. She was obese,
nondistended. She had some mild right upper quadrant
tenderness with no rebound and some voluntary guarding. She
was Guaiac negative on rectal exam. She was edematous on her
extremities.
LABORATORY DATA: Her white count was 25.7, crit 35.4,
platelet count 771. Her chemistries were significant for a
bicarbonate of 29, BUN and creatinine of 12 and 0.7, blood
sugar of 166. Her LFTs were normal. Her ALT was 39, AST 20,
alkaline phosphatase 172, total bilirubin 0.6, amylase 74.
Ultrasound showed multiple stones with some mild gallbladder
wall thickening but no ductal dilatation. A CT scan was
performed to evaluate her pancreatitis as well as the GI
service was consulted for evaluation of her stent, question
of whether or not this was obstructing. Her CT scan showed
extensive pancreatic necrosis and the patient was admitted to
the surgical service.
HOSPITAL COURSE: She was brought to the intensive care unit.
She was significantly aggressively fluid resuscitated and
managed with broad spectrum antibiotics. Her pulmonary status
continued to be poor and a central line as well as an
arterial line was placed. Physical therapy was consulted and
followed her throughout her hospitalization. She continued to
require a significant amount of fluids as well as having
decreased 02 saturations. She was started on stress-dose
steroids in order to control her COPD flare. Her white count
continued to come down and her steroids were slowly tapered.
Her oxygen saturation improved and she reached a sat of 98%
on a face mask but continued to have poor oxygenation on
blood gases. She was continued on vanco, Meropenem, and
fluconazole for prophylaxis with the necrosis of her
pancreas.
We began gentle diuresis on [**2181-1-23**] in order to improve
her pulmonary status. Repeat CT scan showed no improvement of
her pancreatic necrosis and some mild fluid. Therefore, it
was decided that she would go to the operating room on [**2181-1-25**]. She was also consented for a tracheostomy as well
as a G/J tube. Please see the operative report for further
details. Postoperatively, the patient tolerated the procedure
well. She continued to have severe pulmonary issues and
required increasing ventilatory support. She was extubated on
postoperative day #1 and was on trach mask.
Dermatology was consulted for a rash on her body which was
felt to be drug related. Her NG tube was removed and she was
fully advanced on her tube feeds. She was kept on an insulin
drip for tight blood glucose control as she had elevated
blood sugars from her diabetes postoperatively as well as
from her extensive pancreatic necrosis. Antibiotics were
stopped on postoperative day #3 and her white count continued
to come down. Her TPN which was started preoperatively was
weaned off on postoperative day #4 after her tube feeds
reached goal. Her JP drains which were placed in the
pancreatic bed continued to put out a large amount of fluid
and were working well. [**Last Name (un) **] Diabetes was consulted as the
patient had very little residual pancreatic function. They
followed her throughout her hospital stay.
Speech and swallow was consulted also for Passy-Muir valve as
the patient was able to remain extubated for multiple days.
The patient began having high secretions from a pulmonary
standpoint and was started on broad spectrum antibiotics
including vanco and Zosyn. She began having high temperatures
shortly thereafter. Her lines were changed and tips were sent
for culture. Her sputum ultimately grew out E. coli as well
as MRSA and her peritoneal fluid grew out gram-negative rods
from the JP drains. Interventional radiology placed a pigtail
drain of the fluid collection upon repeat imaging. She was
also started on fluconazole after her peritoneal fluid from
her JP had mild fungus.
ID was consulted as the patient continued to have high fevers
while on appropriate antibiotics. The infectious disease
department followed the patient throughout her hospital stay.
The patient underwent a bronchoscopy on [**2181-2-4**] and it
was found that she had minimal secretions at that time and
her airway was patent. She was placed back on a ventilator as
she began to slowly tire out. Her pulmonary function slowly
worsened. From an abdominal standpoint, her abdomen was well
drained with the JP drains and there were no residual fluid
collections and the area of fluctuance over her right flank
was also drained percutaneously at the bedside with only
minimal serous fluid recovered. Skin began to continue to
slowly worsen in the next couple of days and required more
and more ventilatory support, ultimately requiring APRV in
order to keep saturations in the 90s. CT scan imaging showed
that she had complete collapse of both bilateral lower lobes
and significant atelectasis. Again, the patient had a
brachial A line placed in order for blood gas evaluation and
hemodynamic monitoring. This showed that the patient
continued to have very poor oxygenation and began having high
PC02 levels even with complete aggressive pulmonary
management.
The patient continued to do more and more poorly and
esophageal manometry was used in order to maximize her PEEP.
Again, her oxygen saturations were not able to be kept above
90 and she was on 100% FI02. She was restarted on her TPN and
her antibiotics were changed to linezolid, meropenem, and
caspofungin.
The renal service was consulted in order for CVVH in order to
help with oxygenation. A Quinton catheter was placed and the
patient was placed on CVVH. Again, her oxygen saturations did
not improve significantly and her PC02 was in the 80s. A new
A-line was placed on the 25th and the patient continued to
have significantly poor oxygenation and 02 sats slowly began
to drop. She was completely paralyzed and sedated and was
started on Levophed for blood pressure support. She was given
continuous bicarb drip through her CVVH to correct her
acidosis.
A discussion was carried out with the family and the grave
prognosis was discussed at length. The family decided to make
this patient comfort measures only and her pressors were
stopped as well as her ventilator. The patient expired at
10:40 p.m. on [**2181-2-9**] after removal of her pressors.
Postmortem was denied. The patient died on [**2181-2-9**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 7542**], [**MD Number(1) 7543**]
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2181-5-24**] 09:50:08
T: [**2181-5-24**] 10:35:35
Job#: [**Job Number 95508**]
|
[
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"244.9",
"789.5",
"584.9",
"518.5",
"482.82",
"577.0",
"428.0",
"250.00",
"414.01",
"038.9",
"782.1",
"278.01",
"285.9",
"V58.67",
"V09.0"
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icd9cm
|
[
[
[]
]
] |
[
"00.17",
"31.1",
"39.95",
"54.91",
"96.6",
"99.15",
"86.01",
"96.72",
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"33.21",
"38.91",
"38.93",
"44.39",
"52.22",
"99.04",
"51.22",
"38.95",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
2710, 8343
|
1017, 1492
|
1515, 2692
|
175, 889
|
911, 993
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,703
| 123,064
|
46951
|
Discharge summary
|
report
|
Admission Date: [**2169-8-29**] Discharge Date: [**2169-9-8**]
Date of Birth: [**2096-3-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
ICD firing /occ. lightheadedness
Major Surgical or Invasive Procedure:
[**2169-8-31**]
1. Redo sternotomy and ventricular tachycardia ablation
using epicardial ventricular radiofrequency ablation.
2. Ventricular tachycardia mapping
History of Present Illness:
73 year old male that presented to
the ED [**7-14**] with complaints of ICD firing multiple times.
He had recently been admitted for GAS bacteremia which he was
started on ceftriaxone which was changed this admission due to
concern of drug induced neutropenia.
He continued to have ventricular tachycardia episodes in the
hospital and underwent attempted ablations for Ventricular
tachycardia on [**7-17**] and [**7-20**] with EP - that were not successful.
He completed a course of antibiotics on [**7-26**] and PICC was
removed
after tPA injection in the ICU on [**7-27**]. RUE DVT noted. Bridged
with lovenox and coumadin restarted. Presents today for further
planning for surgery.Now off abx for 13 days. Reports no fevers.
He has been at [**Hospital 9188**] Rehab since discharge from [**Hospital1 18**] with
planned discharge to home in a few days.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- PACING/ICD: VVI [**Company 1543**] pacer/AICD, placed in [**2168**]
- Non-ischemic cardiomyopathy with EF of 20%
-Endocardial ablation, failed Epicardial ablation [**3-8**] adhesions
- Rheumatic Heart Disease (in childhood) s/p bioprosthetic AVR
[**68**] years ago in FL
- paroxysmal atrial fibrilation on Coumadin (confirmed by phone
by his [**State 108**] cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 99581**] (Holywood,
[**Numeric Identifier 99582**])
- Ventricular tachycardia
3. OTHER PAST MEDICAL HISTORY:
- Gout
- Hypothyroidism
- Traumatic injury to his left arm 30 years ago
- GAS bacteremia
- Neutropenia thought to be [**3-8**] CEftriaxone
- Suspected Sleep Apnea
Social History:
The patient lives in [**State 108**] but recently moved to [**Location (un) 86**] to
live with his daughter. [**Name (NI) **] is a lifelong nonsmoker and does not
drink alcohol. He denies any illicit drug use. He has a
girlfriend who lives in [**Name (NI) 108**].
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
Skin: Dry [x] intact [x] scar on back, left arm multiple scars
from previous trauma, midline surgical scar healed, right knee
surgical scar healed
Chest: Lungs clear bilaterally except for faint basilar rales;
healed sternotomy and L ant. chest pacer scars
Heart: RRR [x] Irregular [] Murmur - none
Extremities: Warm [x] Edema - none
Varicosities: None [x] venous stasis changes bilateral lower
extremities
Neuro: Alert and oriented x3 slight limitation ROM left arm due
to trauma gait unsteady strength r=l [**6-8**]
Pertinent Results:
[**2169-9-7**] 05:59AM BLOOD WBC-5.3 RBC-3.63* Hgb-9.3* Hct-28.7*
MCV-79* MCH-25.6* MCHC-32.3 RDW-15.2 Plt Ct-238
[**2169-8-29**] 07:45PM BLOOD WBC-4.7 RBC-5.26 Hgb-13.4* Hct-40.6
MCV-77* MCH-25.6* MCHC-33.1 RDW-14.8 Plt Ct-205
[**2169-9-8**] 04:38AM BLOOD PT-18.7* INR(PT)-1.7*
[**2169-8-29**] 07:45PM BLOOD PT-15.7* PTT-26.4 INR(PT)-1.4*
[**2169-9-8**] 04:38AM BLOOD UreaN-24* Creat-0.7 Na-139 K-4.2 Cl-105
[**2169-8-29**] 07:45PM BLOOD Glucose-139* UreaN-22* Creat-1.1 Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 99586**] (Complete)
Done [**2169-8-31**] at 3:36:52 PM 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: [**2096-3-22**]
Age (years): 73 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Refractory VT ablation
ICD-9 Codes: 785.0
Test Information
Date/Time: [**2169-8-31**] at 15:36 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: *6.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Aorta - Sinus Level: *5.5 cm <= 3.6 cm
Aorta - Arch: *3.8 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Severe regional LV systolic dysfunction.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Severe dilation of aorta at sinus level. Normal ascending
aorta diameter. Mildly dilated aortic arch. Mildly dilated
descending aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The rhythm appears to
be A-V paced. Results were personally reviewed with the MD
caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The right atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler.
There is severe regional left ventricular systolic dysfunction
with preserved function in anterior, anteroseptal and
inferoseptal walls..
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis.
The aortic root is severely dilated at the sinus level. The
aortic arch is mildly dilated. The descending thoracic aorta is
mildly dilated.
A bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Dr.[**Last Name (STitle) 914**] was notified in person of the results before surgery
start.
After postbypass, on epinephrine 0.02 mcg/kg/min
Mild global RV systolic function.
LVEF 25%.
Mild TR.
Trivial MR.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2169-8-31**] 15:43
?????? [**2161**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mr.[**Known lastname 99580**] is a 73 year old male with ventricular tachycardia
that was unable to be ablated in EP lab and referred for
epicardial ablation. He was seen in clinic and preoperative
testing was performed.He was advised to take his last dose of
coumadin [**8-25**] and he was admitted to [**Hospital1 18**] for IV
heparin/cardiac cath/carotid US/PATs on [**8-29**].
On [**2169-8-31**] he was taken to the operating room and underwent a
Redo sternotomy and ventricular tachycardia ablation using
epicardial ventricular radiofrequency ablation/Ventricular
tachycardia mapping, dictated separately by Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **]. cardiopulmonary Bypass time=155 minutes. Please refer
to operative report for further details. He tolerated the
procedure well and was transferred to the CVICU intubated and
sedated. He required multiple pressor support to optimize
cardiac output. Immediately postoperatively he required a
bronchoscopy for left chest collapse seen on xray. He was slow
to awake, although neurologically intact, and was extubated on
POD#1. He weaned off all pressors and was started on Carvedilol
and Captopril to reduce afterload for his LVEF 25-30% He was
also placed on Statin/Aspirin and diuresis. He remained in the
CVICU for change in mental status requiring Haldol and narcotics
to be discontinued. His mental status improved to baseline and
on POD#6 he was transferred to the step down unit for further
monitoring. Anticoagulation was initiated for his chronic Afib.
Physical Therapy was consulted for evaluation of strength and
mobility. On [**9-4**] an Orthopeadics consult was called for left
knee joint swelling and warmth,with Mr.[**Known lastname 99587**] history of gout
and concern for septic joint.Ortho performed an arthrocentesis
to evaluate for gout versus infection, which was negative. He
placed back on his Colchicine. The remainder of his
postoperative course was essentially uneventful. On POD# 8 he
was cleared for discharge to [**Location (un) 9188**] Care and Rehab. All follow
up appointments were advised.
Medications on Admission:
Coumadin 5 mg daily (adjusted based on INR - for afib)
amiodarone 200 mg daily
Calcium 500 mg/ Vit D 400 units daily
Lasix 40 mg daily
Levothyroxine 25 mcg daily
Ropinirole 1 mg QHS
Carvedilol 12.5 mg [**Hospital1 **]
Lisinopril 2.5 mg daily
Klor-con 20 mEq daily
Digoxin 125 mcg daily
Colchicine 0.6 mg daily
Aspirin 81 mg daily
Multivitamin daily
lorazepam 1 mg daily prn anxiety
oxycodone 5 mg prn chronic hip pain
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2-2.5
First draw [**2169-9-9**]
Check INR Monday, Wednesday, Friday for 2 weeks and dose
coumadin for goal INR 2-2.5 [**Name8 (MD) **] MD
2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily):
MD to dose daily for goal INR 2-2.5.
17. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
18. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 9188**] Care and Rehabilitation Center
Discharge Diagnosis:
aortic root aneurysm (5.8 cm)
RUE DVT [**7-15**]
Rheumatic heart disease
Chronic systolic heart failure
Ventricular tachycardia
Paroxsymal atrial fibrillation
Group A Strep bacteremia dx [**6-13**] on ceftriaxone stopped and
changed to vancomycin d/t neutropenia ( finished [**7-26**])
Nonischemic cardiomyopathy
obstructive sleep apnea (CPAP encouraged)
Gout
Hypothyroidism
Left arm injury - got caught in machines
Past Surgical History
Aortic valve replacement -tissue (in [**State **] 10 years ago)
ICD placement [**2165**]
Biventricular pacer [**2168**] (sprint Fidelis)
Right total knee replacement
Left knee arthroscopy
back surgeries for rem. melanoma
? lumbar disc [**Doctor First Name **].
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
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**]
**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:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**], [**2169-10-10**] 1:45
Electrophysiology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2169-10-19**] 1:00
Please call to schedule appointments with your
Primary Care: Dr. [**Last Name (STitle) **] [**Name (STitle) **] ([**Last Name (un) 37901**], Fl) in [**5-9**] weeks
Cardiologist: [**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 85645**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2-2.5
First draw [**2169-9-9**]
Check INR Monday, Wednesday, Friday for 2 weeks and dose
coumadin for goal INR 2-2.5 [**Name8 (MD) **] MD
Completed by:[**2169-9-8**]
|
[
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"244.9",
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"V53.39",
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icd9cm
|
[
[
[]
]
] |
[
"33.23",
"88.56",
"39.61",
"96.6",
"37.23",
"37.49",
"37.27",
"81.91",
"37.26",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
11974, 12056
|
7655, 9756
|
307, 474
|
12799, 13032
|
3163, 6092
|
13871, 14914
|
2477, 2592
|
10225, 11951
|
12077, 12778
|
9782, 10202
|
13056, 13848
|
6141, 7632
|
2607, 2607
|
1466, 1983
|
234, 269
|
502, 1359
|
2621, 3144
|
2014, 2179
|
1381, 1446
|
2195, 2461
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,585
| 139,734
|
24979
|
Discharge summary
|
report
|
Admission Date: [**2163-1-2**] Discharge Date: [**2163-1-13**]
Date of Birth: [**2112-6-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Constipation / Obstruction
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy.
End transverse colostomy with mucous fistula development
History of Present Illness:
This is a 50 year old male with pancreatic CA diagnosed [**8-7**] who
presents with abdominal distension and constipation/obstipation
for 1 1/2 weeks. He has not moved his bowels or passed gas
during this time. He tried stool softeners, laxatives and
suppositories without effect. He has no nausea, vomitting,
fevers. He reports abdominal pain, that is sharp and
intermittent.
Past Medical History:
Pancreatic CA, s/p chemotherapy
Neuropathy from chemo
psoriasis
Social History:
He reports no ETOH, and no tobacco currently (1.5 packs for 20
years, age 16-36).
He works as a school custodian.
Married with 3 children
Family History:
father died at age 60 of colon cancer
Physical Exam:
95.2, 92, 149/57, 18, 100% RA
Gen: comfortable, A+O x 3, cachectic
Chest: CTA bilat.
CV: RRR
Abd: distended, nontender, no inguinal hernia present
Rectal: no stool in vault
Ext: no edema
Pertinent Results:
[**2163-1-2**] 12:15PM [**Month/Day/Year 3143**] WBC-9.4 RBC-4.14* Hgb-12.8* Hct-37.9*
MCV-92 MCH-30.9 MCHC-33.7 RDW-16.0* Plt Ct-262
[**2163-1-4**] 06:25AM [**Year/Month/Day 3143**] WBC-9.4 RBC-3.31* Hgb-10.3* Hct-30.4*
MCV-92 MCH-31.3 MCHC-34.0 RDW-15.5 Plt Ct-200
[**2163-1-2**] 12:15PM [**Month/Day/Year 3143**] Glucose-131* UreaN-46* Creat-0.9 Na-130*
K-6.2* Cl-94* HCO3-25 AnGap-17
[**2163-1-5**] 07:35AM [**Year/Month/Day 3143**] Glucose-152* UreaN-11 Creat-0.5 Na-136
K-3.6 Cl-105 HCO3-20* AnGap-15
[**2163-1-2**] 12:15PM [**Month/Day/Year 3143**] Calcium-8.7 Phos-4.7* Mg-3.0*
[**2163-1-5**] 07:35AM [**Year/Month/Day 3143**] Albumin-3.0* Calcium-7.9* Phos-1.9*
Mg-2.0 Iron-PND
CT ABDOMEN W/CONTRAST [**2163-1-2**] 3:03 PM
INDICATION: 50-year-old with metastatic pancreatic CA and now
likely SBO. Please evaluate extent.
IMPRESSION:
1) Extensive dilatation and fecalization of the majority of the
large and small bowel, with transition point at the mid sigmoid
colon at which there appears to be abnormal soft tissue
suspicious for peritoneal implants causing distal large bowel
obstruction. Additionally, the dilated bowel demonstrates
enhancing thickened wall, which because of its diffuse extent is
likely reactive from carcinomatosis
.
2) Pancreatic carcinoma with extensive metastases as described
above, with peritoneal carcinomatosis.
3) Occluded splenic vein as before. Moderate ascites. Right
hepatic lesion previously characterized as a hemangioma.
[**2163-1-10**] 06:29AM [**Year/Month/Day 3143**] WBC-7.6 RBC-2.95* Hgb-9.0* Hct-26.6*
MCV-90 MCH-30.6 MCHC-33.9 RDW-15.4 Plt Ct-120*
[**2163-1-12**] 08:58AM [**Year/Month/Day 3143**] Glucose-104 UreaN-13 Creat-0.6 Na-137
K-3.5 Cl-99 HCO3-29 AnGap-13
[**2163-1-12**] 08:58AM [**Year/Month/Day 3143**] Calcium-8.1* Phos-3.8# Mg-1.9
[**2163-1-10**] 06:29AM [**Year/Month/Day 3143**] calTIBC-131* TRF-101*
Brief Hospital Course:
He was admitted on [**2163-1-2**]. A CT showed extensive dilatation
and fecalization of the majority of the large and small bowel,
with transition point at the mid sigmoid colon at which there
appears to be abnormal soft tissue suspicious for peritoneal
implants causing distal large bowel obstruction. Additionally,
the dilated bowel demonstrates enhancing thickened wall, which
because of its diffuse extent is likely reactive from
carcinomatosis.
He was made NPO with NGT and IV fluids. He was putting out
brownish, feculent drainage. He received an IV bolus for
hypovolemia.
Several enemas were tried, including mineral oil and tap water.
These were without success.
A GI consult was obtained. On [**2163-1-4**], GI attempted to delineate
the stricture using a balloon catheter. Contrast was injected.
No contrast was seen to pass the stricture. We then attempted to
pass the stricture using the catheter and guidewire. We
exhanged the therapeutic scope for a diagnostic scope to gain a
better position but we were still unable to pass the stricture.
After 45 minutes the procedure was abandoned.
Impression: 1. Obstructing extraluminal sigmoid colon lesion.
2. Failed colonic stent placement.
Recommendations: 1. NPO, NG decompression.
2. IV fluids
3. Consider surgical decompression.
.
He had a PICC line placed and TPN was started on [**2163-1-5**].
He then went to the OR on [**2162-1-6**] for a Exploratory laparotomy.
End transverse colostomy with mucous fistula development.
He recovered well from the surgery. He continued on TPN for
nutritional support.
GI/Ostomy: He had a NGT and was NPO. The NGT was D/C'd on POD 3.
He was slowly started back on a diet and was tolerating a
regular diet at time of discharge.
He was seen by the Ostomy nurse for care of both pouches.
Both pouches intact. Patient states he will not be able to
perform ostomy/fistula care due to his medical condition,and his
wife will not be capable of assisting in ostomy care.
Ostomy Note: Removed ostomy pouch RUQ, protrudes about [**1-6**] inch.
Stoma is 80%
pink, with edges of mucous sloughing off dark tissue. Effluent
is
pasty brown.Mucocutaneouns junction is intact,and peri-stoma
skin
also intact. Cleanse skin with warm water, measured stoma,placed
Convatec 2 piece 1 [**3-6**] inch wafer [**Last Name (un) **]-fit Natura with
transparent
drainable pouch.
Mucous fistula LUQ,pink mucous tissue, oval shape, measures 1
[**1-4**]
x [**7-10**] inch. small amount of liquid brown effluent in pouch.
Peri-fistula skin intact.
Cleanse skin with warm water, cut out wafer, placed Convatec one
piece Active Life. Discussed function of fistula.
Discussed with patient pouches need to be changed 2x/wk, and
emptied when [**1-5**] full.
Pain: He had Morphine PCA and had good pain control. He was
transitioned to PO meds once tolerating a diet.
CV: He had post-op tachycardia and hypovolemia and received a
bolused of iVF. He was then started on Lopressor IV for rate
control. His HR was 90 to low 100's at time of discharge.
Ascities: His ascites was expanding. He received Lasix starting
on POD 5 and then Aldactone was added. These continued for 2
days to help with diuresis after all the fluid resuscitation and
becoming slightly hypervolemic. He was noted to have some lower
extremity edema also.
Abd: The wicks were removed from the incision on POD 7. The
wound was slightly red along the incision line, and there was no
suspicious drainage from the wound.
ID: He was on Fluconazole, Zosyn, Vancomycin post-operatively
for prophylaxis. He continued on the antibiotics for 7 days and
then these were stopped. He WBC normalized to 7.6 on POD 4.
Endo: [**Last Name (un) **] was consulted for post-op TPN related hyperglycemic
[**Last Name (un) **] glucose management. His glucose increased while on TPN and
he will continue with testing and administration at home.
Hypokalemia: He received IV potassium repletion for post-op
hypokalemia.
Palliative Care and Hospice: He was seen by palliative care and
understands his grave situation. He will go home with VNA and
then bridge to Hospice care.
Medications on Admission:
Fentanyl patch, dulcolux
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for 1 months.
Disp:*50 Tablet(s)* Refills:*0*
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
Disp:*30 Capsule(s)* Refills:*2*
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): See Sliding Scale.
administer if [**Last Name (un) **] sugar >160. Give at meals and bedtime.
Disp:*qs * Refills:*2*
6. Insulin Syringe 0.5cc/28G Syringe Sig: One (1)
Miscellaneous four times a day.
Disp:*qs * Refills:*2*
7. [**Last Name (un) **] Glucose Test Strips Sig: One (1) four times a day.
Disp:*qs * Refills:*2*
8. Lancets Misc Sig: One (1) Miscellaneous four times a
day.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Malignant bowel obstruction.
Metastatic pancreatic cancer
Discharge Condition:
Poor
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please resume all of your regular medications and take any new
meds as ordered.
.
Monitor your incision for signs of infection - redness,
drainage, fevers. Change dressing daily.
.
Continue with care of your Ostomy and Mucous fistula as
instructed by the Ostomy Nurse
.
Please monitor your [**Name (NI) **] sugars 4x/day. Administer Insulin per
the sliding scale as needed. Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **]
sugars are above 200.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-5**] weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
Please follow-up with Oncolgy in [**2-5**] weeks. Call [**Telephone/Fax (1) 6568**] to
schedule an appointment.
Completed by:[**2163-1-13**]
|
[
"560.9",
"157.8",
"357.7",
"276.52",
"263.0",
"276.8",
"197.6",
"E933.1",
"696.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.11",
"46.13",
"45.23",
"99.15",
"54.23"
] |
icd9pcs
|
[
[
[]
]
] |
8476, 8547
|
3263, 7356
|
354, 437
|
8649, 8656
|
1362, 3240
|
9338, 9618
|
1101, 1140
|
7431, 8453
|
8568, 8628
|
7382, 7408
|
8680, 9315
|
1155, 1343
|
272, 316
|
465, 843
|
865, 930
|
946, 1085
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,940
| 185,849
|
46421
|
Discharge summary
|
report
|
Admission Date: [**2195-7-16**] Discharge Date: [**2195-7-19**]
Date of Birth: [**2135-8-2**] Sex: M
Service: MEDICINE
Allergies:
Gluten
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
59 y/o male with Hyperlipidemia, Mild Emphysema, GERD, and
Obstructive Sleep Apnea presented to [**Hospital1 **] [**Location (un) 620**] on [**2195-7-15**] with
shortness of breath described as inability to get in a
satisfying breath. Patient has been experiencing symptoms for
last 4-5 days. Symptoms associated with increased fatigue,
subjective fevers/chills, swollen neck glands, and palpitations.
Patient denies any chest pain or light-headedness. In the last
week, patient had developed of a vesicular rash, which began on
abdomen, with 2-3 areas of patchy involvement progressing
towards back. He began taking acyclovir for presumed herpes
zoster.
.
Initial vitals at [**Location (un) 620**] were T 98.5, HR 99, BP 109/79 RR 16
SAT 98% RA. Found to be in rapid AFib with HR in the 190's.
Given two pushes of lopressor, which did induce improvement
ventricular rate, but precipitous fall in systolic blood
pressures to 70-80s. Patient was cardioverted with 50, 100, and
finally three hundred joules, with successful breaking of atrial
fibrillation. The patient re-entered AFibb within one hour, and
was loaded with amiodarone. Patient's CXR showed an enlarged
cardiac silloute, and CT showed large pericardial effusion.
Patient was transfered to [**Hospital1 18**] CCU for further manegement.
.
Patient denies any history of arrythmias, joint pain, cancer,
past heart attack, cardiac surgery, hemoptysis, or recent
thoracic trauma. He reports recent intentional weight loss of 30
pounds in last nine months. On two previous CT's patient had
small noted 4mm non-calcified lung nodule, which has not
increased in size.
Past Medical History:
Hyperlipidemia
Obstructive Sleep Apnea
Mild Emphysema PFT's [**2-20**] showed mild obstructive ventilatory
defect
GERD
Hiatal Hernia
Celiac Disease
Colon Polyps
Diverticulosis
No known drug allergies
Social History:
Social history is significant for the absence of current tobacco
use. He is a former smoker of two packs a day for twenty years,
quit 17 years ago. There is no history of alcohol abuse.
Family History:
There is a family history of sudden death, with his father dying
of cardiac arrest at age 75. His mother died at 79 of cancer. He
has a brother with seizure disorder and another with crohns
disease.
Physical Exam:
T 99.1 HR 105 BP 113/89 RR 18 SAT 96% PULSUS 15
HEENT: No scleral icterus, injected conjunctiva, PERRL, no
submandibular, sublingual, ant/post cervical adenopathy.
Oralpharynx without edema or erythema, no purulence. No oral
lesions noted.
NECK: No jugular venous distension, no lyphadenopathy, no
hepatojugular reflex
CHEST: No axillary lymphadenopathy noted. Slight cardiac rub
appreciated in RLL upon expiration.
HEART: Tachycardic. S1S2. No murmurs or gallops appreciated.
Cardiac rub appreciated, best at apex, with patient leaning
forward.
ABD: Soft, non-tender, non-distended. Normoactive bowel sounds.
No pulsitile mass noted. 2cm by 2cm escar noted on LLQ of
abdomen.
EXT: No edema noted in extremities. 2+
DP/PT/Poplitieal/Femoral/and Radial pulses. No cycanosis.
Neuro: Answers appropriatly to questioning. AAOx3. No focal
motor/sensory deficits. Cranial Nerves intact.
Pertinent Results:
LABORATORY DATA:
WBC 8.9 HCT 44 PLT 431
Na 141 Cl 104 K 5.5 Bicarb 28 BUN 15
Ca 8.9
Tprot 6.9 Alb 3.1 Tbili 0.62 Alk Phos 356 ALT 113 AST 58
Amylase 32 Lipase 192
Cr 1.1
INR 1.1
TSH 1.8
CK 92
CK-MB 2 CK Index 2.2
Troponin T <0.01
D Dimer 8.53 (0-0.99)
.
EKG showed sinus tachycardia with a ventricular rate of 104bpm.
Normal axis. PR depressions noted in I, II, V3. Upsloping ST
segment elevations of 1mm in V3, V4, V5. Minimal electrical
alternans noted in precordium.
.
CXR at [**Location (un) 620**]: Massive Cardiomegaly
.
CT CHEST at [**Location (un) 620**]: Large Pericardial Effusion, Small Bilateral
Pleural Effusions
.
CT scan of Chest [**2-20**]:
Several small mediastinal nodes are seen which do not meet the
criteria of pathological lymph node enlargement and they are
stable in
comparison. The heart size is normal. No pericardial effusion
or thickening is seen. Small calcification in LAD is noted. The
thoracic aorta is unremarkable as well as the pulmonary
arteries. Stable 4-mm left upper lobe nodule is seen on series
2, image 10. A calcified pulmonary nodule is again seen near the
fissure in the left upper lobe, series 2, image 22. No other
pulmonary nodules or lesions suspicious for malignancy are seen.
Stable mild predominantly centrilobular emphysema is again
noted mostly involving the upper lobes. Bilateral symmetric
gynecomastia is present unchanged in comparison to the previous
film.
The upper images of the abdomen again demonstrate unchanged
small porta hepatis lymph nodes. The imaged portion of the
liver, pancreas, kidneys, spleen do not reveal any pathology.
Degenerative spine changes are seen predominantly in the upper
thoracic spine.
.
2D-ECHOCARDIOGRAM performed on [**2193-8-1**] (baseline) demonstrated:
Mildly Dilated RA. The LA is normal in size. LV wall thicknesses
are normal. The LV cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). RV chamber
size and free wall motion are normal. The aortic root is
moderately dilated. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
.
Echo [**2195-7-16**]:
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is unusually small. Right
ventricular systolic function is normal. The aortic valve
leaflets are mildly thickened. The mitral valve leaflets are
mildly thickened. There is a large pericardial effusion. There
is sustained right atrial collapse. There is right ventricular
diastolic collapse and probable compression, consistent with
impaired fillling/tamponade physiology. There is significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, consistent with impaired ventricular filling.
.
Post-pericardiocentesis Echo [**2195-7-16**]:
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal. Right ventricular systolic
function is normal. There is a pericardial effusion that is very
small anteriorly and upto 1.7 cm wide and echodense (consistent
with organization/possible thrombus) posterior to the basal left
ventricle. There are no echocardiographic signs of tamponade.
Compared to the study earlier today, the pericardial effusion is
now much smaller.
.
Echo [**2195-7-17**]:
Left ventricular wall thickness, cavity size and regional/global
systolic
function are normal (LVEF >55%) There is a small pericardial
effusion
subtending the right atrial free wall. There are no
echocardiographic signs of tamponade. No right atrial or right
ventricular diastolic collapse is seen. Compared with the
findings of the prior study (images reviewed) of [**2195-7-16**],
there has been some reaccumulation of fluid around the right
atrial free wall.
.
Echo [**2195-7-19**]:
There is a small to moderate sized pericardial effusion
measuring 1.2 cm
subtending the right atrial free wall and 1.1 cm inferior to the
LV basal to mid inferior wall. No right atrial or right
ventricular diastolic collapse is seen. Compared with the prior
study (images reviewed) of [**2195-7-17**], there is no change in the
size of pericardial effusion.
.
CT chest, abdomen, pelvis [**2195-7-17**]:
1. Unchanged centrilobular emphysema and 4 mm left upper lobe
pulmonary
nodule. Continued follow up in 12 months is recommended.
.
2. Large bilateral pleural effusions with dependent atelectasis.
.
3. Moderately large pericardial effusion with prominent
hyperenhancing
pericardium. This could be related to patient's recent
pericardiocentesis and drain placement. No definite nodularity.
.
4. Mild ascites with mild retroperitoneal free fluid. No
retroperitoneal
lesions or masses or disease process was seen. No definitive
evidence of
malignancy.
Brief Hospital Course:
59 y/o male with pericardial effusion causing shortness of
breath.
.
1. Pericardial effusion:
Echocardiogram demonstrated pericardial effusion with
compression of right ventricle during diastole consistent with
tamponade physiology. Patient had 1100cc pericardiocentesis
performed with resolution of dyspnea. Follow-up echo performed
the day of pericardiocentesis as well as 1 day later did not
show significant reaccumulation of his effusion. His drain was
pulled without creating a pericardial window, and follow-up
echocardiogram on [**7-19**] did not show further accumulation of
effusion.
.
The etiology for the effusion was unclear. Differential for a
pericardial effusion includes viral infection, including HIV,
purulent pericarditis, tuberculosis, myocardial infarction,
cardiac surgery, chest trauma, drugs and toxins, metabolic
disorders (especially uremia, dialysis, and hypothyroidism),
malignancy, collagen-vascular diseases. No evidence of uremia
lab work, normal TSH, no description of symptoms consistent with
lupus, no history of heart diseae or chest pain and negative
troponins, and no correlation between patient's current
medications and pericardial effusion.
.
The patient describes recent syndroms consistent with a viral
podrome, which lends itself to a viral etiology. However, given
the massive size of the effusion compared to symptoms, it would
seem more chronic in nature, making an malignant cause seem more
likely.
.
Patient reports that he had a negative colonoscopy at age 55.
PPD was placed and was negative 48 hours later. HIV test was
sent with the patient's consent, and came back negative.
Cytology from his pericardiocentesis revealed "Predominantly
lymphocytes with few reactive mesothelial cells and blood." CT
of chest, abdomen, and pelvis was performed to search for occult
malignancy, and there was no evidence of malignancy or
lymphadenopathy. He was advised to follow-up with his PCP for
further care, including obtaining a second colonoscopy.
Moreover, the covering physician for his PCP was [**Name (NI) 653**]
regarding his hospital admission and the need for follow-up. He
has a follow-up appointment with cardiology in 1 week with a
preceding echocardiogram to evaluate for any reaccumulation of
his pericardial effusion.
.
2. Atrial Fibrillation:
The patient has no history of cardiac arrythmia, and it was felt
that his AFib was due to compressive pericardial effusion. His
only symptom was a vague feeling of flutter in his chest. He
continued to have episodes of AFib even after
pericardiocentesis. He was put on an amiodarone drip and then
switched to oral amiodarone. For breakthrough episodes of
AFib, pt was given IV metoprolol, which caused him to become
hypotensive to 90s systolic. AFib did respond to diltiazem.
Prior to discharge, patient was placed on oral metoprolol and
oral amiodarone with good control of his AFib and he was
discharged on these medications. He was directed to take one
extra dose of metoprolol if he felt he was in AFib.
.
3. GERD--maintained on PPI during admission
.
4. Hypercholesterolemia: will maintain home dose of lipitor.
.
5. Patient had thrombophlebitis on right forearm. On exam, the
area was erythematous and warm to the touch, though the area
involved had become smaller on the day of discharge. He was
given a 5 day course of Keflex for treatment.
Medications on Admission:
ASA
Lipitor
Androgel
Prevacid
MVI
Fishoil
Flomax
Discharge Medications:
1. Atorvastatin 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
2. Zolpidem 5 mg Tablet [**Name (NI) **]: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
3. Metoprolol Tartrate 50 mg Tablet [**Name (NI) **]: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*0*
4. Amiodarone 400 mg Tablet [**Name (NI) **]: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
6. AndroGel 1 % (25 mg/2.5 g) Gel in Packet [**Name (NI) **]: as directed as
directed Transdermal as directed.
7. Prevacid 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
8. Flomax 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24 hr PO once a day.
9. Keflex 500 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day for
5 days.
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Dx: Pericardial effusion.
Secondary Dx: Paroxysmal atrial fibrillation
Discharge Condition:
Patient's shortness of breath had greatly improved following
pericardiocentesis. He had several episodes of paroxysmal
Atrial fibrillation, which were controlled with metoprolol upon
discharge. He was sent home in stable condition with amiodarone
and metoprolol for control of AFib. He has follow-up within [**11-18**]
weeks with cardiology to assess for reaccumulation of the
pericardial effusion. The covering physician for his PCP was
[**Name (NI) 653**] regarding the need for this follow-up.
Discharge Instructions:
You were admitted with fluid around your heart, called a
"pericardial effusion." This fluid was tapped and we followed
you to make sure that it did not reaccumulate.
1. Please take all medications as prescribed.
2. Please attend all follow-up appointments as listed below.
3. Please return to the hospital if you have shortness of
breath, chest pain, fevers, or any other concerning symptom.
Followup Instructions:
Please call the cardiology office at [**Telephone/Fax (1) 62**] on Tuesday
morning to find out if you have an appointment already
scheduled. If you do not have an appointment yet, you need to
have an appointment within the next 1-2 weeks. Your primary
doctor, Dr. [**Last Name (STitle) 1728**], knows that you need this appointment and can
help you get it soon if you are having difficulties. Your dose
of amiodarone will be adjusted at this cardiology appointment.
Also, you should see Dr. [**Last Name (STitle) 1728**] within the next month.
Addendum--patient informed prior to discharge that he had a
cardiology appointment on Friday, [**7-24**]. He was to call the
above cardiology number to get the exact time and place.
Completed by:[**2195-7-22**]
|
[
"530.81",
"553.3",
"272.0",
"427.31",
"423.9",
"492.8",
"V12.72",
"511.9",
"562.10",
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icd9cm
|
[
[
[]
]
] |
[
"37.0",
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icd9pcs
|
[
[
[]
]
] |
12931, 12937
|
8456, 11824
|
285, 306
|
13060, 13563
|
3517, 8433
|
14004, 14765
|
2401, 2601
|
11923, 12908
|
12958, 13039
|
11850, 11900
|
13587, 13981
|
2616, 3498
|
226, 247
|
334, 1958
|
1980, 2182
|
2198, 2385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,043
| 135,417
|
14224
|
Discharge summary
|
report
|
Admission Date: [**2176-6-17**] Discharge Date: [**2176-7-4**]
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins / Coumadin / Oxycodone / Megestrol
Acetate / Remeron / Ritalin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
Endotracheal intubation.
PICC line placement.
Dobhoff (nasogastric) tube placement.
PEG tube placement
History of Present Illness:
Mr. [**Known lastname 42290**] is an 87 year-old man with atrial fibrillation,
diabetes mellitus II, prostate cancer s/p XRT, cerebrovascular
accident, dementia, and bladder rupture most recently on [**6-3**],
s/p repair and complicated by peritonitis, delirium who presents
from rehab with altered mental status.
Regarding his prior hospitalization, he presented to [**Hospital1 18**] on
[**6-3**] after the onset of abdominal pain and hematuria. His foley
was replaced with no improvement in his symptoms, subsequently
undergoing CT scan with findings consistent with ruptured
bladder. He had also become hypotensive at that point requiring
pressors and transfer to the MICU. He underwent repair of an
anterior bladder rupture on [**6-4**] with placement of a foley, SP
catheter, and JP drain. Peritoneal culture grew rare
Pseudomonas, and his antibiotics were initially Vanco, Cefepime,
Gent x10 days, narrowed to Cefepime. A follow up CT scan
demonstrated a small fluid collection, though it was unclear if
it was indeed an abscess. He was discharged to rehab with a
PICC, foley, SP catheter, completion of 14-day course of
Cefepime, and follow up CT scan and urology follow-up.
Per report, the patient was found today at [**Hospital **] rehab with
altered mental status. Per report, he was more lethargic and
confused during the course of the day. Patient is usually
verbal, though was found to be non-verbal prior to transfer,
lying supine and moaning. FSBG 187. The son visited him last
Thursday and was reportedly at his baseline, conversing, lucid,
awake and alert. However, yesterday he was less conversant,
calling his wife's name, but responding to commands. He was also
noted to be tremulous all over. There was no obvious indication
of new symptoms such as new pain, respiratory symptoms, new
numbness/weakness or other neurological symptoms.
In the ED, vitals were 99.6, 74, 130/85, 25, 95% on RA. He was
agitated without meningismus, and was intubated for airway
protection (100% AC 550x12, 100%). Admission labs revealed a
white count of 23 and Cr of 2.3. LP done in ER, needle trauma at
end of tap. He was given vancomycin, ceftriaxone, and zosyn
(started), which was changed to cefepime given his PCN allergy.
Given 2L fluid, and was transiently hypotensive to 90s, which
responded to 130s systolic after 250cc bolus.
Past Medical History:
-DM II, on insulin
-prostate CA s/p XRT [**2156**]
-chronic urinary incontinence, s/p TURP [**10-6**]
-history of UTIs, including prior MRSA, klebsiella, proteus,
pseuduomonas
-s/p bladder rupture and repair x2, [**2-8**], [**6-8**]
-atrial fibrillation, not anticoagulated due to h/o bleeding
-hyperthyroidism
-depression
-hypertension
-moderate aortic stenosis on TTE [**5-/2176**]
-peripheral vascular disease
-h/o CVA [**2172**]
-severe chronic axonal neuropathy, radiculopathy and plexopathy
(due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop for many
years
-L3 compression fracture
-cataract s/p bilateral laser surgery, also with "macular edema"
s/p dexamethasone injection
-hard of hearing
-left thyroid nodule, benign
Social History:
Smoked 2 ppd tobacco x24 years. Quit in [**2137**]. Denies EtOH.
Former WWII vet. Former Fire Fighter. Wife is HCP. Daughter is
RN, son is engineer.
Family History:
No illnesses, strokes, DM or early heart attacks run in the
family.
Physical Exam:
Vitals: Tm 98.4, Tc 97.8, HR 58 (58-78), BP 143/82, RR 17, sat
100%RA
General: minimally interactive; squeezes hands on command but
will not close eyes on command; winces when pressure is applied
to suprapubic region
Lungs: clear anteriorly
Chest: RRR, normal S1/S2
Abdomen: moderate suprapubic tenderess, normal bowel sounds;
suprapubic catheter, folety catheter, and rectal tube are in
place
Extremites: hands with trace pitting edema, diffuse ecchymoses,
legs are non-edematous
Pertinent Results:
Labs at Admission:
[**2176-6-17**] 03:22AM BLOOD WBC-22.6*# RBC-3.76* Hgb-11.3* Hct-35.8*
MCV-95 MCH-30.0 MCHC-31.4 RDW-16.3* Plt Ct-522*#
[**2176-6-17**] 03:22AM BLOOD Neuts-88.5* Lymphs-6.3* Monos-3.4 Eos-1.4
Baso-0.4
[**2176-6-17**] 03:22AM BLOOD PT-15.5* PTT-29.5 INR(PT)-1.4*
[**2176-6-17**] 03:22AM BLOOD Glucose-184* UreaN-53* Creat-2.3*# Na-135
K-4.7 Cl-102 HCO3-24 AnGap-14
[**2176-6-18**] 04:17AM BLOOD ALT-9 AST-14 LD(LDH)-247 TotBili-0.2
[**2176-6-17**] 03:22AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.5*
Mg-2.1
[**2176-6-18**] 04:17AM BLOOD calTIBC-164* Hapto-184 Ferritn-251
TRF-126*
[**2176-6-19**] 03:49AM BLOOD VitB12-1024* Folate-14.6
Micro Studies:
[**2176-6-29**] URINE URINE CULTURE- negative
[**2176-6-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-
negative
[**2176-6-20**] BLOOD CULTURE Blood Culture, Routine- negative
[**2176-6-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE- yeast
[**2176-6-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-
negative
[**2176-6-19**] BLOOD CULTURE Blood Culture, Routine- negative
[**2176-6-19**] URINE URINE CULTURE- negative
[**2176-6-18**] URINE Legionella Urinary Antigen - negative
[**2176-6-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST, STAPH AUREUS COAG +}; LEGIONELLA CULTURE- negative
GRAM STAIN (Final [**2176-6-17**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): YEAST(S).
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2176-6-17**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-
negative
[**2176-6-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-
negative
[**2176-6-17**] BLOOD CULTURE Blood Culture, Routine- negative
[**2176-6-17**] BLOOD CULTURE Blood Culture, Routine- negative
[**2176-6-17**] URINE URINE CULTURE- negative
Cerebrospinal Fluid:
[**2176-6-17**] 05:30AM CEREBROSPINAL FLUID (CSF) WBC-19 RBC-8450*
Polys-78 Lymphs-14 Monos-5 Eos-3
[**2176-6-17**] 05:30AM CEREBROSPINAL FLUID (CSF) WBC-11 RBC-1650*
Polys-78 Lymphs-15 Monos-7
[**2176-6-17**] 05:30AM CEREBROSPINAL FLUID (CSF) TotProt-59*
Glucose-101
[**2176-6-17**] 11:19AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-negative for HSV 1 and HSV 2
Imaging Studies:
CT Abdomen and Pelvis ([**6-17**]):
1. Anasarca. New small left greater than right pleural
effusions. Tiny pericardial effusion.
2. Right basilar airspace opacity concerning for aspiration.
3. Superpubic and Foley catheter remain within the decompressed
bladder. [**Doctor Last Name 406**] drain is removed. The fluid in the previously
seen rim-enhancing pelvic fluid collection has essentially
resolved, with now 2.4 x 1.7 x 1.8 cm soft tissue seen remaining
where fluid collection was. No definite new fluid collection
seen.
EEG ([**6-17**]):
IMPRESSION: This is an abnormal portable EEG recording due to
the independent left and right parasagittal discharges and the
focal slowing
in the parasagittal area. The background was slow alternating
with periods of relative suppression, as well as multifocal
slowing. For about 15 minutes, there were bifrontally
predominant triphasic waves that evolved into more rhythmic
pattern reaching a maximum of 1.5-2 Hz. The first and second
abnormalities suggest cortical irritability as well as
subcortical dysfunction in the parasagittal areas. The third
abnormality suggests multifocal a moderate to severe
encephalopathy. The fourth abnormality may be seen in
encephalopathies but also raises concern for electrographic
seizure activity, although no clear change was seen in the
patient's behavior on video. Thus, continuous EEG recording may
be of further diagnostic value in this patient to evaluate for
subclinical seizures. Of note is the irregular cardiac rhythm
suggestive of atrial fibrilllation.
TTE ([**6-19**]):
The left atrium is normal in size. 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 low normal (LVEF 50-55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade. Compared with
the prior study (images reviewed) of [**2172-12-17**], the degree of
AS is now moderate.
MRI Head ([**6-24**]):
IMPRESSION: No evidence for acute ischemia. Slight progression
of periventricular hyperintensity which could reflect
progression of small vessel ischemia. Less likely, this could
represent transependymal CSF flow from NPH. Foci of hypersignal
in the right frontal and parietal lobe which were not present on
the prior MRI may represent interval ischemia which is chronic.
.
.
DISCHARGE LABS:
.
Na: 147
Cl: 118
Cr: 1.7
Hct: 23.8
Ca: 8.0
Brief Hospital Course:
In summary an 87 year-old man with history of atrial
fibrillation, diabetes mellitus II, dementia, history of
prostate cancer s/p XRT c/b bladder rupture x2 with recent
surgical repair, MDR UTIs, who presents from rehab with altered
mental status.
# Altered mental status: etiology is not clear. He was intubated
in the emergency room for airway protection (extubated later on
[**6-24**]). He had a leukocytosis of 23 with neutrophilic
predominance at admission. CSF was traumatic but we could not
exclude bacterial meningitis. Other considerations included
delirium in setting of infection (meningitis, aspiration
pneumonia, or urinary tract infection), acute renal failure, and
seizures. He was treated empirically for meningitis with
ceftriaxone, vancomycin, and Bactrim. Neurology was consulted.
EEG showed possible non-convulsive status epilepticus while in
the intensive care unit. Therefore he was started on Dilantin.
MRI showed no evidence of acute vascular event. Despite the
above treatments, his mental status did not return to
pre-admission baseline. After transfer to the floors, he had
completed a 14-day course of antibiotics and remained
therapeutic on Dilantin. The patient's mental status has
gradually improved, and Neurology recommended continuing
Dilantin and follow up with Neurology upon discharge.
# Seizures: MRI was without mass or evidence of stroke.
Non-convulsive status epilepticus was felt to be precipitated by
meningitis. He was loaded on phenytoin and levels were followed
until therapeutic.
# Acute renal failure: His creatinine was up to 2.3 during this
admission from previous baseline 0.5-1.0. This was thought
secondary to gentamicin toxicity during prior admission or
possibly precipitated by infection/sepsis. His creatinine came
down with treatment of infection, but has not reached previous
baseline. He is still producing good amount of urine and
creatinine has been stable at 1.7.
# Anemia: his baseline hematocrit from early [**2176**] is 30. There
were no signs of active bleeding on exam. The anemia was felt to
be due to phlebotomy effect and inflammation and chronic
disease. We maintained an active type and screen. Blood
transfusion was not necessary.
# S/p Bladder repair: He has had two bladder ruptures in the
last two years. He now has a chronic foley and suprapubic
catheter. At last admission the bladder perforation appeared to
be healing well with clear drainage. During this admission there
was a small fluid collection in the peritoneum, which was a
non-specific finding. His foley and supra-pubic catheters
continued to drain clear urine, and abdominal exam was benign.
# Diabetes mellitus II: bood sugars were stable. We continued
his home insulin sliding scale and held his Lantus initially.
We restarted this medication on [**7-2**], and his sugars remained
within good contol.
# Atrial fibrillation: he is not on anticoagulation due to
history of bleeding. In the intensive care unit he had episodes
of atrial fibrillation with RVR. He was intially treated with
metoprolol, then was loaded on amiodorone with good rate
control. After transfer to the floors, there was concern of
high-degree atrioventricular block. Electrophysiology service
was consulted and recommended that amiodorone be discontinued.
He was kept on metoprolol at a dose of 25 mg twice daily and he
was started on ASA 81 mg daily prior to admission.
# Hypertension: We continued metoprolol and held amlodipine.
Blood pressure control was good on this regimen.
Medications on Admission:
Amlodipine 5 mg PO DAILY (Daily).
Acetaminophen 500 mg (2) Tablet PO Q 8H (Every 8 Hours) as
needed Miconazole Nitrate 2 % Powder (1) Appl Topical [**Hospital1 **]
Ondansetron 4 mg IV Q8H:PRN nausea, vomiting
Senna 8.6 mg (1) Tablet PO DAILY (Daily) as needed for
constipation
Metoprolol Tartrate 50 mg PO Q8H
Docusate Sodium 50 mg/5 mL Liquid (1) PO DAILY
Insulin Glargine 6 Units Subcutaneous at bedtime
Cefepime 2 gram [**Hospital1 **] through [**6-16**]
Lovenox 40mg SC Daily
Metoclopramide 5 mg PO every six 6 hours
Discharge Medications:
1. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO TID (3
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
7. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6) Units
Subcutaneous at bedtime.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY DIAGNOSES
Meningitis
Atrial fibrillation with rapid ventricular response
Non-convulsive status epilepticus
Acute renal failure
.
SECONDARY DIAGNOSES
History of bladder rupture
Moderate aortic stenosis
Diabetes type II
Discharge Condition:
Vital signs stable. Afebrile.
Discharge Instructions:
You were admitted to the hospital for evaluation of altered
mental status. We believe that you had an infection, although we
were not able to isolate the source. We treated you with a
fourteen-day course of antibiotics, which you completed while in
the hospital. In addition, we noticed that you were having
seizures and started you on a medicine to help prevent seizures
in the future. We also placed a G-tube in your stomach in order
to improve your nutrition.
.
While you were here, we made the following changes to your
medications:
1. We started you on Dilantin for seizures
2. We discontinued your Amlodipine and decreased your
Metoprolol to 25 mg PO twice daily
3. We discontinued your Ondansetron
4. We started you on Aspirin 81 mg daily
5. We increased your senna to twice daily instead of once daily
6. We discontinued your Lovenox injections and started you on
Heparing injections three times daily
Please take all medications as prescribed.
Please keep all previously scheduled appointments
Please return to the ED or your healthcare facility if you
experience shortness of breath, chest pain, fevers, chills,
increasing confusion, seizures, or any other concerning
symptoms.
Followup Instructions:
Please follow-up with your primary provider one week after being
discharged from [**Hospital 100**] Rehab. Their phone number is
[**Telephone/Fax (1) 3070**].
PROVIDER: [**Name10 (NameIs) **] [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] (Nephrology). Date and time: [**8-9**] at 11am. Location: [**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**].
Phone number: [**Telephone/Fax (1) 60**]
PROVIDER: [**Name10 (NameIs) **], [**Name11 (NameIs) 1112**] MD (Neurology). Date/Time: [**2176-10-2**] at
1 PM. Location: [**Hospital Ward Name 23**] Building [**Location (un) **].
Completed by:[**2176-7-4**]
|
[
"322.9",
"707.20",
"E879.8",
"345.3",
"276.7",
"353.0",
"276.2",
"424.1",
"788.39",
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"401.1",
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"458.9",
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"250.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"43.11",
"96.07",
"96.72",
"96.04",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
15138, 15204
|
9966, 10225
|
317, 422
|
15474, 15506
|
4326, 6991
|
16752, 17405
|
3741, 3810
|
14043, 15115
|
15225, 15453
|
13498, 14020
|
15530, 16729
|
9898, 9943
|
3825, 4307
|
255, 279
|
450, 2791
|
10240, 13472
|
2813, 3559
|
3575, 3725
|
7009, 9882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,293
| 160,581
|
24156
|
Discharge summary
|
report
|
Admission Date: [**2126-4-12**] Discharge Date: [**2126-4-17**]
Date of Birth: [**2085-11-20**] Sex: F
Service: UROLOGY
Allergies:
Compazine
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
Right renal mass
Major Surgical or Invasive Procedure:
right open nephrectomy (debulking)
History of Present Illness:
This is a 40 year old woman with history of multiple neoplasias
(thyroid medulary CA) and recurrence who presents with a renal
mass found on routine abdominal CT. She is otherwise in her
baseline state of health, and presents to day for resection of
the mass
Past Medical History:
Anxiety
Thyroid medulary cell CA, with recurrence
Social History:
Quit tobacco 20 yrs ago
Family History:
Multiple relatives with thyroid cancer
Grandfather with RCC
Physical Exam:
99.1 103/73 62 19
NAD, AOx3, but anxious
RRR
CTA
Abd: benign
Ext: warm well perfused
Pertinent Results:
[**2126-4-12**] 02:23PM freeCa-1.18
[**2126-4-12**] 02:23PM HGB-9.6* calcHCT-29 O2 SAT-98
[**2126-4-12**] 02:23PM GLUCOSE-114* LACTATE-1.1 NA+-137 K+-3.5
CL--109
[**2126-4-12**] 02:23PM TYPE-ART PO2-225* PCO2-36 PH-7.42 TOTAL
CO2-24 BASE XS-0
[**2126-4-12**] 04:29PM freeCa-1.12
[**2126-4-12**] 04:29PM HGB-9.2* calcHCT-28 O2 SAT-98
[**2126-4-12**] 04:29PM GLUCOSE-149* LACTATE-2.1* NA+-136 K+-3.9
CL--109
[**2126-4-12**] 04:29PM TYPE-ART PO2-250* PCO2-35 PH-7.40 TOTAL
CO2-22 BASE XS--1
[**2126-4-12**] 05:45PM freeCa-0.99*
[**2126-4-12**] 05:45PM HGB-7.8* calcHCT-23
[**2126-4-12**] 05:45PM GLUCOSE-140* LACTATE-2.1* NA+-134* K+-3.3*
CL--113*
[**2126-4-12**] 05:45PM TYPE-ART TIDAL VOL-500 O2-45 PO2-267*
PCO2-33* PH-7.36 TOTAL CO2-19* BASE XS--5 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2126-4-12**] 07:47PM WBC-12.3*# RBC-3.76* HGB-10.8* HCT-31.6*
MCV-84 MCH-28.7 MCHC-34.1 RDW-13.8
[**2126-4-12**] 07:47PM CALCIUM-7.2* MAGNESIUM-1.1*
[**2126-4-12**] 07:47PM GLUCOSE-141* UREA N-8 CREAT-0.7 SODIUM-140
POTASSIUM-4.1 CHLORIDE-115* TOTAL CO2-18* ANION GAP-11
Brief Hospital Course:
The patient was admitted to the ICU post op for chest tube
managment, close monitoring and initial presence of ET tube.
She was extubated on POD 1 as well as having her chest tube
removed. Acute pain service was consulted and helped manage her
post op pain. She was also txf'ed to the floor after her chest
tube was removed. On post op day 2 and beyond her diet was
advanced slowly, not taking a true full diet until pod 4, before
she was d/c'ed. Her foley was d/c'ed on POD 2 with out
incident. She urinated normally and her creatinine stayed at a
low level. Her post op course was otherwise uneventfull and she
was d/c'ed on POD 4
Medications on Admission:
Synthroid
OCP
Zoloft
Clonazepam
Discharge Medications:
1. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for prn insomnia.
3. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Renal Mass
Discharge Condition:
Good
Discharge Instructions:
Notify your MD if you experience increasing pain, bloody urine,
decreasing urine output or concering signs at your incision such
as redness, pain, swelling, or discharge
Followup Instructions:
Call Dr.[**Name (NI) 13919**] office for an appointment. ([**Telephone/Fax (1) 4230**]
Completed by:[**2126-4-17**]
|
[
"189.0",
"198.7",
"197.7",
"459.2",
"V10.87",
"198.89",
"196.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.77",
"07.22",
"40.3",
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
3264, 3270
|
2037, 2677
|
287, 323
|
3324, 3330
|
924, 2014
|
3548, 3666
|
742, 803
|
2759, 3241
|
3291, 3303
|
2703, 2736
|
3354, 3525
|
818, 905
|
231, 249
|
351, 612
|
634, 685
|
701, 726
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,682
| 189,383
|
27250
|
Discharge summary
|
report
|
Admission Date: [**2191-6-25**] Discharge Date: [**2191-7-6**]
Date of Birth: [**2116-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
74 year old gentleman presented with a complaint of R flank pain
for 1 week about 2 months s/p an emergent TAGx2 stent placement
for a ruptured thoracoabdominal aortic aneurysm.
Major Surgical or Invasive Procedure:
[**6-29**] Angioplasty of thoracic aortic stent
History of Present Illness:
75 year-old gentleman who presented to his post-operative
cardiac surgery clinic appointment with a complaint of 1 week of
right flank pain s/p emergent placement of [**Doctor Last Name **] TAGx2 for a
ruptured thoracoabdominal aortic aneurysm. He describes this
pain as intermittent and lasting only a few minutes.
Past Medical History:
Hypertension
Coronary Artery Disease
Hypercholesteolemia
Obesity
s/p AAA repair in past
Social History:
lives with wife
Physical Exam:
T:96 P:76 Rhythm:SR BP:146/75 I/O:1340/2170 Wt:103kg O2 94% on
RA
Neuro: AAOx3
Pulm: lungs CTA B/L
Cardiac: RRR, no M,C,R
Abd: soft,non-tender, non-distended, +BS, +BM today
Ext: +1
Skin: L groin incision with staples, C/D/I
Pertinent Results:
[**2191-7-3**] 05:20AM BLOOD WBC-9.4 RBC-3.62* Hgb-10.6* Hct-30.8*
MCV-85 MCH-29.2 MCHC-34.4 RDW-14.7 Plt Ct-203
[**2191-7-6**] 06:50AM BLOOD Glucose-106* UreaN-28* Creat-1.6* Na-147*
K-3.4 Cl-102 HCO3-37* AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] was admitted for work-up of his complaint of R flank
pain s/p endovascular stent repair af a thoracoabdominal aortic
aneurysm repair. A CT angiogram was obtain which revealed a
type II endoleak. He was seen in consultation by the vascular
surgery service given this finding, and was taken to the
operating room by this service for noninvasice ballooning of the
existing stent. Mr. [**Known lastname **] [**Last Name (Titles) 8337**] this procedure well. His
blood pressure management was maximized. A repeat MRI of his
aorta was unchanged from the CT performed at the time of
admission. He was discharged to home in stable condition.
Medications on Admission:
1. Theophylline 200 mg [**Hospital1 **]
2. Zocor 20 mg daily
3. Aspirin 81 mg daily
4. Metoprolol 50 mg [**Hospital1 **]
5. Lasix 40 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Theophylline 200 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO BID (2 times a day).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Type I Endoleak
s/p endovascular repair of thoracic aortic aneurysm
Hypertension
Coronary artery disease
Hyperlipidemia
s/p AAA repair
Discharge Condition:
Good.
Discharge Instructions:
Keep incisions clean and dry.
Call with fever, redness or drainage from incisions, or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no swimming.
Followup Instructions:
See Dr. [**Last Name (STitle) 914**] in 4 weeks.
See PCP [**Name9 (PRE) 66826**] [**Name9 (PRE) **] in [**12-20**] weeks.
See Dr. [**Last Name (STitle) 14527**] from vascular surgery in 6 weeks.
Completed by:[**2191-7-6**]
|
[
"272.0",
"996.1",
"403.91",
"V45.82",
"414.01",
"278.00",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"38.84",
"88.47",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
3321, 3327
|
1536, 2203
|
496, 546
|
3506, 3514
|
1297, 1513
|
3742, 3966
|
2406, 3298
|
3348, 3485
|
2229, 2383
|
3538, 3719
|
1052, 1278
|
279, 458
|
574, 892
|
914, 1003
|
1019, 1037
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,186
| 114,430
|
47877
|
Discharge summary
|
report
|
Admission Date: [**2159-2-1**] Discharge Date: [**2159-2-4**]
Date of Birth: [**2097-8-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Small Bowel Obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 year-old male with a history of a renal transplant on [**2137**]
that has now failed, and also a history of multiple abdominal
operations. He has a long history of small bowel obstructions
and was recently hospitalized last week with an episode of small
bowel obstruction. He reports last night had a similar episode
of pain and presented to clinic. He denies nausea, vomiting,
fevers, chills, chest pain, and shortness-of-breath. He was
evaluated by Dr. [**First Name (STitle) **] in the clinic and was sent to the
emergency room for further evaluation for a possible small bowel
obstruction.
Currently, he continues to have pain that has improved. He
continues to have no nausea, vomiting, fevers, chills, chest
pain, or shortness-of-breath. He continues to have high output
from his ostomy with copious amounts of gas. He empties the
ostomy approximately 7-8 times per day.
Past Medical History:
ESRD on HD (secondary to post-streptococcal
glomerulonephritis, Renal transplant '[**37**] failed, transplant
nephrectomy in [**2143**]), Hyperparathyroidism, Hypertension, Atrial
fibrillation (started on warfarin [**Date range (1) 101024**]), CAD, Diastolic CHF
with remote history of systolic CHF MSSA, Endocarditis w/ Aortic
and Mitral valve involvement, Repeated episodes of pneumonia,
VRE
septic arthritis, L wrist MSSA infective arthritis, Right hip
fracture s/p Right hip hemiarthroplasty, [**2157-1-11**], Right
Prosthetic Hip infection s/p explantation [**2-18**], Ischemic
colitis/ileitis s/p subtotal colectomy and terminal ileal
resection, followed by ileocolonic anastomosis with diverting
loop ileostomy and gastrostomy tube placement [**2156**]
PAST SURGICAL HISTORY:
[**2158-11-7**]: Aortic valve replacement(21 mm ON-X, Mitral valve
replacement 25/33 On-X Conform-X mechanical valve)
[**2158-10-5**]: Right heart catheterization
[**2158-10-3**]: Paracentesis
[**2158-7-13**]: Fistulogram, 6-mm balloon angioplasty of
juxta-anastomotic segment
[**2157-6-16**]: Washout and drainage right hip wound infection.
[**2157-6-14**]: Revision left radiocephalic arteriovenous fistula,
endarterectomy radial artery.
[**2157-2-22**]: Evacuation drainage of right hip deep hematoma-abscess.
[**2157-2-18**]: Removal right hip hemiarthroplasty.
[**2157-2-3**]: Irrigation, debridement and evacuation of hematoma of
right septic hemiarthroplasty.
[**2157-1-26**]: Right hip revision of hemi arthroplasty due to
dislocation.
[**2157-1-15**]: Exploratory laparotomy, gastrostomy tube, ileocolonic
anastomosis and diverting loop ileostomy.
[**2157-1-14**]: Exploratory laparoscopy, subtotal colectomy.
[**2157-1-13**]: Exploratory laparotomy, Subtotal colectomy, Resection
of terminal ileum, Temporary abdominal closure.
[**2157-1-11**]: Right hip hemiarthroplasty.
[**2156-12-10**]: Left wrist incision and drainage.
[**2156-2-17**]: Right ring finger closed reduction percutaneous pinning
for mallet finger. Left index and long ring finger PIP joint
manipulation under anesthesia.
[**2155-12-16**]: Left carpal tunnel release and left index, long and
ring finger trigger releases
Social History:
Owner of a clothing store in [**Location (un) 4398**]. No current tobacco and
alcohol h/o intermittent tobacco use in the past (~3
pack-years). Denies illicit drug use. HIV negative [**2156-12-27**]
Family History:
Positive for cancer (father-prostate), [**Name (NI) 2481**] (mother).
Father deceased. Brother has fibromyalgia. Daughter in good
health
Physical Exam:
Gen: NAD
HEENT: MMM no lesions
CV: RRR no MRG
RESP: CTAB no WRR
ABD: soft, NT ND. Ostomy w stool and gas. G tube with drainage
bag, thin gastric contents present.
Ext: No LE edema
Pertinent Results:
[**2159-2-3**] 06:50AM BLOOD WBC-3.5* RBC-3.96* Hgb-11.9* Hct-36.7*
MCV-93 MCH-30.1 MCHC-32.4 RDW-19.6* Plt Ct-75*
[**2159-2-3**] 06:50AM BLOOD Glucose-65* UreaN-14 Creat-3.1* Na-138
K-4.2 Cl-96 HCO3-33* AnGap-13
[**2159-2-3**] 06:50AM BLOOD Calcium-9.4 Phos-4.4 Mg-1.7
[**2159-2-3**] 01:35PM BLOOD CK-MB-4 cTropnT-0.47*
[**2159-2-3**] 06:50AM BLOOD CK-MB-4 cTropnT-0.48*
[**2159-2-2**] 07:15PM BLOOD CK-MB-5 cTropnT-0.43*
[**2159-2-2**] 02:00PM BLOOD cTropnT-0.41*
[**2159-2-2**] 04:00AM BLOOD CK-MB-5 cTropnT-0.31*
[**2159-2-1**] 08:15PM BLOOD CK-MB-4 cTropnT-0.28*
KUB [**2-1**]:
FINDINGS: Dilated small bowel in the lower abdomen measuring up
to 4.3 cm in diameter containing air-fluid levels on the upright
view. Findings concerning for small-bowel obstruction.
Brief Hospital Course:
Pt was admitted from ED in good condition with the diagnosis of
small bowel obstruction. He was given hemodialysis for an
elevated potassium. His small bowel obstruction was treated
conservatively with IV hydration, PPI's, and nothing by mouth.
On HD2, the patient's ostomy began to put out stool and gas. He
was advanced to a clear, then regular diet on HD3. By HD 4 the
patient was comfortable eating a regular diet, having stool and
gas from his ostomy, without abdominal pain or distention. He
was then deemed safe for discharge home. Of note, the patient
had a set of troponins that were drawn in the ED for the symptom
of epigastric pain. An EKG was normal, and the pt was
hemodynamically stable. Thus his troponin elevation was thought
to be due to his renal failure and not from cardiac ischemia. He
was restarted kept on coumadin throughout his hospitalization
and made sure his INR levels were therapeutic by his discharge,
as he came with subtherapeutic levels. He was discharged on
[**2-4**] with an INR of 3.0 and will closely follow-up his levels
with the coumadin clinic from the labs drawn at [**Month/Year (2) 2286**].
Medications on Admission:
atorvastatin 10mg daily, B complex-vitamin C-folic acid 1,
cinacalcet 60, ciprofloxacin 500mg daily, epoetin alfa
injection,
pantoprazole 40mg daily, warfarin 2mg daily, aspirin 81 daily
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Coumadin 2 mg Tablet Sig: please take according to levels
Tablet PO once a day.
5. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Alert and Oriented to all spheres, ambulating and voiding
without difficulty
Discharge Instructions:
You were admitted to the hospital with a small bowel
obstruction. Your obstruction was relieved on hospital day 2,
and you were then able to eat regular food without any problems.
Make sure to monitor for symptoms of nausea, vomiting, or
abdominal pain while eating. Keep track of your daily ostomy
output, and whether or not you have gas and stool in the bag.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please call and make an appointment with Dr. [**First Name (STitle) **] in 2 weeks
[**Telephone/Fax (1) 673**]
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2159-2-15**] 3:40
Please follow the coumadin levels and follow up with the
coumadin clinic for dose tomorrow.
Completed by:[**2159-2-6**]
|
[
"414.01",
"560.9",
"428.0",
"V44.2",
"588.81",
"276.7",
"V43.3",
"585.6",
"403.91",
"428.40",
"V45.11",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6664, 6670
|
4834, 5976
|
324, 331
|
6738, 6817
|
4041, 4811
|
7319, 7756
|
3686, 3824
|
6213, 6641
|
6691, 6717
|
6002, 6190
|
6841, 7296
|
2048, 3453
|
3839, 4022
|
261, 286
|
359, 1242
|
1264, 2025
|
3469, 3670
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,645
| 161,754
|
37522
|
Discharge summary
|
report
|
Admission Date: [**2181-8-17**] Discharge Date: [**2181-8-25**]
Date of Birth: [**2120-1-28**] Sex: M
Service: SURGERY
Allergies:
Biaxin / Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
h/o TIIN0 esophageal adenoca, s/p MIE [**3-15**] c/b failure of
gastric conduit requiring takedown of gastric conduit now w/spit
fistula and J tube feeding, presenting for elective colonic
interposition
Major Surgical or Invasive Procedure:
[**2181-8-17**] colonic interposition
[**2181-8-24**] neck exploration
History of Present Illness:
61M h/o TIIN0 esophageal adenoca, s/p minimally invasive
esophagogastrectomy and
laparoscopic feeding jejunostomy [**3-15**] c/b failure of gastric
conduit requiring takedown of gastric conduit, creation and spit
fistula and indefinate plan for J tube feeding. Patient made a
choice not to continue to live in this state and elected to
undergo a colonic interposition to restore continuity of his
gastrointestinal tract.
Past Medical History:
-Aflutter s/p cardioversion
-UGIB
-HTN
-gout
-CRI (2.5)
Social History:
20 pack year smoking history, no etoh
Family History:
n/c
Physical Exam:
patient had no signs of life, he had no respiratory sounds or
chest rise, he did not have a pulse, there are no audible heart
sounds, patient's skin is cold and clamy to touch
Pertinent Results:
[**2181-8-17**] 03:17PM BLOOD WBC-7.4# RBC-2.94* Hgb-9.6* Hct-28.0*
MCV-95 MCH-32.7* MCHC-34.3# RDW-17.2* Plt Ct-265
[**2181-8-20**] 04:10PM BLOOD WBC-4.0 RBC-2.56* Hgb-8.3* Hct-25.5*
MCV-99* MCH-32.3* MCHC-32.5 RDW-18.0* Plt Ct-105*
[**2181-8-22**] 01:22AM BLOOD WBC-3.8* RBC-2.75* Hgb-8.8* Hct-27.3*
MCV-99* MCH-32.1* MCHC-32.3 RDW-17.1* Plt Ct-72*
[**2181-8-24**] 02:11AM BLOOD WBC-6.1 RBC-2.63* Hgb-8.6* Hct-25.8*
MCV-98 MCH-32.6* MCHC-33.3 RDW-16.3* Plt Ct-80*
[**2181-8-25**] 02:03AM BLOOD WBC-8.5 RBC-2.78* Hgb-8.9* Hct-27.2*
MCV-98 MCH-32.1* MCHC-32.8 RDW-16.4* Plt Ct-112*
[**2181-8-17**] 03:17PM BLOOD Neuts-77* Bands-10* Lymphs-12* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2181-8-24**] 02:11AM BLOOD Neuts-83.5* Lymphs-9.3* Monos-5.1 Eos-1.8
Baso-0.2
[**2181-8-17**] 03:17PM BLOOD PT-14.8* INR(PT)-1.3*
[**2181-8-20**] 04:07AM BLOOD PT-50.2* PTT-56.6* INR(PT)-5.3*
[**2181-8-22**] 01:22AM BLOOD PT-13.5* PTT-33.1 INR(PT)-1.1
[**2181-8-25**] 02:03AM BLOOD PT-15.1* PTT-38.2* INR(PT)-1.3*
[**2181-8-17**] 08:31PM BLOOD Glucose-134* UreaN-47* Creat-4.2* Na-138
K-4.6 Cl-99 HCO3-21* AnGap-23*
[**2181-8-18**] 09:40PM BLOOD Glucose-136* Na-138 K-4.4 Cl-102 HCO3-20*
AnGap-20
[**2181-8-19**] 08:53AM BLOOD Glucose-119* UreaN-33* Creat-2.7* Na-135
K-4.1 Cl-99 HCO3-21* AnGap-19
[**2181-8-20**] 02:42PM BLOOD Glucose-117* UreaN-17 Creat-1.6* Na-138
K-4.5 Cl-104 HCO3-25 AnGap-14
[**2181-8-23**] 07:58PM BLOOD Glucose-122* UreaN-17 Creat-1.4* Na-138
K-4.0 Cl-103 HCO3-25 AnGap-14
[**2181-8-25**] 02:03AM BLOOD Glucose-86 UreaN-32* Creat-2.3* Na-134
K-4.3 Cl-99 HCO3-24 AnGap-15
[**2181-8-19**] 01:33AM BLOOD ALT-14 AST-49* AlkPhos-117 TotBili-0.5
[**2181-8-20**] 02:34AM BLOOD ALT-5 AST-35 LD(LDH)-302* AlkPhos-123
Amylase-31 TotBili-0.5
microbiology:
[**2181-8-22**] BAL
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2181-8-23**] mini-BAL
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2181-8-23**] blood culture - pending
[**2181-8-24**] urine culture - pending
[**2181-8-24**] abscess culture
GRAM STAIN (Final [**2181-8-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
imaging:
[**2181-8-24**] CT neck/ chest/ abdomen/ pelvis
1. Air adjacent to the proximal anastomotic site of the colonic
interposition is more than expected in a patient who is
postoperative day 8. A small amount of fluid also adjacent to
the proximal anastomosis. These findings are concerning for
anastomotic leak.
2. Small amount of fluid within the anterior mediastinum apart
from the
colonic interposition is likely post-surgical.
3. Trace left pleural effusion.
4. Moderate amount of ascites.
5. Non-obstructing 9-mm stone at the interpolar region of the
left kidney.
6. Small incisional seroma in the subcutaneous fat of the
anterior abdomen.
7. Indeterminate hypodensity in the upper pole of the right
kidney measures
up to 1 cm and has increased in size since the prior study of
[**2180-5-2**].
Further evaluation with renal ultrasound could be performed on a
non-emergent
basis.
Brief Hospital Course:
Date of Admission: [**2181-8-17**]
Date of Death: 8/ /11
Procedures:
[**2181-8-17**]
1. Colon interposition graft with esophagocolostomy
gastrostrocolostomy, and colocolostomy.
2. Extensive lysis of adhesions.
3. Revision of jejunostomy.
4. Excision of clavicular head and portion of the manubrium.
5. Neck dissection.
gen: The patient was admitted to the SICU for managment after
the elective colonic interposition after a perviously failed
gastric conduit after an esophagectomty for esophageal
carcinoma.
neuro: Patient was treated with fentanyl, versed and propofol.
He was awake and alert on POD 2. He would write notes to
communicate his needs.
CV: Due to low blood pressures he was started on pressors and he
remained intubated. Nephrology was aware of this patient and he
started on CVVH through his tunneled subclavian catheter on
POD#1 with ultrafiltration with a goal of remaining even. He
remained on low dose vasopressors unitl POD 5. After his
re-intubation he became hypotensive likely due to the
medications for sedation. He developed a pressor requirement
that remained for the rest of his admission.
Pulmonary: He was brought to the ICU intubated. He received
approximately 3.5L of fluid in the OR along with 4 units of
pRBCs. He remained intubated, but was put onto PS ventilation by
POD2. Due to his volume status, vocal cord paralysis, and
vasopresor requirement great care was taken in deciding when to
extubate. On POD6 he was off pressors, tolerating dirusesis,
and had good strength and mental status. He was extubated with
Anesthesia on stand by. During this trial of extubation he
became slightly tachypnic with a moderate increase in his work
of breathing. His pCO2 steadily increased, and as a result he
was re-intubated. He remained intubated for the remainder.
GI: On POD 4 low volume, diluted tube feeds were started via the
J-tube. Pt tolerated this well. Prior to his extubation they
were held and then re-started after his re-intubation.
He was taken back to the OR on [**8-24**] for exploration of the neck
wound. This demonstrated necrosis of the condiut. Please see
op note for full description of procedure.
ID: After his re-intubation on POD6 there was concern for an
aspiriation PNA. A BAL was sent and eventually grew
ENTEROBACTER CLOACAE
heme:
Post-operatively he did require blood transfusions to maintain
his hematocrit. The patients Hct stablized.
t/l/d:
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18821**] catheter was placed for hemodynamic monitoring. He did
require frequent fluid bolus to maintain his pressors in
addition to Albumin. On POD#2 his lactate was trending down and
NorEpi was being weaned though he did require a small amount to
maintain his MAP. His INR spiked to 5.9 and he was treated with
2 units FFP and his repeat INR came back at 1.2. POD#3 he was
started on trophic feeds. His HD catheter clotted off and TPA
was instilled which worked.
After the patient returned from the OR on [**8-24**] (POD8)
discussions were held with the family and the patient. They
wished no further treatment and care was withdrawn. The patient
passed after vasopressors were withdrawn.
Medications on Admission:
Moviprep, cellulose, zinc sulfate
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
esophageal carcinoma s/p colonic interposition for restoration
of GI tract continuity after a failed gastric conduit
Discharge Condition:
patient was made CMO and died
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
|
[
"285.1",
"327.23",
"038.9",
"V10.03",
"682.1",
"276.2",
"997.4",
"482.83",
"585.6",
"V45.11",
"244.9",
"998.59",
"403.91",
"287.5",
"568.0",
"530.89",
"518.5",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"38.95",
"39.95",
"96.72",
"40.41",
"45.94",
"42.55",
"77.91",
"77.81",
"46.39",
"93.90",
"38.93",
"54.59",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8313, 8322
|
5020, 8199
|
508, 580
|
8482, 8513
|
1396, 4997
|
8576, 8593
|
1180, 1185
|
8284, 8290
|
8343, 8461
|
8225, 8261
|
8537, 8553
|
1200, 1377
|
266, 470
|
608, 1030
|
1052, 1109
|
1125, 1164
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,406
| 174,735
|
52245
|
Discharge summary
|
report
|
Admission Date: [**2139-8-12**] Discharge Date: [**2139-8-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
CC: Fever
Reason for MICU admission: Line sepsis
Major Surgical or Invasive Procedure:
R femoral line insertion
Hemodialysis
Removal of left portacath
Placement of right PICC
History of Present Illness:
This [**Age over 90 **] year old genleman with hx of ESRD on HD, CAD s/p CABG,
CHF, HTN, A-fib, ventricular brady-paced, RCC s/p L nephrectomy
presented to ED after dialysis as he experienced fever to 103,
rigors approximately 30 minutes into start of dialysis.
Of note, he is s/p new AV fistula placement on LUE with
temporary right fem line and placement of L permacath at recent
hospitalization ([**2139-7-26**]). Today he reports he hasn't felt quite
right since last hospitalization but today finally felt "back to
his usual self". Denies any history of nausea, vomiting, or
diarrhea since his last hospitalization.
Patient initally afebrile with systolic blood pressure initially
in 130 range, other VS stable. Through the course of his stay
his blood pressure trended downward to the 90's range (which
reportedly is his baseline) One hour later the patient's blood
pressure fell to 76/44, HR 70s, RR 20, 97% RA. Laboratories
revealed WBC 7.6 with bandemia of 8 and a lactate of 3.8.
Received fluid bolus with brief rise to systolic blood pressure
to 80's range. Pt began to act more confused and SBP to 70's.
Dopamine started. Given concern for line sepsis, perm-a-cath was
removed by transplant surgery team. R femoral line placed. SBP
returned to 100-110 range. Pt transferred to MICU.
Past Medical History:
1) CAD s/p CABG
-Cardiac catheterization [**5-4**] w/L main and 3 vessel dz w/
patent LIMA to LAD w/ 70% stenosis in distal LAD, patent SVG to
diagnoal ramus w/ 50% stenosis in native diagonal branch, patent
SVG to OM1/OM2 but occluded OM1 at touchdown. s/p unsuccessful
PTCA of LM, Moderate right and left ventricular diastolic
dysfunction
-5-vessel CABG [**2124**] (LIMA-LAD, SVG-D1, SVG-RI,
SVG-OM1, SVG-OM2)
2) CHF: Echo ([**6-4**]) EF 30-35%, [**12-1**]+ MR, 2+ TR, moderate
pulmonary artery systolic HTN. Reportedly small ASD on a TEE
3) S/p pacemaker placement Tachy-Brady syndrome [**3-/2128**],
w/replacement
[**11-2**]
4) HTN
5) Hypercholesterolemia
6) ESRD, on HD (since [**2134**]) MWF evenings via left arm AV graft
(evening shift at [**Location (un) 4265**], [**Location (un) **])
7) Chronic anemia associated w/ renal failure
8) Renal cell carcinoma, s/p left nephrectomy
9) Gout w/flairs 1-2x/mo
10) s/p TURP for BPH
11) Bilateral cataracts
12) Left hydrocele w/ hydrocelectomy [**12/2130**]
#. Multiple episodes of SOB
.
PSHx:
#. Right common femoral artery thrombus s/p cath in [**5-4**]
#. Left CEA [**2127**] (s/p TIA)
#. Thrombectomy and revision of LUE AV graft [**2-1**] w/multiple
interventions to graft in the past.
Social History:
He lives alone in [**Location (un) 745**]. Recently retired fully from selling
furniture, pt had reduced from full time work to part time work
over the past year.
+ tob: cigar/pipe smoking, daily x20-25 years w/cessation 20yrs
prior
- EtOH
- Illicit/Recreational drug use
Family History:
Daughter with MI in mid-40s, had Type 1 DM, deceased 56y/o
Brother w/heart disease, ?MI. + hypertension, + diabetes
mellitus, Brother w/lymphoma, ? question liver ca
Physical Exam:
(on presentation to MICU):
Vital Signs: T=99.7; HR=73; BP=100-110/30-40 on 7.5 of dopamine;
RR=20; O2Sat=98% on 2L
General: Elderly gentleman in NAD, sleepy but fully arousable.
HEENT: NC/AT, MM slightly dry, scar c/w previous CEA
Neck: Old permcath site c/d/i
CV: RR S1S2, S3 gallop audbile, no murmur, no rub
Pulm: CTA bilaterally, no rhonchi, wheezes or crackles
Abd: Soft, NT/ND with normoactive BS.
Ext: No cyanosis, 2+ radial and 2+ DP bilat, AV graft in L arm
Pertinent Results:
Admission laboratories notable for:
WBC 7.8 with 8 bands, lactate 3.8 K 4.4 BUN 25 Cr 4.5
HCT 33.5 with MCV 111
.
CXR: There is a small amount of pleural fluid at the left
costophrenic angle. No evidence of pneumonia.
EKG: V paced with rate 60, ST depressions I and aVL, unchanged
from [**2139-7-22**]
U/S L AV graft- no fluid around the graft, flow appropriate
.
Trends:
INR 2.9 on admission then down to 1.5 on discharge (after
coumadin was held briefly).
.
Starting [**8-14**]:
Trop 0.54 - 0.55 - 0.62 - 0.65 - 0.74 - 0.81 - 0.69
CK: 95 - 52 - 39 - 32 - 23 - 30 - 27 - 35 - 21
.
TSH 4.6, FT4 4.8
Vit B12 1658
Folate: "greater than normal range"
.
Echo:
Conclusions:
The left atrium is moderately dilated. The left ventricular
cavity size is normal. Resting regional wall motion
abnormalities include inferolateral
akinesis. Right ventricular chamber size is normal. Right
ventricular systolic function is normal. The aortic root is
moderately dilated. The ascending aorta is moderately dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-1**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is severe pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2139-2-11**],
estimated
pulmonary artery systolic pressure is now higher and left
ventricular systolic function is similar (prior ejection
fraction may have been underestimated).
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM:
# Coag neg staph sepsis: The patient had [**1-3**] blood cultures
positive with coag neg staph sepsis. He was treated with
vancomycin and gentamicin starting on [**2139-8-12**]. Initially the
patient was hypotensive and required dopamine/levo for blood
pressure support briefly. His recently placed left port-a-cah
was removed given evidence that suggested that the sepsis was
likely [**1-1**] the line. He remained afebrile thereafter and his
blood pressure improved. We monitored survelliance cultures and
continued with vancomycin (stopped the gentamicin). We would
like him to complete a two week course of antibiotics. We had
been dosing by level (goal >15) and were giving the vancomycin
with hemodialysis.
.
# ESRD on HD: There was a concern that the patient had some
swelling of his LUE fistula. This was seen by the transplant
surgery team and an ultrasound was negative for any fluid
collection. His graft was mature and usable for hemodialysis.
The patient continued on his routine schedule of HD once his
blood pressure had stabilized. He has HD on Mondays,
Wednesdays, and Fridays.
.
# CAD: The patient has a known history of coronary disease. He
had a brief episode of chest pain, shortness of breath, and
troponin elevation on [**8-14**]. His CKMB did not rise and his EKG
was difficult to interpret due to a paced rhythm. The pain
lasted 30 seconds and was pleuritic in nature. He was seen by
the cardiologists who initially recommended medical management
with isosorbide mononitrate, statin, aspirin, and the beta
blocker. They did not request further intervention at that
time. We subsequently obtained an echocardiogram which showed
inferolateral akinesis. When compared to the previous echo done
on [**2139-6-9**], the degree of inferior akinesis was unchanged.
.
# Atrial Fibrillation: The patient's coumadin was held initially
since he had the port-a-cath removed and also had a femoral line
placed briefly. However, in the setting of his chest pain, the
patient was started on a heparin drip. We started coumadin at
3mg qhs and bridged the patient with heparin to obtain an INR of
[**1-2**]. He will leave the hospital on hep gtt until he becomes
therapeutic.
.
# CHF: The patient had his AceI, digoxin, and BB held on
admission. The beta blocker was restarted and the patient also
was started on isosorbide mononitrate. His fluid was regulated
also by hemodialysis.
.
# Anemia: It was stable throughout his hospitalization. We
continued the patient on his B12 and Folate. A free T4 level
was normal.
.
# Hypertension: Initially the patient's antihypertensives were
held on admission due to his hypotension. The patient was
started on isosorbide mononitrate 15mg [**Hospital1 **] in addition to his
atenolol 50mg qd once his blood pressure could tolerate it.
.
# Code status: The patient's code status was confirmed to be DNR
DNI with both the patient and his daughter.
Medications on Admission:
1) Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY
2) Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
3) Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet PO DAILY
4) Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO BID
5) Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
6) Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
7) B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY
8) Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
9) Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO WITH
BREAKFAST AND LUNCH
10) Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO WITH
DINNER
11) Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12) Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO every other day.
13) Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
14) Digoxin 50 mcg/mL Solution Sig: One (1) mL PO every other
day.
15) Colchicine prn gout flair
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B Complex Plus Vitamin C Tablet Sig: One (1) Tablet PO
once a day.
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day.
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO twice
a day: please take with breakfast and with lunch.
10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO once
a day: please take with dinner.
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: variable Intravenous ASDIR (AS DIRECTED): goal PTT is
60-80. please continue until INR [**1-2**].
13. Isosorbide Mononitrate 10 mg Tablet Sig: 1.5 Tablets PO BID
(2 times a day).
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous QHD (each hemodialysis) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
- Coag negative staph sepsis
- Chest Pain
- ESRD on HD
- HTN
- Atrial Fibrillation
Secondary:
- CAD s/p CABG in [**2124**].
- Systolic and diastolic CHF with EF 30-35%
- s/p pacemaker placement for Tachy-Brady syndrome [**3-/2128**], with
replacement [**11-2**].
- Hypercholesterolemia
- Chronic anemia associated with renal failure
- RCC s/p left nephrectomy
- Gout
- s/p TURP for BPH
- Bilateral cataracts
- remote hx of TIA
- s/p right common femoral artery thrombus
- Left CEA in [**2127**]
- Thrombectomy and revision of LUE AV graft [**2-1**] with mx
revisions
- Left hydrocele with hydrocelectomy
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with a fever and chills. You
had bacteria growing in your blood and we treated you with
antibiotics. You tolerated this very well and recovered
rapidly. If you experience chest pain, shortness of breath,
recurrent fever or chills, please call your doctor or return to
the emergency department.
.
Please take your medications as directed. Notably you will need
a total of two weeks of vancomycin. Your vanco course started
on [**2139-8-12**]. You will get your doses based on the level detected
in your blood. After you receive your last dose, you should
have the PICC line removed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
Please take your medications as directed. Please contact your
physician to make [**Name Initial (PRE) **] followup appointment.
Followup Instructions:
Please followup with your cardiologist Dr. [**Last Name (STitle) **].
Please followup with your nephrologist, Dr. [**Last Name (STitle) 1366**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"995.91",
"403.91",
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"996.62",
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"V15.82",
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"285.21",
"038.19",
"V10.52",
"V45.81",
"428.0",
"V18.0",
"427.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10985, 11051
|
5682, 5682
|
311, 400
|
11708, 11717
|
3969, 5659
|
12622, 12864
|
3298, 3466
|
9663, 10962
|
11072, 11687
|
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|
11741, 12599
|
3481, 3950
|
222, 273
|
5710, 8629
|
428, 1725
|
1747, 2992
|
3008, 3282
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,672
| 168,810
|
7926
|
Discharge summary
|
report
|
Admission Date: [**2182-2-1**] Discharge Date: [**2182-2-7**]
Date of Birth: [**2129-12-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with DES to LAD x1 and LCx lesion x1
History of Present Illness:
This is a 52 year old male with no previous cardiac history or
significant angina who developed epigastric pain at around 1 pm
after lunch [**1-31**]. Patient took prevacid and felt a little
better.
5pm epigastric pain with bilateral arm weakness.
Patient spoke to PCP and was referred to ED. After persistent
pain, he presented to the ED at 8 pm.
.
In the ED
VS arrival: 97.9, HR 80, BP 180/112, RR20 Sats 97% RA
EKG on arrival sinus rhythm q waves on III, aVf.
Later on, increasing substernal chest pain, diaphoresis, and
shortness of breath.
EKG was done with new st elevation 2-3mm v1, v2 v3 v4
Patient went into Vi fib arrest, shock 200J, CPR initiated for
about 45 seconds.
He received ASA 325,, Nitro paste, Lopressor 5mg IV and 25 PO,
Integrilin, Heparin, Lidocain 100, Epinephrine, Amiodarone 150
mg IV, and intubated with etomidate and succinylCholine.
.
Patient transfer to the cath lab with dx of anterior STEMI.
Past Medical History:
Hypercholesterolemia
hypertension,
Hiatal hernia.
Social History:
Social: 1p/day for 6-7 years, quit 20 y/o, ocassional alcohol
Married. Dentist.
Family History:
DM, mother increased Triglycerides and HTN
Physical Exam:
BP 129/83 HR: 92 AC:
General: Patient intubated and sedated
HEENT: ETT tube in placed, OGT in placed
Lungs: Clear to auscultation anteriorly
CV: RRR, s1-s2 normal, no murmurs, no gallops
Abdomen: BS +1, soft, non tender, non distended.
Extremities: LE no edema
Right groin site - arterial and femoral sheaths in placed.
No active bleeding.
Pertinent Results:
Labs on admission:
CK: 400 MB: 7 Trop-*T*: 0.04
Ca: 9.9 Mg: 2.2 P: 3.2
WBC 8.8 HCT 43 Plat 242
PT: 11.9 PTT: 23.3 INR: 1.0
.
Labs during hospitalization:
HgbA1C 6.6
Chol 142, TG 314, HDL 31, LDL 48
Peak CK 2971, CK-MB 151, trop 4.24 on [**2-1**]
.
Labs on discharge:
WBC 10.3, Hct 36.1, Plt 428
PT 14.4, PTT 28.5, INR 1.3
Na 139, K 4.6, Cl 100, HCO3 27, BUN 28, Cr 1.1, Glu 185
Ca 9.4, Mg 2.4, Ph 4.5
.
Micro:
[**2182-2-6**]: urine cx **FINAL REPORT [**2182-2-10**]**
URINE CULTURE (Final [**2182-2-10**]):
ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES PERFORMED ON CULTURE # 202-3701K
([**2182-2-5**]).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2182-2-5**]: urine cx
**FINAL REPORT [**2182-2-7**]**
URINE CULTURE (Final [**2182-2-7**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2182-2-5**] blood cx NGTD
.
Imaging:
CXR [**2182-1-31**]: No acute cardiopulmonary process. Somewhat higher
than optimal positioning of the endotracheal tube. Likely
cardiomegaly.
.
CATH [**2182-1-31**]:
RA 10, RV 30/7 Mean 12, PA 30/17 Mean 22, PCW 15
LMCA: normal,
LAD: occluded after D1
LCx 80% MID
RCA minimal disease
Cypher DES to LAD was placed.
.
ECG [**2182-1-31**]:
Sinus rhythm. Non-diagnostic Q waves in the inferior leads. Rate
74, PR 160, QRS 114.
.
CXR [**2182-2-1**]: There is a new vague opacity overlying the right
upper lung zone with peribronchial cuffing.
.
ECHO [**2182-2-1**]: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is moderate regional left ventricular systolic dysfunction
with severe hypo/akinesis of the anterior septum and anterior
wall and apex. There is a small apical left ventricular
aneurysm. The remaining left ventricular segments contract
normally. No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) 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. IMPRESSION: Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
CAD (proximal LAD lesion). Small apical left ventricular
aneurysm.
.
CATH [**2182-2-4**]:
The mid CX lesion was directly stented with a 3.5 X 18mm Cypher
stent
and post dilated with a 3.75 X 12mm Maverick balloon with lesion
reduction from 90% to 0%. The final angiogram showed TIMI III
flow with
no dissection or embolisation.
.
CXR [**2182-2-5**]: Resolution of right upper lobe opacity. Minimal
residual patchy right lower lobe opacity, which may be due to
resolving atelectasis or pneumonia.
.
ECHO [**2182-2-7**]: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed (ejection fraction 40-50 percent)
secondary to moderate hypokinesis of the anterior septum and
severe hypokinesis of the apex. 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 arch is mildly dilated. 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. Compared with the
findings of the prior study (images reviewed) of [**2182-2-1**], the left ventricular ejection fraction is significantly
increased secondary to improved function of the anterior septum
and anterior free wall.
.
Brief Hospital Course:
# CV:
* Ischemia/CAD: On presentation to the ER, Mr. [**Known lastname 28467**] was
hypertensive and had an EKG which showed sinus rhythm with q
waves in III, avF. He then developed worsening substernal chest
pain, diaphoresis, and shortness of breath. A repeat EKG was
performed and showed new ST elevations of 2-3mm in V1-V4, likely
demonstrating anterior STEMI. His rhythm deteriorated into
ventricular fibrillation and a code blue was called. He was
given ASA 325mg, nitro paste, lopressor 5mg IV and 25mg PO,
lidocaine 100mg, epinephrine, and amiodarone 150mg IV; he was
started on both an integrillin gtt and a heparin gtt; and he
was intubated with use of etomidate and succinylcholine. A
normal sinus rhythm was restored with CPR and defibrillation x1
and he was brought emergently to the cath lab. He first had a
DES placed in his LAD, which was felt to be the most critical
lesion. He spent the night in the CCU and once stable, was able
to be extubated without any complications. He then went back to
the cath lab on [**2-4**] and had a DES placed in his Lcx. His CEs
peaked at CK 2971, MB 100, and trop of 4.24 on [**2-1**] and then
trended down throughout the remainder of his hospital stay. He
was started on plavix, aspirin, statin, bblocker, and ACE-i. He
tolerated these medications well and his BP and HR were under
good control on discharge.
.
* Pump: He had an ECHO on [**2-7**] which showed an EF of 30-35% with
severe HK/AK of anterior septum, anterior wall, and apex. He was
started on anticoagulation with coumadin for his wall motion
abnormalities, bridging with lovenox until his INR was
therapeutic between [**2-8**]. He was continued on anticoagulation
despite bleeding into his tongue as it appeared that the
bleeding had subsided and his swallowing and talking abilities
had improved by discharge.
.
* Rhythm: On arrival in the ER, Mr. [**Name14 (STitle) 28468**] was in NSR w/ what
appeared to be an acute MI, but he soon developed worsening
chest pain and went into v-fib arrest. He was defibrillated x1
at 200J and CPR was initiated, with restoration of normal sinus
rhythm. He was then [**Last Name (un) 4662**] immediaately to the cath lab.
Post-cath, he had bouts of NSVR and ventricular ectopy, but
these arrhythmias resolved over time and by discharge, his tele
showed mostly NSR.
.
# Hypertriglyceridemia: When assessing Mr. [**Last Name (Titles) 28469**] risk
factors for heart disease, it was discovered that he has a
hypertriglyceridemia (TG of 314), likely familial vs. hereditary
dyslipidemia. As an outpatient, he was on Welchol. A high dose
statin was added for his acute coronary syndrome, but a fibrate
was held as his transaminases were already elevated (ALT 62, AST
132). An appointment was made for him in lipid clinic with Dr.
[**Last Name (STitle) **] and it was recommended that he have his children and
other first degree family members screened for triglyceride
abnormalities. An appointment was also made for him with a
nutritionist from lipid clinic, but the patient was also given
the name of another nutritionist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**Location (un) **] for
a sooner appointment. The decision to add a fibrate was deferred
to the outpatient setting, after he has been stabilized on the
statin.
.
# Hyperglycemia: Mr. [**Name14 (STitle) 28468**] had multiple elevated serum
glucoses, so he was put on QID fingersticks and a humalog
insulin sliding scale. A hemoglobin A1C was checked to see if
his condition was chronic and his A1c was 6.6. It was
recommended that he follow-up with a nutritionist and his PCP
for possible medical management.
.
# HTN: Mr. [**Name14 (STitle) 28468**] had HTN as an outpatient and was on norvasc
previously. Post-MI, his BP was low but he was able to tolerate
a bblocker and ACE-i without any problems.
.
# Fever: Mr. [**Name14 (STitle) 28468**] had a fever one evening after his first
catheterization. The team felt that it was most likely a post-MI
fever, but he had a CXR, blood cx, UA and urine cx drawn. His
CXR showed resolution of a previously seen R upper lobe opacity,
his blood cx were negative, his UA was unremarkable, but his
urine cx grew Proteus. It was repeated and again grew 10-100,000
colonies, so he was started on cefzil as an outpatient. ENT was
consulted while the patient was in house for his tongue hematoma
and they recommended starting clindamycin empirically as he had
visible bite marks on the L side of his tongue which could be a
source of infection. He was afebrile for the remainder of his
hospital course.
.
# Anemia: His Hct on admission was 43, but dropped to 36.7 after
his v-fib arrest and first catheterization. His Hct remained
between 33 and 37 throughout the remainder of his hospital
course. His anemia was first attributed to blood loss from his
catheterizations, but when it persisted and his tongue became
more swollen, the team became concerned that he may have
bleeding into his tongue from the anticoagulation and
anti-platelet regimen he was on for his ACS. It was stable
during his hospitalization and it was recommended that he
undergo a workup for anemia as an outpatient if it does not
resolve after his hematoma improves.
.
# Tongue hematoma: He had a tongue hematoma that was sustained
during his v-fib arrest. His tongue unfortunately became more
swollen and ecchymotic, likely exacerbated by ASA, plavix, and
lovenox/coumadin. He was seen by ENT who recommended IV steroids
x 24 hours for the swelling and clindamycin empirically for
possible infection. His tongue improved dramatically after 24
hrs on steroids and he was again able to speak clearly and
tolerate POs. He was discharged on a 1 week course of
clindamycin and will follow-up with Dr. [**Last Name (STitle) 3878**] in 2 weeks.
.
# Prophylaxis: Anticoagulated w/ lovenox (as well as coumadin),
PPI, bowel regimen.
.
# Communications: with his wife, who is his HCP
.
# Code: Full
.
# Dispo: He was discharged home on lovenox and coumadin and will
follow-up with Dr. [**Last Name (STitle) **] on Friday for an INR check.
.
# Follow up: with PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6993**] and Dr. [**Last Name (STitle) **]
Medications on Admission:
Prevacid PRN,
Norvasc
Paroxetine
Lipitor - self d/c'd
Welchol 625 [**Hospital1 **] recommended by hepatology
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Colesevelam 625 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
6. Enoxaparin 100 mg/mL Syringe Sig: One (1) 100mg syringe
Subcutaneous Q12H (every 12 hours).
Disp:*14 100mg syringe* Refills:*0*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-11**]
hours.
11. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
12. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q 5 minutes as needed for chest pain: Can repeat x3
for chest pain. If no relief after 3 tablets, call EMS. .
Disp:*30 tablets* Refills:*2*
13. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior STEMI complicated by Vfib arrest.
.
Hypercholesterolemia
Hypertension
Hiatal hernia
Discharge Condition:
Good, chest pain free, hemodynamically stable with good oxygen
saturation on room air, afebrile.
Discharge Instructions:
1. Please take all your medications as directed.
2. Please keep all outpatient appointments.
3. Please call your doctor or go to ED right away if you have
chest pain/pressure, nausea, vomiting, shortness of breath,
fever, abnormal bleeding or any concerning symptoms.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] on Friday, [**2182-2-15**] at
10:30am.
.
2. Please follow-up with Dr. [**Last Name (STitle) 3878**] from ENT on [**2182-2-20**] at
8:00am. They ask that you arrive at 7:45am to register with
their office. His phone number is [**Telephone/Fax (1) 2349**]. His office is
located at [**Street Address(2) 28470**]. in [**Location (un) 55**], on the Eastbound
side of Rt. 9.
.
3. You have an exercise stress test scheduled for [**2182-2-21**] at
10am. [**Telephone/Fax (1) 1566**]. It will be located in the [**Hospital Ward Name 23**] building,
[**Location (un) 436**].
.
4. Please call Dr.[**Name (NI) 1565**] office from the division of
cardiology ([**Telephone/Fax (1) 22784**] to make a follow up appointment in 4
weeks, after your stress test. You also need to set up a repeat
ECHO prior to your appointment with Dr. [**Last Name (STitle) **]. His office
should be able to help you set that up.
.
5. Please follow up with [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5250**], M.D. in [**Hospital **]
Clinic on [**2182-3-1**] at 8:30am. His office phone number is
[**Telephone/Fax (1) 5251**]. Please call his office if you have any questions
or need to reschedule. This appointment will be followed by an
appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1843**], RN, at 9:00am (her number is
[**Telephone/Fax (1) 28471**]) and the LIPID NUTRITIONIST at 9:30am (phone
[**Telephone/Fax (1) 2207**]).
.
6. You are being discharged on coumadin (warfarin). Please
follow up your INR tomorrow (Friday [**2182-2-8**]) at Dr.[**Name (NI) 27495**]
office to make sure your dosing is appropriate. You do not need
to make an appointment, you just need to go in and have your
blood drawn. It is VERY important this be done and your doctor
get the results given your ongoing complication including
bleeding within your tongue.
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
[
"427.5",
"272.4",
"E879.8",
"529.8",
"272.1",
"285.1",
"300.4",
"780.6",
"401.9",
"410.11",
"250.00",
"553.3",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"36.07",
"00.66",
"88.56",
"96.71",
"37.21",
"00.45",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
15655, 15661
|
7716, 13803
|
324, 387
|
15798, 15897
|
1952, 1957
|
16213, 18298
|
1529, 1573
|
14089, 15632
|
15682, 15777
|
13955, 14066
|
15921, 16190
|
1588, 1933
|
13814, 13929
|
274, 286
|
2224, 7693
|
415, 1343
|
1971, 2205
|
1365, 1416
|
1432, 1513
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,546
| 190,044
|
6902
|
Discharge summary
|
report
|
Admission Date: [**2162-1-4**] Discharge Date: [**2162-1-8**]
Date of Birth: [**2082-7-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79yo M w/signif cardiac hx, EF 25%, Crohn's, c/o epigastric
pain, with WBC 15, elevated LFTs, INR 3.3, Cr 2.1 (1.3
baseline), and trop 0.25; he was recently hospitalized [**12-5**] for
chest pain, SOB and treated for CHF exacerbation. Of note, at
that time, he was found to be in a.fib and later started on
coumadin as an outpatient. He states that for the last 2 months
he has had nonradiating epigastric abdominal pain which he
cannot describe in further detail however, he admits that it is
worse post prandially and he has had decreased PO intake because
of it. He came to the ED for evaluation because he began to
worry when it got worse.
.
In the ED, Mr. [**Known lastname 26010**] was found to be afebrile but hypotensive
to 88/68 with increased LFTs. Morphine, 500 mg levofloxacin, 500
mg flagyl, 1 gm vanco, 4 units FFP, were administed and the
patient was admitted to the SICU. GI was consulted for ? ERCP
and hep serologies were sent. Levo/Flag were continued. RUQ u/s
showed some GB edema but not convincing for cholecystits or
cholangitis; CT abd/pelv w/o IV contrast shows atherosclerosis,
unable to eval biliary tree. He was then transfered to the MICU
for further evaluation and management. This morning he complains
of thirst, says abdominal pain gone and wants to eat.
Past Medical History:
1. Coronary artery disease s/p cath with PCI stent to LCx, RCA
2. Hypertension
3. Crohn's disease
4. Hypercholesterolemia
5. BPH
6. Macular degeneration both eyes - legally blind
7. Hypothyroidism
8. s/p 2 hip surgeries
9. s/p back surgery
[**66**]. s/p knee surgery
[**67**]. history of GI bleed d/t PUD
12. Colonic polyps
13. Chronic renal insufficiency baseline creat 1.3
Social History:
Former [**Year (2 digits) 26009**]. Married with two daughters, lives with his wife.
Smoked 1-1.5 ppd x 35 years. Quit in [**2137**]. EtOH: ~ once a week,
socially. No drugs.
Family History:
Mother with MI in 70s. Father with MI 80s. Brother and Sister
with "heart problems".
Physical Exam:
Vitals - Afebrile, HR 80, BP 112/63, RR 22, O2 89%-96% on 2L NC
to 95%-96% on 3L NC
HEENT - dry MM
Neck - JVD to angle of jaw, no noted carotid bruits
CVS - irregularly irregular, no M/R/G
Lungs - decreased BS diffusely, mild crackles at L base
Abd - Soft, NT/ND, +BS
Ext - 1+ pitting edema in ankles b/l
Pertinent Results:
[**2162-1-4**] 04:25PM LACTATE-5.4*
[**2162-1-4**] 04:20PM GLUCOSE-103 UREA N-79* CREAT-2.1* SODIUM-132*
POTASSIUM-5.2* CHLORIDE-90* TOTAL CO2-22 ANION GAP-25
[**2162-1-4**] 04:20PM ALT(SGPT)-1083* AST(SGOT)-1068* CK(CPK)-52
ALK PHOS-279* AMYLASE-62 TOT BILI-1.8*
[**2162-1-4**] 04:20PM LIPASE-70*
[**2162-1-4**] 04:20PM cTropnT-.25*
[**2162-1-4**] 04:20PM CK-MB-NotDone
[**2162-1-4**] 04:20PM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-6.0*#
MAGNESIUM-2.3
[**2162-1-4**] 04:20PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2162-1-4**] 04:20PM HCV Ab-NEGATIVE
[**2162-1-4**] 04:20PM WBC-15.3*# RBC-3.83* HGB-11.9* HCT-36.5*
MCV-95 MCH-31.2 MCHC-32.7 RDW-16.6*
[**2162-1-4**] 04:20PM NEUTS-82.6* LYMPHS-13.9* MONOS-3.4 EOS-0
BASOS-0.1
[**2162-1-4**] 04:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+
[**2162-1-4**] 04:20PM PLT COUNT-368
[**2162-1-4**] 04:20PM PT-21.4* PTT-37.0* INR(PT)-3.3
Brief Hospital Course:
Patient was initially admitted to the surgery service. There is
no dictated summary of the events that transpired while he was
on that service from [**1-4**] - [**1-5**]. He was then transferred to
the MICU. No MICU course was dictated or entered by the MICU
housestaff. Patient was transferred to [**Hospital Unit Name 196**] on the afternoon on
[**1-7**] to Dr. [**Last Name (STitle) 2418**] and then transferred again the following
morning ([**1-8**]) to Dr. [**First Name (STitle) **]. He was then discharged home
later that same day. All of the following hospital course is
per record review:
.
#ABD pain: Patient was admitted with chief complaint of abd pain
and elevated LFT's. Ddx included acute hepatitis,stones (u/s
negative), ascending choleangitis (blood cx negtaive, no fever),
ischemia. LFT's not consitent with EToH or NASH. Iron studies
not c/w hemasiderosis. Also consider drugs vs autoimmune.
Zetia and hydral were held. Blood cultures were negative.
Hepatitis panel negative. Hepatology was consulted. Liver
enzymes were trended and it was noted that the LFT's began to
improve dramatically on HD2, which was consistent with an
ischemic insult to the liver. Eventually the elevated LFT's
were attributed to shock liver [**3-4**] hypoperfusion, possibly due
to a silent NSTEMI. Patient improved clinically and was
discharged with close follow-up with his cardiologist who is
also his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
# leukocytosis: Unknown source. Patient covered empiracally for
48 hours with Vanco, flagyl, levo util blood cultures were
negative. Trended down and had normalized by day of discharge.
.
# ARF: unknown etiology but likely prerenal as patient complains
of thirst and has decreased PO intake. Patient has had a recent
renal u/s without hydro and it was not noted on CT abdomen so
likely not post renal obstruction. This could be his new
baseline as his Cr was 2 during his last admit in [**Month (only) **].
Creatinine did improve slightly with gentle IV hydration.
.
#CHF: EF of 30%. stable.
.
# Rhythm: Hx of a fib. Anticoagulation was reversed with FFP
and vit k.
.
# arteries: has history of stents, most recent in [**Month (only) 956**]. EKG
unchanged. Trop up, consistent with ARF. Baseline 0.1. EKG w/
ST elevations in inferior leads and depressions in anterior
leads, unchanged or improved from prior.
.
# anemia: normocytic baseline HCT 28. Iron level was 41, TIBC
248, ferritin 383, consistent with iron deficiency in [**Month (only) 321**].
.
# depression: continued paroxetine
.
# prophylaxis: hep SQ, PPI
.
# FEN: cardiac, low salt diet
.
# communication: wife, [**Name (NI) 26011**] [**Telephone/Fax (1) 26012**]
.
Medications on Admission:
1. Atorvastatin 20 QD - recently d/ced on last hospital
admission [**3-4**] elevated LFTs
2. Aspirin 81 mg QD - recently d/ced on last hospital admission
[**3-4**] GIB
3. Sulfasalazine 1500 PO BID
4. Ferrous Sulfate 325 QD
5. Docusate Sodium 100 mg [**Hospital1 **]
6. Cyanocobalamin 50 mcg QD
7. Multivitamin QD
8. Lisinopril 5 mg QD - recently d/ced on last hospital
admission [**3-4**] elevated Cr
9. Paroxetine HCl 10 mg QD
10.Carvedilol 25mg [**Hospital1 **].
11. Azathioprine 50 mg QD
12. Pantoprazole 40 mg QD
13. Furosemide 40mg QD - recently changed from 60 mg qAM and 40
PO qhs
14. Levothyroxine Sodium 50 mcg QD
15. Albuterol INH PRN
16. Atrovent INH
Discharge Medications:
1. Sulfasalazine 500 mg Tablet, Delayed Release (E.C.) Sig:
Three (3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
11. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
hepatitis
congestive heart failure
leukocytosis
acute renal failure
atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Take all of your medications as ordered. Do not stop or change
any of your medications without first speaking to your doctor.
Follow-up with your doctor [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.
Please call your doctor immediately if you start having chest
pain, shortness of breath, abdominal pain, or any other
concerning symptoms.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Please call and confirm that you
have an appointment on [**1-20**]. [**Telephone/Fax (1) 2394**] You should
have your blood drawn at that visit to confirm that your liver
functions tests are still recovering.
|
[
"410.71",
"412",
"244.9",
"V45.82",
"428.0",
"401.9",
"570",
"369.3",
"427.31",
"792.1",
"276.7",
"584.9",
"555.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.93",
"38.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8369, 8427
|
3613, 6331
|
289, 296
|
8559, 8568
|
2650, 3590
|
9079, 9383
|
2221, 2309
|
7044, 8346
|
8448, 8538
|
6357, 7021
|
8592, 9056
|
2324, 2631
|
241, 251
|
324, 1613
|
1635, 2011
|
2027, 2205
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,019
| 120,182
|
12905
|
Discharge summary
|
report
|
Admission Date: [**2170-6-27**] Discharge Date: [**2170-7-8**]
Date of Birth: [**2102-2-11**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / Nitrofurantoin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hyperglycemia and generalized poor care of self reported by VNA,
Admitted with concern for urosepsis
Major Surgical or Invasive Procedure:
IJ placement
History of Present Illness:
Ms. [**Known lastname 39666**] is a 68 YOF with a past medical history significant
for lupus, NIDDM, distant breast cancer, PE (stopped coumadin
after recent admission [**6-2**]), and autoimmune versus drug-induced
hepatits (diagnosed last month), with two recent admissions over
the last 2 months to [**Hospital1 18**] for weakness and hypoglycemia. She
presents from home after her VNA found her to be hyperglycemic
and urinated over herself with no one taking care of her. Of
note she has reportedly not been compliant with her medications
recently. She was initially brought to [**Hospital 32036**] Hospital where
she was found to have a bp 109/42 with tachycardia and a
positive UA. She was given ceftriaxone then transferred to [**Hospital1 18**]
to resume care.
.
Less than one month ago, the pt was discharged from [**Hospital1 18**] with a
new diagnosis of autoimmune versus drug induced hepatitis and
was started on steroids. Other significant changes include
stopping her coumadin given she had been on this medication for
5 years following her DVT and her risk of future clot was
thought to be minimal. She recently saw Dr. [**Last Name (STitle) 497**] on [**6-21**] in
follow up and he tapered her steroids. He also changed her
antibiotics (which had recently been started for a UTI) from
nitrofuratoin to amoxacillin due to hepatotoxicity of
nitrofurantoin. She states she has been taking this medication
every day as prescribed. She also has a history of E. Coli
urosepsis.
.
In the ED at [**Hospital1 18**], initial vs were: T 101 P 96 BP 106/48 R 16
O2 97% sat. Patient was a poor historian but denied pain. The ED
had difficulty getting labs and placed a Left IJ. She was given
vancomycin and started on levophed for bp 90s/50s after
receiving 3 L NS. Labs were significant for UA that was poor
specimen, but showed many bacteria and WBCs. Lactate was 2.5,
WBC was 12.5 with 85% neutrophills.
Vitals at the time of transfer were: temp 101, HR 88, BP 142/94
(on levo) 99% 2 L. On the floor, pt denied diarhea, cough, CP,
SOB, nausea, anorexia. She admits to malaise over the past few
days, and her only localizing symptom is urinary
urgency/frequency.
.
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:
1. Diabetes
2. Splenectomy secondary to "splenic fluid accumulation"
3. Breast cancer s/p masectomy 27 years ago; treated with
tamoxifen for 7 years
4. Obesity
5. Pulmonary emboli
6. Depression
7. Lupus
8. Arthritis
9. Gastroesophageal reflux disease
10. Hypertension
Social History:
She lives with her husband and son in [**Name (NI) **] MA, and has been
immobile for the past few months. She reports no tobacco,
alcohol or ilicit drug use.
Family History:
No history of liver cancer or unexplained liver failure in the
family. Mother passed away for breast cancer and father passed
away due to prostate cancer.
Physical Exam:
Vitals: T: afebrile BP: 114/63 P: 76 R: 18 O2:100% on RA
General: morbidly obese, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds, but no rhales/rhonchi
CV: Distant heart sounds, Regular rate and rhythm
Abdomen: colostomy bag in place with brown stool, soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, unable to appreciate organs
GU: foley
Ext: warm, well perfused, 2+ pulses, 2+ pitting edema
Skin: erythematous macular rash under pannus/folds near abdomen,
legs, and arms. multiple ulcers in the mons pubis and axilla.
pressure ulcers
Pertinent Results:
[**2170-6-27**] 04:15AM PT-18.1* PTT-38.4 INR(PT)-1.6
[**2170-6-27**] 04:15AM PLT SMR-LOW PLT COUNT-92
[**2170-6-27**] 04:15AM NEUTS-85.1 LYMPHS-11.7* MONOS-2.9 EOS-0.1
BASOS-0.2
[**2170-6-27**] 04:15AM WBC-12.5 RBC-3.65* HGB-12.3 HCT-38.0 MCV-104
MCH-...................33.5 MCHC-32.2 RDW-20.3
[**2170-6-27**] 04:15AM CALCIUM-8.0 PHOSPHATE-2.6 MAGNESIUM-1.7
[**2170-6-27**] 04:15AM LIPASE-260
[**2170-6-27**] 04:15AM ALT(SGPT)-50 AST(SGOT)-37 ALK PHOS-140 TOT
BILI-4.4
[**2170-6-27**] 04:15AM GLUCOSE-407 UREA N-55 CREAT-1.3 SODIUM-125
POTASSIUM-5.4 CHLORIDE-100 TOTAL CO2-17 ANION GAP-13
[**2170-6-27**] 04:38AM LACTATE-2.5
[**2170-6-27**] 04:40AM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-1000 KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2170-6-27**] 04:40AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.021
[**2170-7-6**]:....WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
..............11.9* 3.90* 12.7 40.6 104* 32.5* 31.2 19.6* 197
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
............... 76.4* 17.7* 5.3 0.3 0.4
....................Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2170-7-6**] 09:30 128*1 49* 1.0 130* 5.3* 108 17* 10
...................ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2170-7-6**] 09:30 52* 60* 472*1 179* 2.6*
......................Albumin Globuln Calcium Phos Mg UricAcd
Iron
[**2170-7-6**] 09:30 1.4* 8.2* 3.1 1.8
.....................%HbA1c eAG
[**2170-7-5**] 05:44 8.0*1 183*2
.
[**2170-7-7**] 06:34AM BLOOD WBC-10.6 RBC-3.64* Hgb-11.9* Hct-37.3
MCV-103* MCH-32.7* MCHC-31.9 RDW-19.4* Plt Ct-217
[**2170-7-6**] 09:30AM BLOOD Neuts-76.4* Lymphs-17.7* Monos-5.3
Eos-0.3 Baso-0.4
[**2170-7-4**] 06:15AM BLOOD PT-16.1* PTT-30.3 INR(PT)-1.4*
[**2170-7-7**] 06:34AM BLOOD Glucose-114* UreaN-50* Creat-1.1 Na-133
K-4.7 Cl-109* HCO3-18* AnGap-11
[**2170-7-6**] 09:30AM BLOOD ALT-52* AST-60* LD(LDH)-472* AlkPhos-179*
TotBili-2.6*
[**2170-7-7**] 06:34AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.9
[**2170-7-6**] 06:23AM BLOOD VitB12-1579* Folate-13.4
[**2170-7-5**] 05:44AM BLOOD %HbA1c-8.0* eAG-183*
[**2170-7-1**] 06:20AM BLOOD TSH-0.93
[**2170-7-4**] 06:15AM BLOOD HIV Ab-NEGATIVE
[**2170-6-27**] pelvic CT
1) Increased mesenteric stranding. Non-specific. DDx includes
inflammatory, mesenteric panniculitis, lymphoma.
2) Known enterocutaneous fistula appears unchanged. No new
fistulas.
Specifically, no fistulous connection to mons pubis.
3) Right inguinal lymphadenopathy unchanged.
4) Status-post splenectomy [**2170-6-27**] abdominal CT
1. No change in the enterocutaneous fistula and stoma in the
right lower
abdominal wall.
2. Increase mesenteric fat stranding in the peripancreatic
region. This
appearance could be due to inflammation, previous radiotherapy,
panniculitis, lymphoma.
3. A 1.2 cm portocaval lymph node, unchanged in appearance
compared with the previous study.
[**2170-6-29**] mons pubic ulcer specimen:Deep ulceration with mixed
acute and chronic inflammation and infection with
cytomegalovirus \
.
URINE CULTURE (Final [**2170-6-29**]):
YEAST. >100,000 ORGANISMS/ML
[**2170-6-28**] mons publis ulcer
GRAM STAIN (Final [**2170-6-28**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
CMV Viral Load (Final [**2170-7-5**]):
4,550 copies/ml.
CMV IgG ANTIBODY (Final [**2170-7-6**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
> 400 AU/ML.
GRAM STAIN (Final [**2170-6-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39667**] @ 2045, [**2170-6-29**].
TISSUE (Final [**2170-7-2**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2170-7-3**]): NO ANAEROBES ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2170-7-2**]):
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2170-7-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Blood Culture, Routine (Final [**2170-7-3**]): NO GROWTH.
Mons Pubis Biopsy:
DIAGNOSIS:
Skin, mons pubis, biopsy:
Deep ulceration with mixed acute and chronic inflammation and
infection with cytomegalovirus, see note.
Note: Rare cytomegalovirus inclusions are seen on the H&E
sections and also on immunostain for cytomegalovirus. Gram
positive cocci are also identified on the tissue Gram stain. No
fungal micro-organisms are seen on the PAS-D or GMS stains. The
findings are consistent with cytomegalovirus and bacterial
co-infection. Clinicopathologic correlation is recommended.
Multiple levels have been examined.
Brief Hospital Course:
68 y/o female with obesity, diabetes, hepatitis who initially
presented with concern for urosepsis but was ultimately found to
have CMV viremia, CMV soft tissue infection, MSSA soft tissue
infection and yeast UTI.
# CMV viremia: Patient has had [**3-29**] punch ulcers on her mons
pubis that were cultured and biopsied and came back positive for
MSSA and CMA. A pelvic CT determined that the ulcers are not in
communication with her enterocutaneous fistula. Blood cultures
revealed CMV viremia with 4550 copies/mL. Optho consult came
back negative for CMV retinitis. He was followed closely by
infectious disease. She was started on treatment initially with
IV ganciclovir and transitioned to oral valganciclovir 900mg [**Hospital1 **]
for a minimun of 3 weeks. She will follow-up in [**Hospital **] clinic prior
to determine a further course. She will likely need continued
suppressive therapy until she is no longer immunosuppressed on
steroids.
#. MSSA Skin Infection: Patient had multiple skin ulcerations.
She had wound swabs and deep tissue cultures from her mons pubis
wound. She was initially treated with Vancomycin and CTX in the
ICU. She was continued on CTX and transitioned to Dicloxacillin
500 mg by mouth every six hours for a total 14 day course. last
day: [**7-11**]). Her course was extended secondary to continued
purulent drainage from her wound that improved with antibiotics.
She was started on IV lasix to reduce edema and promote wound
healing. Given electolyte abnormalities, Chem 7 should be
checked daily to ensure no worsening of hyponatremia or
hypokalemia. Please see attached wound care note for wound
care.
#. Yeast UTI: Pt with persistent yeast growing from her urine.
She was not treated initially and repeat cultures continued to
show yeast. Her symptoms were difficult to assess, but given
her immunosuppression, continued yeast on multiple cultures,
severity of illness, and suprapubic pain (confounded by her pns
pubis ulcers) she was empirically treated with fluconazole for a
planned 7 day course (last day [**7-11**]).
# Hypotension: The patient was transferred from an OSH with
presumed urosepsis on CTX. On arrive the patient presented
hypotensive with a positive UA, elevated WBCs, and lactate of
2.5. Her blood pressures were 90s/50 and a temperature of 101.
She was transfered to the unit and remained hypotensive despite
3 L NS and started on levophed which was weaned over the course
of the first 24 hours. She was also started on stress dosed
steroids. She was started empirically on vancomycin and
ceftriaxone for treatment of a presumed UTI. Her leukocytosis
delined and she was admited to the floor. Throughout her stay on
the floor, she remained normotensive and was given normal saline
and lactated ringers as needed for hypovolemia. Her hypotension
was likley multi-factorial inlcuding sepsis from urinary and
skin source and adrenal insuff. Please see management of
infections above.
# Autoimmune vs drug hepatitis: Patient with prior admission for
autoimmune vs drug induced hepatitis. Her [**Doctor First Name **] pos 1:320 and
anti smooth +. The patient was on 30mg prednisone daily on
admission. Her LFT remained stable (ALT/AST ranging 50-60's)
during her hospitalization. She was briefly on stress dose, but
changed back to 30mg prednisone daily. She will be continued on
prednisone 30mg daily until follow-up with her Liver Clinic per
Hepatology recommendations. She should have LFTs monitored
weekly.
# ARF: The patient initially presented with Cr 1.3, up from
baseline 0.8. Also has elevated BUN and hyperkalemia. This
likely was prerenal in the setting of dehydration and infection.
Her renal function improved with IV hydration. Additionally,
the patient had continued output from her fistula.
# Hyponatremia: Component of pseudohyponatremia given elevated
glucose. However, she was hyponatermic secondary to hypovolemia
and corrected after IVF. She should have her sodium monitored
at rehab.
# Diabetes: Pt has poor glucose control at baseline that was
worsened on steroids & infection. Her Lantus and ISS were
titrated up and maintained FS between 120-200. She should
continued on lantus and HISS.
# enterocutaneous fistula: Pt with fistula secondary to prior
surgical complications. She continued to have 1L output from
her ostomy.
#. Hyperkalemia: Pt with episodes of hyperkalemia without ECG
changes. She was monitored on tele. She was also given
kayexalate for her hyperkalemia and improved.
#. PCP [**Name Initial (PRE) 5**]:
Given need for long-term steroids for autoimmune hepatitis,
patient needs to be on PCP [**Name Initial (PRE) 1102**]. Patient cannot receive
Bactrim prophylaxis due to hepatotoxicity. She was started on
Atovaquone for prophylaxis.
#. s/p Splenectomy: Pt with splenectomy following complication
of her prior surgeries. She has documentation of a pneumovax,
but no other vaccinations are documented. She should follow-up
with her PCP to ensure vaccination of H. flu and Meningococcal
vaccine.
Medications on Admission:
1. Bisacodyl 5 mg Tablet 2 tabs PO DAILY
2. Senna 8.6 mg [**Hospital1 **]
3. Miconazole Nitrate 2 % Powder TID
4. Omeprazole 40 mg tabs po daily
5. Cholecalciferol (Vitamin D3) 800 unit Q day
6. Calcium Carbonate 500 mg TID
7. Prednisone 40 mg Q day
8. Insulin Glargine 22 units QHS
9. Insulin Lispro per SS
10. Tramadol 50 mg PO Q 4-6 PRN pain
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
8. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
10. Dicloxacillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours).
11. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26)
Units Subcutaneous at bedtime.
13. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
once a day.
14. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day: to
begin after 5 days of IV lasix.
15. Lasix IV
20mg IV daily for 5 days, then switch to po lasix as written
16. Outpatient Lab Work
-Please monitor daily electrolytes including sodium, potassium,
glucose while on IV lasix, then can space out to q2-3 days.
- Please monitor weekly LFT
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary Diagnoses:
1. CMV Viremia
2. Fungal UTI
3. Methicillin Sensitive Staphylococcus Aureus (MSSA) Skin
Infection
Secondary Diagnoses:
1. Autoimmune Hepatitis
2. Diabetes/Hyperglycemia
3. Acute Renal Failure
4. Hyponatremia
5. Enterocutaneous Fistula
6. Lupus
7. GERD
8. Hypertension
9. H/O breast cancer s/p mastectomy
10. Arthritis
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 39666**]:
You were admitted to the hospital with low blood pressure, high
blood sugars and concern for an infection. Your urine, blood and
skin was examined for possible sources of infection. The ulcers
on your skin had evidence of both a viral and bacterial
infection. Ultimately, a virus was identified in your blood and
treatment was initiated. You were also given antibiotics for the
bacteria found on your skin. Also, a common fungus was
identified in your urine and treatment was provided for that as
well.
Of note, your blood sugars were difficult to control during this
admission and changes to your insulin regimen were made.
Please limit your fluid and sodium intake.
These medications were started during this admission and will
need to be continued:
1. Valganciclovir 900 mg by mouth twice a day (Start: [**7-6**],
Continue for at least 3 weeks, follow-up with Infectious Disease
in next two weeks to determine total course)
2. Fluconazole 200 mg by mouth daily (Start: [**7-5**], Stop: [**7-11**])
3. Dicloxacillin 500 mg by mouth every six hours (Start: [**7-6**],
Stop: [**7-11**])
4. Lasix 20mg IV once a day as needed for 4-5 days (then can
switch to 80mg lasix PO)
These medications were changed during your hospitalization:
1. Lantus (Glargine) 22 mg at night was changed to Lantus 26 mg
at night
Followup Instructions:
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2170-7-25**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: LIVER CENTER
When: THURSDAY [**2170-7-26**] at 2:40 PM
With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2170-7-9**]
|
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81,053
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39529
|
Discharge summary
|
report
|
Admission Date: [**2198-7-10**] Discharge Date: [**2198-7-14**]
Date of Birth: [**2130-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tetanus
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
"Excruciating back pain"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr.[**Known lastname 9241**] reports waking up this AM with "excruciating back
pain" ([**9-16**])located above his shoulder blades. He reports
associated shortness of breath and nausea. Denies
dizziness/lightheadedness/vomiting. Denies having this
pain prior to this morning. He was seen at OSH where he
underwent a Chest CT scan that revealed a Type B dissection. He
was transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
Hypercholesterolemia
Asthma
Anxiety
Chronic Back pain-herniated discs
arthritis
*awaiting a triple fusion to the (R)foot with Dr.[**First Name (STitle) 732**]
prostate ca.
Social History:
Lives with:wife
[**Name (NI) 1139**]:denies
ETOH:2 days/week
Family History:
Father died age 66 of myocardial infarction
Physical Exam:
Pulse:66 Resp:15 O2 sat:99%4L
B/P Right:141/80 Left:128/76 on admission
Height:5'[**98**]" Weight:247lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur IV/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:1+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit: none appreciated,pulses=Right: 2+ Left:2+
Pertinent Results:
[**2198-7-12**] 01:19AM BLOOD WBC-9.1 RBC-3.51* Hgb-11.4* Hct-32.5*
MCV-93 MCH-32.4* MCHC-35.0 RDW-14.0 Plt Ct-158
[**2198-7-12**] 01:19AM BLOOD PT-12.2 PTT-26.1 INR(PT)-1.0
[**2198-7-12**] 01:19AM BLOOD Glucose-124* UreaN-20 Creat-1.0 Na-139
K-4.5 Cl-107 HCO3-24 AnGap-13
CT Chest [**2198-7-11**]
IMPRESSION:
1. Type B aortic dissection originating just distal to left
subclavian artery
extending caudally to the level of the renal arteries. The
celiac trunk,
superior mesenteric artery and renal arteries originate from the
true lumen.
Dissection extends somehwat (about 1cm) into the the superior
mesenteric
artery without significant compromise of the blood flow through
its branches.
This extension is a new finding.
2. Multiple right pulmonary nodules. Prior studies are needed
for comparison
to ensure their stability. If none are available, PET scan may
be considered
for further evaluation as one nodule measure 1cm.
[**2198-7-14**] 06:15AM BLOOD WBC-14.5*# RBC-3.15* Hgb-10.2* Hct-30.7*
MCV-97 MCH-32.3* MCHC-33.2 RDW-13.6 Plt Ct-107*
[**2198-7-14**] 06:15AM BLOOD Plt Ct-107*
[**2198-7-14**] 06:15AM BLOOD PT-16.0* PTT-53.2* INR(PT)-1.4*
[**2198-7-14**] 06:15AM BLOOD Glucose-334* UreaN-19 Creat-1.1 Na-139
K-4.9 Cl-107 HCO3-10* AnGap-27*
[**2198-7-14**] 06:15AM BLOOD ALT-72* AST-80* LD(LDH)-407* AlkPhos-77
Amylase-26 TotBili-0.8
[**2198-7-14**] 06:15AM BLOOD Calcium-12.2* Phos-7.3*# Mg-2.2
Brief Hospital Course:
He was admitted for further work-up and management of his type B
aortic dissection. He was started on labetalol drip for blood
pressure control. Vascular surgery was consulted. Chest CT was
performed to assess for progression of dissection. This study
showed Type B aortic dissection originating just distal to left
subclavian artery extending caudally to the level of the renal
arteries. The celiac trunk,
superior mesenteric artery and renal arteries originate from the
true lumen.
Dissection extends somehwat (about 1cm) into the the superior
mesenteric
artery without significant compromise of the blood flow through
its branches.
Additionally, pulmonary nodules were noted and thoracic surgery
was consulted. His oral medications were adjusted, he was
weaned off the labetolol drip and transferred to the floor.
Continued to monitor his blood pressure and adjusted
antihypertensives, with plan for discharge [**7-14**]. On [**7-14**] early am
he developed severe pain and was taken to CT scan for CTA of
aorta however he arrested prior to scan and the scan was
intubated and regained pulses and was transferred to the CVICU.
In the CVICU he went into Ventricular fibrillation and he was
defibrillated and CPR resumed with no return to life. The
resuscitative efforts were stopped and he was expired at [**2198-7-14**]
at 0637. Dr [**Last Name (STitle) 914**] spoke with daughter on the phone.
Medications on Admission:
Ultram 50mg po q4-6hrs PRN-pt states he doesn't use anymore
Citalopram 20mg po daily
Simvastatin 80mg po daily
Omeprazole 20mg po daily
Nabumetone 1000mg po daily
Vicodin PRN
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Type B aortic dissection
Cardiac arrest
Hypercholesterolemia
Asthma
Anxiety
Chronic Back pain-herniated discs
arthritis
*awaiting a triple fusion to the (R)foot with Dr.[**First Name (STitle) 732**]
prostate ca.
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2198-7-16**]
|
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icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.0",
"99.60",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
4886, 4895
|
3220, 4628
|
299, 306
|
5150, 5159
|
1787, 3197
|
5212, 5247
|
1056, 1102
|
4854, 4863
|
4916, 5129
|
4654, 4831
|
5183, 5189
|
1117, 1768
|
234, 261
|
334, 765
|
787, 961
|
977, 1040
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,942
| 144,590
|
52975
|
Discharge summary
|
report
|
Admission Date: [**2115-1-2**] Discharge Date: [**2115-1-16**]
Date of Birth: [**2055-8-31**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Valium / Ace Inhibitors
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Chief Complaint: unresponsiveness, respiratory distress
Major Surgical or Invasive Procedure:
Intubation
right subclavian central line
femoral central line - d/c'd
arterial line
History of Present Illness:
History of Present Illness:
Ms. [**Known lastname 1182**] is a 59 year-old woman with a history of pulmonary
fibrosis (thought secondary to radiation therapy), asthma,
achalasia, and chronic low back pain who is admitted to the MICU
today after being found unresponsive at [**Hospital **] Rehab this
morning. By report, Ms. [**Known lastname 1182**] was noted by staff to be
unresponsive to sternal rub around 8:45 am. Her BP was 86/54, HR
87, and she was noted to have pulmonary wheezes and pinpoint
pupils on exam (her fentanyl patch dose had been increased
yesterday). An ABG while on supplemental oxygen was 7.14/88/406.
By report, she was given IV naloxone 0.8 mg IV x2, then 0.4 mg
IV x1 (2mg total) and a dose of SC epinephrine and slowly
started to wake up. Her fingerstick was 247. As she awoke, she
began complaining of severe respiratory distress. She was also
noted by rehab staff to vomit 100cc of dark liquid. EMS was
called and put her on BiPAP.
.
Upon arrival to the [**Hospital1 18**] ED, she was noted to be crying out and
complaining of respiratory distress. She had a T 100.3, HR 140,
BP 143/102, RR 42, O2Sat 88% on BiPAP; an ABG was 7.21/84/57.
She was emergently intubated and a right femoral triple lumen
central line was placed for emergent access. A CXR showed a
dense RLL infiltrate. Post-intubation, she was noted to have low
O2Sats down to the high 70s/low 80s on an FiO2 of 1.0 with peak
airway pressures >60. She was given a bolus of vecuronium
without noticeable improvement in her respiratory function. Her
systolic blood pressure dropped into the 80s, and she was taken
off of her propofol and started on norepinephrine. She was noted
to have slightly improved O2Sats when she was placed with her
left side down. She received methylprenisolone 125mg IV,
ceftazidime 1000mg IV, metronidazole 500mg IV, and azithromycin
500mg IV. She was deemed too unstable to go for a CT angiogram.
.
Also of note, she was noted to have Guaiac positive brown stool
in the ED.
.
Review of Systems:
Unable to obtain since patient is intubated and sedated.
Past Medical History:
Past Medical History:
1. Right breast cancer diagnosed in [**2108**] status post lumpectomy,
radiation therapy and tamoxifen. Currently on arimidex
2. Right seventh rib fracture diagnosed [**2110-7-18**].
3. Interstitial lung disease, diagnosed [**4-24**], on 2 liters home
oxygen prior (restrictive and obstructive lung dx by pfts-
restrictive portion related to radiation)
4. Asthma.
5. Depression.
6. Hypertension.
7. Congestive heart failure, '[**13**] echocardiogram demonstrated
ejection fraction of 60%, mild LVH
8. Gastroesophageal reflux disease.
9. Achalasia status post myotomy, pyloroplasty, vagotomy, and
Roux-en-Y gastrojejunostomy.
10. Chronic low back pain: L4-5, L5-S1 disk herniation
bilaterally
11. Status post cardiac arrest in [**2106**], secondary to
electrolytes abnormality, associated with anoxic brain injury
and rhabdomyolysis.
12. Chronic diarrhea- followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of GI (possibly
bacterial overgrowth as other cx neg)
13. [**3-28**] Open jejunostomy
14. IBS
Social History:
Social History:
Per OMR, no history of drugs, alcohol, or tobacco. On
disability.
Family History:
Family History:
No lung disease. +DM in GF, +HTN, +stroke father at age 75,
+bone cancer in brother, + breast cancer in cousins
Physical Exam:
Physical Examination:
T 98.5 BP 120/80 HR 105 RR 26 Sat 84%
Weight 90.4 kg
Vent: AC 350cc x 26 bpm, FiO2 100%, PEEP 15
General: moderately sedated; intermittently with dark brown
liquid coming out from her mouth around ETT
HEENT: no icterus, pupils 1mm -> 0.5mm bilaterally
Neck: supple
Chest: loud insp/exp ronchi over entire right lung field; mild
ronchi in left lung field with faint end expiratory wheezing
CV: tachycardic, regular, no murmurs
Abdomen: obese, (+) PEG, nondistended, no HSM
Extremities: warm, no edema, 2+ PT pulses, no clubbing
Skin: no rashes
Neuro: sedated, pupils constricted but equal and reactive
bilaterally
Pertinent Results:
CXR ([**2115-1-2**]):
Single bedside AP examination labeled "supine at 11:30 hours"
compared with most recent study dated [**12-11**], as well as previous
study, dated [**2114-10-4**]. The ET tube tip is not well seen, but
appears to lie some 2.7 cm proximal to the carina, and the
distal portion of the endogastric tube reaches the gastric body,
with sidehole projected over the fundus. There is a diffuse,
patchy and confluent airspace process involving the right mid
lung and base, new. There is also patchy retrocardiac opacity,
which has become more confluent over the interval. The heart
size is not much changed, with no further vascular
redistribution (allowing for this positioning). Again
demonstrated are numerous surgical clips in the mediastinum when
projected over the esophageal hiatus, and in the upper abdominal
midline, as well as surgical chain suture following the contour
of the lateral left hemidiaphragm.
.
Spirometry ([**2114-10-10**]):
FVC 0.90 (40% predicted) FEV1 0.72 (44% predicted) MMF 0.70 (29%
predicted) FEV1/FVC 80 (109% predicted)
.
ECG ([**2115-1-2**]):
Sinus tachycardia with ventricular rate of 145 bpm; normal axis;
normal intervals; no ST segment or T wave changes.
.
Brief Hospital Course:
This is a 59 year old woman with hypoxemic respiratory failure
likely due to severe aspiration pneumonitis (on top of baseline
radiation pneumonitis) in the setting of altered mental status,
likely from iatrogenic narcotic overdose.
1) Respiratory Failure
In regards to her respiratory failure, this is most likely
secondary to severe chemical pneumonitis due to aspiration on
top of her background pulmonary fibrosis and asthma. In
addition, she has evidence of ARDS given her PaO2/FiO2 ratio and
bilateral infiltrates. She has been vented on the ARDSnet
protocol with low tidal volumes. She was treated empirically
with Vancomycin and ceftazidime for 10-day course, although
cultures (sputum and BAL) have not grown to date. Bronchoscopy
demonstrated frothy, clear secretions. Her MDI's have also been
continued around the clock. Due to her poor oxygenation at
admission, she had a TTE on admission with a bubble study, which
was positive, indicative of an intracardiac shunt. She was
initially on CTX and vanc -> the CTX was changed to Ceftazidime
on [**1-5**] for broader coverage. She finished a 10 day course of
vanco/ceftaz for ARDS/PNA on [**2115-1-13**]. She was extubated
successfully on that day. She continues to do well on minimal
oxygen supplementation. She was transferred to the general
medical floor and did well.
.
2) Hypotension
She was initially hypotensive on admission, likely exacerbated
by her high PEEP at 18-20 on admission, requiring levophed. This
has since been weaned off and her BP's have been stable. Her
anti-hypertensives have been held. She has been started on lasix
for diuresis for goal CVP 3-4 given her concurrent ARDS as her
BP has been allowing for goal negative 1-2 L/day.
.
3) Guiaic positive stool
On admission, she also had guiac positive stool and ?coffee
ground emesis. No further occurences, but she did receive 2 U
PRBCs since admission for decreased Hct. She is on a PPI [**Hospital1 **].
.
4) Chronic Back Pain
Her major active issue on the medical floor remained her chronic
lower back pain and finding a regimen that will achieve adequate
pain control without causing excessive sedation. She was
continued on her fentanyl patch at 100mcg q72hrs, topical
lidoderm patch, tylenol RTC, ultram q6, and oxycodone prn.
Her Neurontin was held since admission due to concern re:
sedation. This may be re-introduced at a low dose and titrated
upward slowly if this is thought to be potentially helpful for
her pain control versus starting Lyrica which does not carry as
much sedation risk. Also, starting Cymbalta (duloxetine) is
also an option to consider which may help with neuropathic pain
symptoms considering she is currently on Celexa for depression
symptoms. Further changes to her regimen are being deferred to
the rehab facility so that she can be followed longitudinally.
Medications on Admission:
Home Medications: (per notes from [**Hospital1 **])
albuterol/ipratropium neb q6h
acetaminophen 975mg q8h
anastrazole 1mg daily
bisacodyl 10mg daily
benzonatate 100mg q8h
citalopram 40mg daily
dalteparin 5000 units sc daily
docusate 100mg [**Hospital1 **]
ergocaliciferol drops 8000 units PO weekly
Advair 250/50 [**Hospital1 **]
gabapentin 600 mg [**Hospital1 **]
Combivent 2 puffs q6h and prn
lansoprazole 30mg [**Hospital1 **]
lorazepam 1mg [**Hospital1 **] prn
metoprolol 50mg [**Hospital1 **]
nifedipine 60mg daily
sodium bicarbonate [**Hospital1 **] (dose unclear)
ondansetron 4mg q12h
Senna syrup 10cc qhs
spironolactone 50mg qam
trazodone 200mg qhs
milk of magnesia 30cc po q6h prn
oxycodone 7.5mg q4h prn
lidocaine patch daily
fentanyl patch 100 mcg/hr q72h (just increased on [**2115-1-1**];
prior dose unclear)
Discharge Medications:
1. Fentanyl 100 mcg/hr Patch 72 hr [**Date Range **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Ipratropium Bromide 0.02 % Solution [**Date Range **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Date Range **]: One (1)
neb Inhalation every 4-6 hours as needed for shortness of breath
or wheezing.
4. Citalopram 20 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily).
5. Senna 8.8 mg/5 mL Syrup [**Date Range **]: Ten (10) cc PO qhs (at bedtime).
6. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: Ten (10) mL PO BID (2
times a day).
7. Anastrozole 1 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution [**Date Range **]: 5000 (5000)
units Injection TID (3 times a day).
10. Advair Diskus 250-50 mcg/Dose Disk with Device [**Date Range **]: One (1)
inhalation Inhalation twice a day.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Twenty (20) mL PO
Q6H (every 6 hours).
14. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q 8H
(Every 8 Hours).
15. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
16. Tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6)
hours.
17. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: [**5-31**] mL PO Q4H (every 4
hours) as needed for pain.
18. Ergocalciferol (Vitamin D2) 8,000 unit/mL Drops [**Month/Year (2) **]: One (1)
mL PO once a week.
19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Year (2) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
20. Insulin Lispro 100 unit/mL Solution [**Month/Year (2) **]: As per attached
scale units Subcutaneous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
ARDS
Pneumonia
Achalasia
Chronic Lower back pain
Discharge Condition:
Stable for discharge to rehab
Discharge Instructions:
You were admitted to the hospital with a severe pneumonia from
aspiration in the setting of profound sedation. You required a
breathing tube and ventilator for 11 days and your breathing
tube was removed on [**2115-1-13**]. You completed a full course of
antibiotics for 10 days for your pneumonia and no longer require
any antibiotics.
.
While you were hospitalized, your J Tube became clogged and
needed to be changed.
.
Please take the medications as listed below.
.
If you develop any worsening fatigue, sedation, fever, cough,
pneumonia, or any other concerning symptoms, please discuss your
care with the rehab doctor or report to the nearest ER.
Followup Instructions:
YOUR PREVIOUSLY SCHEDULED APPOINTMENTS:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 13532**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2115-2-5**] 2:10
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2115-1-16**]
|
[
"338.29",
"515",
"428.0",
"E852.9",
"V10.3",
"507.0",
"311",
"724.2",
"518.82",
"428.30",
"967.9",
"V55.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.23",
"38.91",
"96.04",
"96.6",
"97.03",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11730, 11809
|
5761, 8601
|
351, 436
|
11901, 11932
|
4528, 5738
|
12635, 12957
|
3743, 3857
|
9474, 11707
|
11830, 11880
|
8627, 8627
|
11956, 12612
|
3872, 3872
|
8645, 9451
|
3894, 4509
|
2479, 2538
|
273, 313
|
492, 2460
|
2582, 3611
|
3643, 3711
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,917
| 105,519
|
2470
|
Discharge summary
|
report
|
Admission Date: [**2148-6-12**] Discharge Date: [**2148-7-5**]
Date of Birth: [**2091-2-25**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Biaxin / Ciprofloxacin
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
fever, chills
Major Surgical or Invasive Procedure:
Mechanical Ventilation
Arterial Line Placement
Hemodialysis Line Placement
Internal Jugular Central Line Placement
History of Present Illness:
57m with HIV (last CD4 525 with VL undetectable ~2 months ago)
presents with acute onset of fever, chills, and extreme weakness
several hours prior to presentation. He was at his office
working feeling in his usual state of health until about 9pm
last night. At that time, he developed abrupt onset of fever,
chills, hot flashes. +Nausea. No vomiting. No cough, SOB, chest
pain. No urinary symptoms. No sick contacts. [**Name (NI) 4084**] had episode
like this before. No recent travel.
.
In the [**Hospital1 18**] ED, initial vitals were T 102.5, BP 118/65, HR 116,
RR 20, 94% RA. His BP dropped to 70/30s at one point but
improved with IVF. BP then dropped again. R IJ was placed.
Levophed was started. He remained persistently tachy to
120-130s. Labs notable for lactate of 2.5, no leukocytosis, hct
49. UA neg. CXR unremarkable. Admitted to MICU for closer
monitoring.
.
On arrival to the MICU, the patient's main complaint is feeling
very thirsty. He also has severe back and knee discomfort [**3-18**]
chronic arthritis pain and lying flat on his back. SBP dropped
again to as low as 60s. Vasopressin and neosynephrine were added
to bring up BP.
.
ROS: As above. Otherwise negative in detail.
Past Medical History:
HIV
Hep B, never been treated
Obesity
Hypercholesterolemia
Asthma
R medial meniscal tear
DM type 2
Hx splenic abscess s/p splenectomy in [**2135**]
Social History:
In long term relationship w/ partner. [**Name (NI) **] smoking. No alcohol. No
drugs.
Family History:
Noncontributory
Physical Exam:
VS - T 100.9; BP 90/44; HR 120; RR 12; O2sat 92% on 4L
Gen: anxious appearing, obese male, diaphoretic, alert and
interacting appropriately
HEENT: PERRL, EOMI, dry MM, OP clear
CV: distant HS,
Chest: face tent, CTAB, no w/r/r
Abd: obese, soft, nondistended, mild tenderness at
RUQ/mid-epigastrium
Ext: no LE edema
Skin: no rash
Neuro: A+O x 3
Pertinent Results:
[**2148-6-11**] 10:30PM BLOOD WBC-9.4 RBC-5.26# Hgb-16.2# Hct-49.1
MCV-93# MCH-30.8# MCHC-33.0 RDW-14.3 Plt Ct-432
[**2148-6-12**] 03:42PM BLOOD WBC-24.9* RBC-4.68 Hgb-14.3 Hct-43.9
MCV-94 MCH-30.5 MCHC-32.6 RDW-14.6 Plt Ct-247
[**2148-6-14**] 04:03AM BLOOD WBC-48.3* RBC-4.06* Hgb-12.4* Hct-37.1*
MCV-91 MCH-30.7 MCHC-33.5 RDW-15.1 Plt Ct-23*
[**2148-6-18**] 03:53PM BLOOD WBC-45.6* RBC-3.29* Hgb-10.4* Hct-30.0*
MCV-91 MCH-31.6 MCHC-34.6 RDW-16.4* Plt Ct-72*
[**2148-6-23**] 04:10AM BLOOD WBC-17.4* RBC-2.59* Hgb-8.2* Hct-24.4*
MCV-94 MCH-31.6 MCHC-33.5 RDW-17.1* Plt Ct-355#
[**2148-7-2**] 06:30AM BLOOD WBC-8.2 RBC-2.53* Hgb-8.0* Hct-26.0*
MCV-103* MCH-31.6 MCHC-30.8* RDW-19.2* Plt Ct-811*
[**2148-7-5**] 06:00AM BLOOD WBC-9.5 RBC-3.04* Hgb-9.6* Hct-29.7*
MCV-98 MCH-31.5 MCHC-32.3 RDW-19.5* Plt Ct-738*
[**2148-7-2**] 06:30AM BLOOD WBC-8.2 Lymph-20 Abs [**Last Name (un) **]-1640 CD3%-81
Abs CD3-1333 CD4%-23 Abs CD4-373 CD8%-58 Abs CD8-953*
CD4/CD8-0.4*
[**2148-6-11**] 10:30PM BLOOD Glucose-133* UreaN-27* Creat-1.0 Na-137
K-4.4 Cl-99 HCO3-25 AnGap-17
[**2148-6-28**] 03:00AM BLOOD Glucose-79 UreaN-80* Creat-6.6* Na-147*
K-5.1 Cl-109* HCO3-19* AnGap-24*
[**2148-6-29**] 03:12AM BLOOD Glucose-89 UreaN-73* Creat-6.1* Na-150*
K-4.7 Cl-110* HCO3-18* AnGap-27*
[**2148-7-4**] 06:40AM BLOOD Glucose-86 UreaN-39* Creat-3.1* Na-145
K-4.1 Cl-107 HCO3-24 AnGap-18
[**2148-6-11**] 10:45PM BLOOD Lactate-2.5*
[**2148-6-12**] 12:17PM BLOOD Lactate-6.1*
[**2148-6-15**] 10:21AM BLOOD Lactate-2.0
[**2148-6-29**] 03:53PM BLOOD Lactate-0.8
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2148-6-12**] 8:29 AM
IMPRESSION:
1. Limited examination shows no gross intrahepatic biliary
dilatation.
2. Markedly edematous gallbladder, without stones or distension.
The
appearance of the wall can be seen in patients with underlying
liver disease
or hypoproteinemia.
3. Fluid within the left upper quadrant, of uncertain etiology
or location.
Differential considerations include a fluid-filled, distended
stomach, vs.
post- operative fluid within the splenectomy bed.
4. Small amount of ascites.
Portable TTE (Complete) Done [**2148-6-14**] at 11:43:53 AM:
Left Ventricle - Ejection Fraction: >= 55%
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve,
but cannot be fully excluded due to suboptimal image quality.
Trace aortic regurgitation is seen. No masses or vegetations are
seen on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. There is no pericardial effusion.
IMPRESSION: No vegetations seen (suboptimal-quality study).
Normal global and regional biventricular systolic function. In
presence of high clinical suspicion, absence of vegetations on
transthoracic echocardiogram does not exclude endocarditis.
Brief Hospital Course:
Mr [**Known lastname **] is a 57 year old man with history of HIV,
splenectomy, presented with acute onset of fever, chills and
nausea. Patient was evaluated in the ED where he spiked fever to
102.5 and developed acute hypotension requiring rapid escalation
of care with 3 pressors and large volume resusitation for septic
shock.
.
Patient was in MICU from [**6-12**] where his course included Xigris
administration, CVVH for massive volume overload and treated
with broad spectrum antibiotics. Eventually the patient was
weaned off of pressors, received one dose of IVIG, and
subsequently placed on PCN G for strep viridans culture but had
one episode of hypotension and fever during which time 1 time
doses of vanc/zosyn were given. Today is day 18/28 as per ID of
PCN G course. In addition, the patient had unexplained
transaminitis during his stay, history of HBV infection and HBV
core antigen positive, negative HCV Ab. Transaminitis resolved
as patient was weaned from ventilation and pressures stabilized
-- on transfer AST/ALT have normalized and Alk Phos trending
down. Amylase and Lipase elevated on [**6-18**], continues to be
elevated -- there was an initial concern for pancreatitis and
abd. CT done showing mild pancreatitis; however lipase now
trending down and no signs of infection (fever, leukocytosis) is
present at transfer. Pt. also suffering from ARF likely ATN from
septic shock, received several rounds of CVVH after massive
fluid resuscitation, now auto-diuresing with up to 3L UOP/day,
though Cr still above 5 on transfer. In addition, pt. had a
transient drop in plt's to a nadir of 10 requiring plt
transfusion -- heme/onc consulted, reviewed smear, and believed
pathogenesis to be bone marrow suppression in light of
overwhelming sepsis, and not DIC. Plt levels have since returned
to normal.
.
On transfer to the floor, pt. was alert and talkative. Was seen
by physical therapy and was able to transfer from bed to chair
and back with assistance. Continued to have good urine output,
so renal concluded no need to place HD line. Cr trended
downward to 3.1 the day prior to discharge, and patient was
tolerating adequate PO's. Will be discharged on day 23 of 28 of
his PCN G as per ID. In addition, was having diarrhea, C.diff
negative x 2.
.
Follow Up:
---------
- Please follow up MICROSPORIDIA STAIN, CYCLOSPORA STAIN, and
Cryptosporidium/Giardia DFA stool samples
- When Cr is under 1.5, please resume original HAART medications
MICU COURSE
===============
Events [**6-12**]:
- BCx [**3-18**] GPCs in pairs
- Zosyn changed to ceftriaxone and clindamycin
- Given IVIG
- RUQ u/s showed edematous gallbladder
[**6-13**]
-Climbing WBC
-Renal put in HD cath
-f/u CXR shows decreased pulm edema, effusions, but ?aspiration,
L retrocardiac opacity
-standing tylenol
-started IV hydrocortisone
- 25g albumin x2
- IVFs w/ bicarb
[**6-14**]
-Platelets to 10K, 1 bag of platelets given, increased to 39
-D/C'ed ceftriaxone per ID given interaction with calcium
gluconate on CVVH
-DIC labs
-Heme/Onc does not believe plt drop is DIC, believes it is
suppression of marrow due to sepsis
-Dopamine weaned off, on CVVH
.
[**6-15**] Events:
-PEEP decreased to 16
-cultures growing strep viridans
[**6-16**] events:
d/c-ed vanc, clinda. Started PCN with one dose of [**Last Name (LF) **], [**First Name3 (LF) **] ID
recs
-weaned off levophed and vasopressin!
-please bring up with nephrology whether patient can get
dialysis now that pressures are stable.
[**6-17**] Events
-Patient with labored breathing, PEEP was increased to 20, pt.
placed back on midazolam sedation.
-IP, saw free flowing fluid with no loculations, performed
diagnostic thoracentesis, transudative pleural fluid
-TEE to be done tomorrow, tube feeds restarted, NPO past
midnight
-RUQ ultrasound being done- prelim read -> interval decrease in
gb wall edema, gb not distended, no gstones, no cholecystitis,
small amount of free fluid adj to liver
-[**Month/Day (4) **] level 0.7, given [**Month/Day (4) **] per ID recs
-HIT Ab negative
-Bronch done, demonstrated esophageal balloon in lung, extracted
-PLT increasing
.
[**6-18**] Events:
-TEE showed no vegetations
-labs show pancreatitis, plan to obtain CT abd after off CVVH
-hypotensive to 70s with 500 ccs negative per hour, given 1000
cc bolus, changed CVVH to run at even, held versed
-hepatitis panel sent
-amylase level of pleural fluid added on
-started acyclovir
-need to ask ID in am about IV vs topical acyclovir, need for
[**Month/Day (1) **], and when to restart HAART
[**6-19**] events:
d/c-ed [**Month/Day (4) **] per ID recs
-wanted to continue po acyclovir for now
-considering starting HAART soon, not quite yet
-they did not comment on whether or not to start broader abx
coverage for pna. So we started Levofloxacin for pna.
I/Os: -4.2L
[**6-20**] events:
-two episodes of hypotension with SBP below 100, given two 500cc
boluses of fluid
-temp to 101, pan cultured, given 1x dose of zosyn and
vancomycin
-PEEP @ 12
-HCV and HBV negative
-Increased Cr to 2.1
-EBV IgG positive
.
[**6-21**] events:
-HD
-HD line removed, tip for culture
-ABx d/c'd
-CT abd completed- no abscess or fluid collection, mild
pancreatitis, b/l pleural effusions c/ atelectasis, L opacity
.
[**6-22**] events:
patient more arousable
+2L
.
[**6-23**] Events
- Renal recs to make patient NPO for tomorrow for possible
tunneled cath HD line placement; however, if patient's urine
output is picking up (last UOP decidedly more than prev. at
100-110 every 2 hours)
- Holding heparin
- Patient sitting up, responsive to questions
- ABG pristine on PS ventilation (7.42/40/90)
===================================
Medications on Admission:
Metformin 500mg PO BID
Atripla 1 tab PO daily
Lisinopril 5mg PO daily
Lipitor 10mg PO daily
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Month/Year (2) **]: One
(1) Appl Ophthalmic PRN (as needed).
2. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical PRN
(as needed) as needed for pannus fungal infection.
4. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for aggitation.
8. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing,
SOB.
11. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback
[**Last Name (STitle) **]: 3,000,000 units Intravenous Q4H (every 4 hours) for 6 days:
Please stop on [**2148-7-10**].
12. Insulin Glargine 100 unit/mL Solution [**Date Range **]: Eight (8) units
Subcutaneous QAM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Septic Shock
Acute Renal Failure
Secondary:
HIV on therapy
Hepatitis B, untreated
Obesity
Hypercholesterolemia
Asthma
Diabetes Mellitus Type 2
History of splenic abscess status post splenectomy in [**2135**]
Discharge Condition:
Stable, eating, drinking, voiding, and having bowel movements,
conversant, can get from chair to bed with assistance.
Discharge Instructions:
You were admitted initially for a severe infection and severe
inflammation. Upon arrival you were promptly taken to the
intensive care unit where you were given antibiotics and
resucitated with fluids. After you stabilized in the ICU, you
were transferred to the floor where you were recovering very
well. You are being sent to a rehabilitation facility where you
will work with physical therapy to recover your strength. You
will also complete your course of antibiotics there. Upon
discharge from the rehab facility, please set up an appointment
with your primary care physician [**Name Initial (PRE) 176**] 1 to 2 weeks of
discharge.
Please take all medications as prescribed. The most notable
medication that we are continuing you on is your penicillin, for
which you have 1 more week to complete.
If you experience any sudden chest pain, shortness of breath,
nausea, vomiting, diarrhea, constipation, lightheadedness, or
loss of consciousness, please contact your primary care provider
[**Name Initial (PRE) 2227**].
Followup Instructions:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2148-11-13**]
1:00
Completed by:[**2148-7-5**]
|
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"482.39",
"518.81",
"577.0",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"00.11",
"39.95",
"38.95",
"34.91",
"88.72",
"38.91",
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icd9pcs
|
[
[
[]
]
] |
12806, 12876
|
5425, 7703
|
315, 432
|
13138, 13258
|
2349, 5402
|
14336, 14496
|
1953, 1970
|
11215, 12783
|
12897, 13117
|
11098, 11192
|
13282, 14313
|
1985, 2330
|
7714, 11072
|
262, 277
|
460, 1661
|
1683, 1833
|
1849, 1937
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,297
| 164,371
|
54580
|
Discharge summary
|
report
|
Admission Date: [**2167-12-16**] Discharge Date: [**2167-12-18**]
Date of Birth: [**2100-7-6**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Bactrim / Sulfa (Sulfonamide Antibiotics) /
Penicillins / [**Hospital1 **] Tylenol Plus / Naproxen
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 67 year old female with PMH of recent CVA of the
posterior limb of the internal capsule, esophageal stricture s/p
multiple dilatations most recently on [**12-4**], non-healing peptic
ulcer disease s/p subtotal gastrectomy and repair of hiatal
hernia with fundoplication in [**2163-8-19**], COPD, Depression,
and PTSD presenting from [**Hospital 1820**] Rehab Center with persistent
nausea and vomiting as well as reported hypotension to a
systolic in the 80s. The patient was recently discharged from
[**Hospital1 18**] on [**11-30**] for persistent nausea and vomiting with inability
to take POs. She notes that she usually does have baseline
nausea and vomiting at home, which is helped by a diet
recommended to her by Dr. [**Last Name (STitle) **] but she has been unable to
stick to that diet at rehab. She is unable to quantify the
amount of vomiting she has been having over the last few days.
She describes the vomiting as continuous, but she has not had
any vomiting since arriving to the hospital. She also describes
abdominal pain in her right lower quadrant which is chronic in
nature. She has not had any fevers, chills, hematemesis or
change in bowel habits. Her esophagus was recently dilated on
[**12-4**] and she has not had any dysphagia or odynophagia since.
Her Plavix which is being used for secondary prevention of CVA
was stopped for the EGD procedure and has not yet been
restarted. She also reports lightheadedness and weakness in
association with these symptoms. Of note, she was being treated
at her rehab with cipro for a known UTI.
In the ED, initial vitals were T=98.2, HR=110, BP=104/75,
RR=18, POx=98% 2L NC. Reported vitals at her rehab prior to
transfer were HR=110s, BP=84/62, 88% on RA. A UA performed on
admission was positive for infection and she was given
vancomycin and ertapenem in the ED. A CT of her abdomen was
unremarkable/unchanged from her baseline and her CXR did not
show any signs of infection. She also had [**9-27**] LLQ abdominal
pain in the ED with no CVA tenderness noted. She did reportedly
desaturate to 89% when tried on RA in the ED. She was also
noted to be persistently hypotensive to the 80s which did
respond to 2.5L of IVF boluses in the ED. Prior to transfer,
her vitals were BP=96/67, HR=105, RR=18, POx=94% 2L.
On the floor, the patient reports that she continues to be
nauseous which is no different than her baseline when she does
not adhere to her recommended diet. She reports that her
abdominal pain is at baseline in her right lower quadrant. She
does feel as though her bowels are constantly moving in her
abdomen. She denies any dysuria. She says that she feels close
to her baseline.
.
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 diarrhea, constipation, or changes in bowel habits.
Denies dysuria, frequency, or urgency. Denies rashes or skin
changes.
Past Medical History:
-s/P CVA to posterior limb of internal capsule in [**10-28**]
-Esophageal stricture s/p dilatation
-Peptic ulcer disease s/p subtotal gastrectomy and repair of
hiatal hernia with fundoplication in [**2163-8-19**] by Dr.
[**Last Name (STitle) **] for a
nonhealing ulcer
-COPD
-GERD
-Depression
-PTSD
-Anemia
-Hyperlipidemia
-C-section x 2 ('[**27**], '[**28**])
-s/p cataract surgery in left eye x2
Social History:
Before being discharged to rehab following her admission for CVA
in [**10-28**], the patient lived alone in [**Hospital1 3494**] on SSI and
disability. She has had intermittent tobacco use throughout her
life, but reports no smoking over the last several months. She
smoked about 1.5 packs per day for about 40 years. She denies
any etoh/illicit drug use. Per OMR, she was the victim of
domestic disputes with her ex-husband.
Family History:
Asthma (children), brother with depression and PTSD
Physical Exam:
ADMISSION physical exam:
Vitals: T: 97, BP: 110s/70s, P: 90s-100s, RR: 20, O2: 94% on 2L
NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-distended, mild tenderness in right lower
quadrant, hyperactive bowel sounds, no rebound tenderness or
guarding, no organomegaly
GU: Foley in place
Ext: warm, well perfused; no clubbing, cyanosis or edema
Neuro: A+Ox3. Motor strength and sensory grossly equal and
intact bilaterally.
Pertinent Results:
LABS:
URINE CULTURE (Final [**2167-12-11**]):
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
.
URINE CULTURE (Final [**2167-11-2**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2167-12-16**] 11:35AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.024
[**2167-12-16**] 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2167-12-16**] 11:35AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2167-12-16**] 11:15AM GLUCOSE-105* UREA N-14 CREAT-0.8 SODIUM-137
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
[**2167-12-16**] 11:15AM WBC-8.9 RBC-3.60* HGB-10.6* HCT-30.1* MCV-84
MCH-29.5 MCHC-35.2* RDW-17.2*
[**2167-12-16**] 11:15AM NEUTS-73.5* LYMPHS-19.7 MONOS-3.4 EOS-2.7
BASOS-0.6
[**2167-12-16**] 11:15AM PLT COUNT-326
IMAGING:
[**12-16**] CT abd/pelvis- Prelim read: Gastrojejunostomy anastomosis
appears patent with a small lumen. It is difficult to assess for
lumen distensibility or lumen diameter on this study. If
clinically indicated, upper GI study would better evaluate this
anatomosis. Debris is visualized in the stomach, although it is
unknown when the patient last ate.
.
[**12-16**] CXR: Hilar fullness noted bilaterally with scattered
vascular markings in bilateral lung fields, but no acute process
or infiltrate noted.
.
[**12-17**] CXR: FINDINGS: The apparent opacity projected over the
left lower lobe, is less dense on the current radiograph and
when correlated with lateral views, is consistent with
mediastinal fat rather than a parenchymal abnormality. The
lungs, cardiac and mediastinal contours are normal.
IMPRESSION: No evidence of pneumonia
Brief Hospital Course:
#. UTI. The patient was found to have a positive UA on
admission and was being treated with a 7 day course of cipro at
her rehab facility for a known UTI, but was unclear how far she
was into her course. She was hypotensive on admission which was
fluid responsive and also tachycardic and hypoxic with a normal
lactate. Her vital sign changes were concerning for early
sepsis prompting her admission to the unit. She was given
vancomycin and ertapenem in the ED given her multiple allergies.
Her most recent urine cultures at [**Hospital1 18**] showed gram positive
bacteria and pansensitive Klebsiella. The patient was continued
on vancomycin and ciprofloxacin while in the ICU and was
transferred to the floor the day after admission. UCx grew
presumed lactobacillus in the setting of no acute urinary
symptoms. DC'd vancomycin and transitioned to PO ciprofloxacin
to continue a 7 day course.
.
#. Hypoxia. Patient was satting in the high 80s on room air.
She has COPD at baseline, and reported "sporadic use" of home
O2. Chest xray showed no evidence of pneumonia, she was
continued on her home COPD regimen and required supplemental
oxygen by nasal cannula while in the ED. O2 requirements
decreased to RA to sat in the low 90's which she continued on
the general medical floor.
.
#. Persistent nausea and vomiting, chronic abdominal pain.
Abdominal imaging was unimpressive and the patient rapidly
returned to her baseline. She was continued on her home liquid
diet with custard and Mighty Shakes as well as her home PPI and
sucralfate doses. Received ondansetron and prochlorperazine prn
for nausea. By time of discharge her nausea symptoms and pain
had resolved.
.
#. s/p CVA. The patient had a CVA of the posterior limb of the
internal capsule. She was continued on home aspirin and statin
for secondary prophylaxis. Plavix had been held for esophageal
dilation on [**12-4**] and was restarted by transition to the floor
on [**2167-12-17**].
.
#. COPD. No PFTs in our system but reports sporadic use of home
O2. Continued on home Advair and standing ipratropium with PRN
albuterol and required supplemental O2 per nasal cannula in ICU.
Transiitoned to RA on floors.
.
#. Anemia. Hct is at baseline in the low 30s. Continued on
home iron supplements.
.
#. Depression/anxiety/PTSD/chronic pain. Continued on home
citalopram, lorazepam, duloxetine, gabapentin, codeine, and
lidocaine patch.
Medications on Admission:
1. fluticasone-salmeterol 500-50 mcg/dose Disk inhaled [**Hospital1 **]
2. albuterol sulfate 90 mcg/Actuation HFA 2 puffs every 6 hours
as needed for dyspnea.
3. citalopram 10 mg PO once a day.
4. duloxetine 60 mg PO DAILY.
5. gabapentin 100 mg PO TID
6. lidocaine 5% Patch Topically DAILY.
7. pantoprazole 40 mg PO Q12H.
8. docusate sodium 100 mg PO BID
9. simvastatin 40 mg PO DAILY
10. camphor-menthol 0.5-0.5 % Lotion topically QID as needed for
rash.
11. lorazepam 2 mg PO twice a day as needed for anxiety.
12. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler 1
puff four times a day.
13. sucralfate 1 gram PO four times a day.
14. ferrous sulfate 300 mg Liquid PO once a day.
15. senna 8.6 mg PO twice a day.
16. codeine sulfate 15-30 mg PO every 6 hours as needed for
pain.
17. potassium chloride 20 mEq PO once a day.
18. aspirin 81 mg PO once a day.
19. ciprofloxacin 500mg [**Hospital1 **]
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): continue until [**2167-12-25**].
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for anxiety.
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB,
wheezing.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for pain.
11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) Puff Inhalation QID (4 times a day).
18. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
19. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location 1820**]
Discharge Diagnosis:
Primary Diagnosis:
Hypotension secondary to Nausea/Vomiting
Urinary Tract Infection
Esophageal Candidiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 111638**],
It was a pleasure taking care of you in the hospital. You were
admitted to the hospital for nausea and vomiting. In the
emergency room you had low blood pressure and transferred to the
Intensive Care Unit for closer monitoring. You blood pressure
improved with IV fluids and there was no evidence of a severe
infection. You finished full treatment course for a urinary
tract infection that was completed during your hospitalization.
Your symptoms improved and you were tolerating a diet. Your
blood pressures remained stable.
The following changes were made to you medications:
-- You finished your the antibiotic, Ciprofloxacin, for your
urinary tract infection. You do not need to continue this
medication.
-- You were continued on fluconazole 100mg daily for a total of
21 days (last day [**2167-12-25**])
Followup Instructions:
You have the following follow up appointments scheduled:
.
Please call your PCP and schedule [**Name Initial (PRE) **] follow-up in the next [**12-20**]
weeks.
PCP: [**Last Name (LF) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 14315**]
Department: ENDO SUITES
When: FRIDAY [**2168-1-1**] at 2:00 PM
.
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2168-1-1**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
.
Department: NEUROLOGY
When: WEDNESDAY [**2168-1-6**] at 1:30 PM
With: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD [**Telephone/Fax (1) 657**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"309.81",
"280.9",
"V12.54",
"272.4",
"V45.75",
"787.29",
"787.01",
"338.29",
"276.52",
"041.3",
"799.02",
"V15.82",
"V46.2",
"789.03",
"530.81",
"496",
"269.9",
"112.84",
"458.29",
"599.0",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12854, 12900
|
7545, 9963
|
390, 396
|
13051, 13051
|
5152, 7522
|
14077, 15104
|
4408, 4461
|
10922, 12831
|
12921, 12921
|
9989, 10899
|
13202, 14054
|
4501, 5133
|
3145, 3527
|
334, 352
|
424, 3126
|
12940, 13030
|
13066, 13178
|
3549, 3948
|
3964, 4392
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,183
| 116,907
|
30168
|
Discharge summary
|
report
|
Admission Date: [**2110-9-23**] Discharge Date: [**2110-9-24**]
Date of Birth: [**2038-6-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 3646**] is a 71 year old man with a history of diastolic heart
failure (EF 40-45%), critical aortic stenosis, multiple myeloma,
amyloidosis, and chronic renal insufficiency who presents with
exertional dyspnea worsening over the last 2 weeks or so. He has
noticed increased abdominal girth over this period, without any
abdominal discomfort. He has had some associated poor energy,
limited appetite, and nausea. He vomited once yesterday, and has
had some loose stools without melena or hematochezia. He thinks
he has gained weight but is unsure of the amount. He can ascend
[**1-28**] flights of stairs before having to stop due to dyspnea which
he says is his baseline. His wife however notes that he seems
out of breath just walking across a small room. He has stable 3
pillow orthopnea, but denies any PND. He denies any difficulties
with taking his medications as prescribed, or any increased salt
intake. He denies fevers, chills, sweats, palpitations,
lightheadedness/fainting, chest discomfort, wheezing, leg pains
or history of thrombosis. He does have a chronic cough not
recently worse productive of white sputum, without any
hemoptysis.
.
In the ED, his triage vitals were T98.1, P 98, Bp 104/64, RR 18,
99% on RA. He received 80mg lasix IV x1. On the floor, he was
noted to be "extremely short of breath" tachypneic to the 30's
and wheezing with O2 saturation dipping to 79. He was placed on
a non-rebreather facemask, given 2mg morphine, started on a
nitroglycerin drip, and subsequently transferred to the CCU.
Past Medical History:
CHF EF 40-45%, diastolic HF
AS - valve area <0.8cm2 on [**2110-8-25**] echo
CAD
DM2
HTN
CKD
Hyperlipidemia
Left atrial appendage thrombus
Social History:
The patient is married, lives with wife has children. Retired
from working for Polaroid. Social history is significant for the
absence of current tobacco use, previous use x 50 years, quit 5
years ago. There is no history of alcohol abuse. There is no
family history of premature coronary artery disease or sudden
death.
Family History:
M: suicide. F: died at age 51, is unsure of what cause. No
family
history of premature coronary artery disease or sudden death.
Physical Exam:
T101.8 P 132 BP 108/55 RR 22 O2 100% on nonrebreather
General: Thin elderly man in mild respiratory distress. Able to
speak in short sentences
Neck: JVP 10cm. Carotid upstroke brisk bilaterally
Pulm: Lungs with slightly decreased breath sounds on R, +wheezes
without rales
CV: Regular rate S1 S2 II/VI SEM base
Abd: Soft +BS, +fluid wave, nontender
Extrem: Warm, well perfused with 1+ pitting edema. 2+ distal
pulses bilaterally.
Neuro: Alert and oriented
Lines: Has R PICC
Pertinent Results:
[**2110-9-23**] 11:46AM WBC-15.0*# RBC-3.17* HGB-10.5* HCT-33.0*
MCV-104* MCH-33.1* MCHC-31.8 RDW-17.3*
[**2110-9-23**] 11:46AM PLT SMR-NORMAL PLT COUNT-184
[**2110-9-23**] 11:46AM NEUTS-93* BANDS-3 LYMPHS-1* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2110-9-23**] 11:46AM PT-29.8* PTT-33.9 INR(PT)-3.1*
[**2110-9-23**] 11:46AM ALBUMIN-3.3* CALCIUM-9.3
[**2110-9-23**] 11:46AM proBNP-[**Numeric Identifier 71895**]*
[**2110-9-23**] 11:46AM ALT(SGPT)-90* AST(SGOT)-167* ALK PHOS-236*
AMYLASE-110* TOT BILI-2.4*
[**2110-9-23**] 11:46AM GLUCOSE-99 UREA N-52* CREAT-2.7* SODIUM-131*
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-24 ANION GAP-15
[**2110-9-23**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2110-9-23**] 12:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2110-9-23**] 12:45PM URINE RBC-0 WBC-[**3-31**] BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2110-9-23**] 06:42PM LACTATE-10.6*
.
CXR [**9-23**]
Right-sided pleural effusion, possibly slightly decreased in
size compared to the previous study. Patchy density at the right
lung base likely reflects atelectasis.
.
RUQ Ultrasound [**9-23**]
IMPRESSION: Moderate to large ascites with no ultrasound
evidence suggestive of acute cholecystitis. There is, however
re-demonstration of previously noted gallbladder sludge.
Moderate to large amount of ascites again noted. Doppler
waveform consistent with right heart failure.
.
EKG [**9-23**]
Sinus rhythm 94bpm. Upper limits of normal rate. P-R interval
prolongation. Marked left axis deviation. Low voltage
throughout. Borderline intraventricular conduction delay. Late R
wave progression. ST-T wave abnormalities. Since the previous
tracing of [**2110-8-27**] probably no significant change. Clinical
correlation is suggested.
.
Renal Ultrasound [**9-24**]
1. Limited. Right kidney not visualized. The left kidney appears
normal.
2. Abundant ascites.
.
MICROBIOLOGY
[**2110-9-23**] 9:14 pm BLOOD CULTURE Source: Line-PICC SET #2.
**FINAL REPORT [**2110-9-28**]**
AEROBIC BOTTLE (Final [**2110-9-27**]):
REPORTED BY PHONE TO FA6B [**Last Name (NamePattern4) 71896**] [**2110-9-24**] 930AM.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| |
STAPHYLOCOCCUS, COAGULASE N
| | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S 2 S
CEFTAZIDIME----------- <=1 S 4 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=0.5 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- <=0.12 S
MEROPENEM-------------<=0.25 S <=0.25 S
OXACILLIN------------- <=0.25 S
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC BOTTLE (Final [**2110-9-27**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
PSEUDOMONAS AERUGINOSA.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
AEROBIC BOTTLE (Final [**2110-9-27**]):
REPORTED BY PHONE TO FA6B [**Last Name (NamePattern4) 71896**] [**2110-9-24**] 930AM.
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
236-2195B
[**2110-9-23**].
PSEUDOMONAS AERUGINOSA.
SENSITIVITIES PERFORMED ON CULTURE # 236-2195B [**2110-9-23**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
ANAEROBIC BOTTLE (Final [**2110-9-27**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
236-2195B
[**2110-9-23**].
PSEUDOMONAS AERUGINOSA.
SENSITIVITIES PERFORMED ON CULTURE # 236-2195B [**2110-9-23**].
Brief Hospital Course:
1. Septic shock, likely secondary to spontaneous bacterial
peritonitis: The patient was transferred to the CCU for dyspnea,
initially thought to be due primarily to heart failure. He had
received intravenous furosemide in the emergency room as well as
empiric levofloxacin. The CCU team was concerned about the
presence of spontaneous bacterial peritonitis, therefore we
broadened his antibiotic coverage and planned to do a diagnostic
paracentesis. This was not performed immediately due to concern
for an elevated INR, as well as hemodynamic instability with
systolic blood pressures in the 80's. In addition, his urine
output was poor, so he was administered fluid boluses. He had a
limited renal ultrasound that did not visualize the left kidney
adequately, but showed no evidence of ureteral obstruction or
hydronephrosis on the right that wound account for his poor
urine output. It became clear that his poor urine output was
likely due to poor renal perfusion in the setting of sepsis. His
tachynea had been somewhat improved following admission to the
CCU, but was worsened by the next morning. Given his elevated
lactate, it is likely his tachypnea was at least in part a
compensatory response to his lactic acidosis. A discussion with
the patient and his family resulted in the decision not to place
him on mechanical ventilation. He was started on a morphine drip
and his status was changed to Care Measures Only. The patient
passed away on [**2110-9-24**]. The family declined an autopsy.
Medications on Admission:
Toprol Xl 25 mg PO daily
Allopurinol 100 mg PO daily
Calcitriol 0.25 mcg PO daily
Prilosec 20 mg PO daily
Lasix 80 mg IV daily
Ambien 5 mg PO QHS prn insomnia
Warfarin 5 mg PO daily
Insulin NPH 6 units QAM
Discharge Medications:
N/A, patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary
1. Septic shock, likely secondary to spontaneous bacterial
peritonitis
2. Congestive heart failure, diastolic, acute on chronic
3. Acute on chronic renal failure
Secondary
4. Amyloidosis in setting of multiple myeloma
5. Aortic stenosis, severe
Discharge Condition:
Deceased
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
|
[
"277.30",
"585.9",
"203.00",
"789.5",
"424.1",
"414.01",
"428.30",
"584.9",
"403.90",
"250.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10579, 10588
|
8774, 10277
|
321, 327
|
10884, 10894
|
3057, 8751
|
10957, 10974
|
2419, 2548
|
10533, 10556
|
10609, 10863
|
10303, 10510
|
10918, 10934
|
2563, 3038
|
274, 283
|
355, 1904
|
1926, 2065
|
2081, 2403
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,765
| 101,333
|
41797
|
Discharge summary
|
report
|
Admission Date: [**2137-10-11**] Discharge Date: [**2137-10-16**]
Date of Birth: [**2068-8-25**] Sex: F
Service: NEUROLOGY
Allergies:
Amoxicillin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
lower extremity weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 year-old female with history of AAA, HTN, HLD, ESRD on
dialysis, SLE, questionable dx Multiple Sclerosis 40 years ago
at [**Hospital1 112**] dx Dr [**First Name (STitle) 2617**], neuropathy, Neurogenic Bladder, chronic
fecal incontinence, ESRD on HD presented initially with left
chest pain and later was noted to have dense paraparesis in the
legs. Per further discussion with the patient, she had been
hypotensive on HD on [**10-10**] to 70s (her baseline hypitension) and
had problems moving her legs initially and then at 3pm on [**10-10**]
had not been able to move her legs. She has been bedbound
following a leg fracture and had been on warfarin DVT
prophylaxis stopped [**10-8**] due to problems with bruising and
epistaxis. On examination at [**Hospital1 18**] patent had a flaccid
paraparesis and only be able to just wiggle her toes
bilaterally, sensory level to T8 anteriorly to pain/temp and
T12/L1 posteriorly. Reflexes were absent in the legs and
proprioception was decreased to the ankle on left and the knee
on right. Patient had a SBP 70s in the ED but was mentating well
A+Ox3. Transferred to the neuro ICU for pressors. CTA abdomen
[**10-11**] revealed a stable large infrarenal AAA measuring 7.2 x 7.7
x 9.3 cm of which a large portion was thrombosed with no rupture
or signs of impending rupture. Vascular Surgery had consulted
regarding possible vascular cause for her weakness. Vascular
Surgery did not find evidence of aortic dissection or impending
aortic rupture. CTA legs showed extensive atherosclerotic plaque
throughout the LE vasculature and bilateral popliteal aneurysms
R>L. There was occlusion of the anterior tibial arteries at the
origin on the right and at the mid calf on the left. Patient
refused any surgical or endovascular intervention on her
infrarenal AAA.
MRI whole spine [**10-11**] revealed a completed anterior spinal
artery infarct extending from T9 to conus. Patient was started
on aspirin and was treated conservatively.
Past Medical History:
- ESRD on HD (hypertensive nephropathy)
- Hypertension
- AAA
- Hyperlipidemia
- Lupus
- Multiple Sclerosis
- Question of Atrial fibrillation
- History of Staph Bacteremia
- Anemia
- History of cellulitis
- Hypercalcemia
- spinal stenosis
- Hyperparathyroidism
- s/p Open appendectomy
- s/p CCY
- Tessio catheter placement
Social History:
Social Hx: She lives with her husband. She is retired. 1ppd
smoker x 30 years, quit 6-7 years ago. No ETOH or illicit drug
use.
Family History:
Family Hx: Father deceased from MI. Mother deceased from unknown
causes. Sister deceased from MI.
Physical Exam:
Physical Exam on Admission:
Vitals: P: 86 R: 16 BP: 83/52 SaO2: 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, Dopplerable pedal pulses
Skin: Skin breakdown over sacrum, medial aspect right thigh
erythematous
Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Able to relate history without difficulty. Attentive, able to
name [**Doctor Last Name 1841**] backward without difficulty. Able to follow both
midline
and appendicular commands. No right-left confusion. Able to
register 3 objects and recall [**11-26**] at 5 minutes ([**1-24**] with
prompting). No evidence of apraxia or neglect
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3mm and sluggishly reactive to light. VFF to
confrontation. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: 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 protrudes in midline.
Motor: Normal bulk. LLE flacid. Tone difficult to assess RLE
given history fracture. No pronator drift bilaterally, though
she
has difficulty maintaing left arm in this position (she
attributes this to a left arm prosthesis). No adventitious
movements, such as tremor, noted. No asterixis noted. Right leg
externally rotated. Decreased rectal tone.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4 5 4+ 5- 5 4 0 0 0 0 0
R 4- 5 4 5- 5 4- 0 0 0 0 0
There is trace wiggling of toes on left foot only.
Sensory: Absent light touch and pinprick to feet and diminished
up to ankles. Intact perianal pinprick sensation. No sensory
level. Proprioception intact to large amplitude movements at
left
great toe, absent at right. Vibration absent entire RLE, up to
knee LLE. Distal cold temp. loss b/l.
DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 0 1 0 0
R 1 0 1 0 0
Plantar response was mute bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF. RAMs intact.
Gait: deferred given LE plegia.
Physical Exam on Discharge:
Vitals: T 97.6 BP 125/75 HR 96 RR 20 O2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTAB
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, 1+ LE edema
Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Able to relate history without difficulty. Speech fluent without
dysarthria. Attentive, able to follow both midline and
appendicular commands. No right-left confusion. No evidence of
apraxia or neglect.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: 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 protrudes in midline.
Motor: No pronator drift. No adventitious movements, such as
tremor, noted. No asterixis noted. Right leg externally rotated.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4+ 5 4+ 4+ 5 4 0 0 0 0 2
R 4 5 4 4+ 5 4 0 0 0 0 1
Able to wiggle toes b/l and move ankles slightly L>R.
Sensory: Diminished light touch and pinprick below knees b/l.
Proprioception decreased at b/l great toes, intact at ankles.
Sensory level to T8 anteriorly and T12/L1 posteriorly.
DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 0 1 0 0
R 1 0 1 0 0
Plantar response was mute bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF. RAMs intact.
Gait: deferred given LE plegia.
Pertinent Results:
[**2137-10-11**] 09:10AM %HbA1c-4.9 eAG-94
[**2137-10-11**] 12:44AM GLUCOSE-93 NA+-141 K+-4.4
[**2137-10-11**] 12:30AM GLUCOSE-97 UREA N-25* CREAT-2.9* SODIUM-142
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-26 ANION GAP-24*
[**2137-10-11**] 12:30AM estGFR-Using this
[**2137-10-11**] 12:30AM ALT(SGPT)-32 AST(SGOT)-40 CK(CPK)-125
[**2137-10-11**] 12:30AM CK-MB-6 cTropnT-0.21*
[**2137-10-11**] 12:30AM CALCIUM-9.4 PHOSPHATE-5.2* MAGNESIUM-2.0
CHOLEST-170
[**2137-10-11**] 12:30AM VIT B12-850
[**2137-10-11**] 12:30AM TRIGLYCER-167* HDL CHOL-68 CHOL/HDL-2.5
LDL(CALC)-69
[**2137-10-11**] 12:30AM TSH-1.3
[**2137-10-11**] 12:30AM WBC-8.3 RBC-3.36* HGB-11.1* HCT-35.9*
MCV-107* MCH-33.0* MCHC-31.0 RDW-16.5*
[**2137-10-11**] 12:30AM NEUTS-70.4* LYMPHS-17.9* MONOS-6.5 EOS-4.3*
BASOS-0.9
[**2137-10-11**] 12:30AM PLT COUNT-160
[**2137-10-11**] 12:30AM PT-15.3* PTT-24.0 INR(PT)-1.3*
CTA chest/abd/pelvis:
IMPRESSION:
1. 9.3 cm infrarenal abdominal aortic aneurysm extending into
the bilateral common iliac arteries without evidence of rupture
or acute dissection.
2. Densely calcified vasculature throughout the chest, abdomen,
and pelvis
with significant narrowing of aortic branch vessels and
occlusion or near
occlusion of the bilateral renal arteries and [**Female First Name (un) 899**]. Please note
that the spinal arteries are not evaluated with this technique.
3. Symmetric opacification of the external iliac and common
femoral arteries without evidence of occlusion. (please refer to
separate dictation of lower extremity runoff completed on same
date for lower extremity vasculature).
4. Compression deformity of the T4 and T12 vertebral body with
~50% loss of vertebral body height. No malalignment of the
thoracolumbar spine.
MR C/T/L spine:
IMPRESSION:
1. Mild lower thoracic cord swelling with central [**Doctor Last Name 352**] matter
hyperintensity extending from T9 to the conus, imaging findings
are typical of spinal cord infarction.
2. Scoliotic deformity of the thoracic spine with multilevel
degenerative
changes as described above.
3. Known abdominal aortic aneurysm is partially imaged, better
evaluated on prior abdominal CT scans.
Brief Hospital Course:
69 year-old female with history of AAA, HTN, HLD, ESRD on
dialysis, SLE, questionable dx Multiple Sclerosis 40 years ago
at [**Hospital1 112**] dx by Dr [**First Name (STitle) 2617**], neuropathy, Neurogenic Bladder, chrnic
fecal incontinence, ESRD on HD presented initially with left
chest pain and later was noted to have dense paraparesis in teh
legs. Per further discussion with the patient, she had been
hypotensive on HD on [**10-10**] to 70s (has baseline hypotension) and
had problems moving her legs initially and then at 3pm on [**10-10**]
had not been able to move her legs. She has been bedbound
following a leg fracture. She had been on warfarin DVT
prophylaxis that was stopped [**10-8**] due to problems with bruising
and epistaxis. On examination at [**Hospital1 18**] patent had a flaccid
paraparesis and only able to just wiggle her toes bilaterally,
sensory level to T8 anteriorly to pain/temp and T12/L1
posteriorly. Reflexes were absent in the legs and proprioception
was decreased to the ankle on left and the knee on right.
Patient had a SBP 70s in the ED but was mentating well A+Ox3.
CTA abdomen [**10-11**] revealed a stable large infrarenal AAA
measuring 7.2 x 7.7 x 9.3 cm of which a large portion was
thrombosed with no rupture or signs of impending rupture.
Vascular Surgery had consulted regarding possible vascular cause
for her weakness. Vascular Surgery did not find evidence of
aortic dissection or impending aortic rupture. CTA legs showed
extensive atherosclerotic plaque throughout the LE vasculature
and bilateral popliteal aneurysms R>L. There was occlusion of
the anterior tibial arteries at the origin on the right and at
the mid calf on the left. Patient refused any surgical or
endovascular intervention on her infrarenal AAA. MRI whole spine
[**10-11**] revealed a likely compeleted anterior spinal artery
infarct extending from T9 to conus.
Transferred to the neuro ICU for pressors. Patient was started
on aspirin 325mg daily and was treated conservatively. PT/OT
evaluated. On discusion, it was felt that no further imaging was
needed. Renal were consulted and patient was continued on HD.
On exam on [**10-12**], she improved slightly with increased strength
in her toes bilaterally. On [**10-14**] she had mild improvment in
toes and trace movement in quads on left. Her SBP was stable in
the 100- 130's while off pressors. She was transferred to the
floor on [**10-14**].
Her weakness continued to gradually improve during her
admission. On [**10-15**] she had a transient episode of chest
pressure/SOB - EKG and CM's were negative, CXR unchanged. She
had HD later that day and felt that her symptoms improved. Her
blood pressure remained stable from 100's - 130's. Her home
antihypertensives were held throughout her admission. These will
need to be restarted gradually once her blood pressure begins to
rise about 140. **Goal SBP is 100-140.**
Dermatology was consulted regarding acute on chronic itch and
skin changes in
her hands, arms and back. Given a close contact with scabies,
she had already undergone permethrin cream rx. Dermatology
recommended TAC ointment and Sarna lotion topical therapy. She
also received another permethrin cream whole body skin
application prior to discharge.
She was seen by PT/OT who recommended rehab placement upon
discharge.
TRANSITIONAL CARE ISSUES:
Patient will need close blood pressure monitoring. All of her
home BP medications (Toprol XL 100mg Daily, Lisinopril 10mg PO
Daily, Imdur 30mg QHS, Norvasc 10mg Daily) have been held during
her hospitalization. Her goal SBP is 100-140. Her
antihypertensives may be gradually restarted if her BP begins to
rise above 140. Caution must be taken during dialysis to avoid
hypotension.
Patient will need intensive PT/OT for her severe lower extremity
weakness.
Medications on Admission:
-Imodium 2mg
-Toprol XL 100mg Daily
-Plaquenil 200mg Daily
-Lisinopril 10mg PO Daily
-Zoloft 100mg Daily
-Imdur 30mg QHS
-Oxycodone 10mg prn
-Norvasc 10mg Daily
-PhosLo 3caps Daily
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for pain.
7. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Apply to inguinal folds.
11. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed for puritus.
12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
14. clobetasol 0.05 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): apply to scalp.
15. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): Apply to pruritic areas of back,
arms, abdomen, and flanks. Please Avoid use on face, axilla,
skin folds, or groin.
16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Spinal cord infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 1968**],
You were admitted to [**Hospital1 69**] on
[**2137-10-11**] for weakness in your legs. You were found to
have a blood clot in your spinal cord which is likely causing
your weakness. This may have been related to an episode of low
blood pressure during dialysis. Your weakness has improved
somewhat during your admission but you will need intensive
rehabilitation in order to regain your strength. You should
continue with your previous schedule of dialysis with close
attention to your blood pressure to avoid it dropping too low
again.
We made the following changes to your medications:
STARTED Aspirin 325mg daily
STOPPED Toprol XL 100mg Daily, Lisinopril 10mg PO Daily, Imdur
30mg QHS, Norvasc 10mg Daily. These should be restarted
gradually with close attention to your blood pressure.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
The following appointment has been made for you in our stroke
clinic:
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2137-11-15**] 3:30
You should also make an appointment to see your primary care
doctor within 1-2 weeks.
|
[
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"441.4",
"133.0",
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"707.22",
"403.91",
"710.0",
"427.31",
"585.6",
"440.20",
"707.03",
"110.3",
"336.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15215, 15262
|
9556, 12879
|
308, 314
|
15326, 15326
|
7349, 9533
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|
2827, 2926
|
13595, 15192
|
15283, 15305
|
13389, 13572
|
15502, 16098
|
2941, 2955
|
5538, 5891
|
16127, 16519
|
244, 270
|
12905, 13363
|
342, 2319
|
6178, 7330
|
2970, 3406
|
15341, 15478
|
2341, 2664
|
2680, 2811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,713
| 159,667
|
6233
|
Discharge summary
|
report
|
Admission Date: [**2191-7-22**] Discharge Date: [**2191-7-28**]
Date of Birth: [**2121-3-21**] Sex: M
Service: [**Location (un) **]
CHIEF COMPLAINT: Triple air leaking and chronic obstructive
pulmonary disease flare.
HISTORY OF THE PRESENT ILLNESS: This is a 70-year-old
Caucasian male with history of severe chronic obstructive
pulmonary disease, obstructive sleep apnea on BiPAP, coronary
artery disease status post myocardial infarction times two,
atrial fibrillation, peripheral vascular disease, history of
triple air repair. The patient presented on transfer to the
Medicine Service twenty-four hour after transfer to the MICU
for respiratory distress. The patient originally presented
on [**2191-7-15**] to the [**Hospital3 417**] Hospital with abdominal
pain and fever. At that time, KUB showed probable ileus. CT
of the abdomen was negative. Over the next few days, the
etiology of the abdominal pain remained unclear despite
Gastrointestinal, Urology, Infectious Disease and Cardiology
consults. On [**2191-7-22**], he was transferred to [**Hospital1 346**] for question for leaky thoracic
aortic dissection. At the outside hospital he had been
started on Levaquin for abdominal source and Vancomycin for
MRSA-positive blood cultures and pneumonia.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease.
3. Benign prostatic hypertrophy.
4. Sleep apnea.
5. Paroxysmal atrial fibrillation.
6. Compression fracture.
7. Hypertension.
8. Right hip fracture status post open reduction and
internal fixation.
9. ? seizure disorder.
10. Hypercholesterolemia.
11. History of pneumonia.
12. Osteoarthritis.
13. Gastroesophageal reflux disease.
FAMILY HISTORY: History was notable for coronary artery
disease and TB.
SOCIAL HISTORY: The patient quit tobacco 17 years ago, but
has a 40 pack history. The patient denies alcohol use.
ALLERGIES: The patient is allergic to PENICILLIN, VIOXX, AND
TYLENOL.
[**Hospital1 69**] course was notable for
admission to Vascular Surgery Service, where he underwent CT
of the chest on [**2191-7-22**], which showed evidence for
diaphragm level, descending thoracic aorta aneurysm with
penetrating ulcer versus mycotic aneurysm, without hematoma
or bleeding. Vascular procedure was planned for possibly the
next week. In the SICU the patient had ? seizure and he was
evaluated by the Department of Neurology. At that time he
was not given any treatment. Breathing became increasingly
labored over the next few days and he was transferred to the
MICU for chronic obstructive pulmonary disease and
respiratory distress management.
The MICU course involved activation of nebulized Albuterol
and Atrovent steroids for chronic obstructive pulmonary
disease flare, and continuation of Levofloxacin and
Vancomycin for tracheobronchitis. Per the Department of
Vascular Surgery, blood pressure control was goal to be less
than 140 systolic and he was started on Diltiazem,
Hydrochlorothiazide, and Captopril to prevent the aortic
ulceration. The patient was thought to have acute
respiratory alkalosis or chronic respiratory acidosis by the
MICU team. The patient tolerated BiPAP in the NICU with pH
of 7.53, pCO2 51 and pO2 of 62 on face-mask oxygen.
On [**2191-7-25**], the patient was finally transferred to [**Location (un) 2655**]
Service for further management.
PHYSICAL EXAMINATION: Physical examination on transfer:
Temperature 98.3, pulse 96, blood pressure 122/50, saturating
on 98% on two liters, respiratory rate 25. GENERAL: This is
a chronically ill-appearing male in no acute distress; O2
versus nasal cannula. HEENT: Sclera was clear, anicteric.
Pupils equal, round, with minimal reaction. Extraocular
movements are intact. Mucous membranes moist. NECK: There
was right double lumen catheter placed in the right IJ,
unable to assess JVD at that time. CARDIOVASCULAR: Distinct
heart sounds, regular in rhythm, no murmurs. LUNGS: Air
movement was fair with end-expiratory wheezes, diffusely.
ABDOMEN: Soft, nontender, nondistended, positive bowel
sounds, hypoactive. No masses. EXTREMITIES: Positive
Pneumoboots in place. No appreciable edema. Scattered upper
extremity ecchymosis, positive Foley. NEUROLOGICAL: 5/5
strength bilaterally. The patient was alert and oriented
times three.
LABORATORY DATA: Labs on admission revealed the following:
White count 9.2, down from 40.3, hematocrit 28.2, down from
31.7, platelet count 362,000. PT 12.8, INR 1.1, PTT 26.8.
Urinalysis from [**2191-7-23**] was negative. Chem 7: Sodium 134,
potassium 3.8, chloride 89, bicarbonate 38, BUN 23,
creatinine 0.5, blood sugar 136. CKs were less than 100
times three; troponin 1.5 on [**2191-7-22**]. Potassium was 8.9,
magnesium 1.7, phosphate 3.3, albumin 2.8. ABG on [**2191-7-25**]
at 4:50 AM was pH 7.47, pCO2 57, pO2 165 on four liters
oxygen. Chest x-ray on [**7-25**]/200 showed chronic obstructive
pulmonary disease with linear atelectasis, scarring in the
left upper lobe, no pneumothorax, no congestive heart
failure. Blood cultures from [**2191-7-24**] showed no growth to
date. Urine cultures on [**2191-7-23**] showed no growth to date.
Blood cultures from [**2189-7-15**] had 1 out of 1 bottle notable
for Oxacillin-resistant Staphylococcus aureus. Sputum from
[**2191-7-17**] had moderate Oxacillin-resistant Staphylococcus
aureus with 0 to 5 polys on high power field.
HOSPITAL COURSE:
#1. CARDIOVASCULAR: The patient had history of coronary
artery disease and myocardial infarction. He was continued
on Captopril, but no beta blockade or aspirin secondary to
his triple A. Aspirin and Coumadin were discussed with the
Vascular Surgery Service.
#2. HYPERTENSION: Mr. [**Known lastname 22627**] had history of severe
hypertension, but he has been under good control with
Captopril 50 mg PO t.i.d.; Hydrochlorothiazide; and
Diltiazem. In the last few days, medications have been
titrated up to keep the systolic blood pressure below 140 per
Vascular Surgery. The Department of Vascular Surgery
continued to follow the patient during his stay and
recommended no further treatment at this time.
The patient may undergo aortic repair after the resolution of
medical problems and recommended no further imaging. The
patient will follow with Dr. [**Last Name (STitle) **] after discharge.
#3. PULMONARY: Mr. [**Known lastname 22627**] had severe chronic obstructive
pulmonary disease exacerbation secondary to baseline severe
disease. He was continued on Albuterol and Atrovent nebs and
MDI. He was also continued on Prednisone with slow taper and
....................cast. The patient's oxygen requirement
decreased to two liters, which is his home requirement. He
tolerates BiPAP well at night for approximately four hour to
six hours. In the intervening days, the patient's
respiratory examination improved slightly. He is continued
on antibiotics, Vancomycin one gram q.12 hours for complete
ten-day course for MRSA pneumonia and chronic obstructive
pulmonary disease exacerbation.
#4. HEMATOLOGY: Mr. [**Known lastname 22627**] had baseline chronic anemia.
Hematocrit was notable to be at low 28.2 on [**2191-7-25**]. The
hematocrits since that time have been improved with the
hematocrit on [**2191-7-27**] being 33. Iron studies were done
with the iron of 143, TIBC 183, ferritin greater than 100,
and TRF 141. The patient was thought not to be iron
deficient at this time. The patient has had workup for
anemia over the past six months, which was unrevealing. All
stools were guaiac tested.
#5. RENAL: Mr. [**Known lastname 22627**] had stable renal function and
required occasional repletion of potassium and magnesium.
#6. GASTROINTESTINAL: Mr. [**Known lastname 22627**] was NPO for several days,
but then tolerated clears. Diet was slowly advanced to a
regular diet and the patient was able to tolerate macaroni
and cheese on [**2191-7-26**]. Protonix was given as prophylaxis.
#7. NEUROLOGICAL: Mr. [**Known lastname 22627**] had new seizure without prior
seizure history. Per the Neurological Department the patient
will need head CT and EEG for further evaluation. No further
medications are indicated at this time. He will need further
followup with the Department of Neurology after discharge.
Mr. [**Known lastname 22627**] was on Pneumoboots, but was changed to
subcutaneous Heparin.
DISPOSITION: Mr. [**Known lastname 22627**] is DNR/DNI. He has been seeing the
Department of Physical Therapy and he has been recommended
for [**Hospital 3058**] rehabilitation.
DISCHARGE DIAGNOSES:
1. Leaking triple A.
2. Severe chronic obstructive pulmonary disease.
3. Obstructive sleep apnea on BiPAP.
4. Coronary artery disease.
5. Triple A repair.
6. Right hip surgery.
7. Hypertension.
8. Gastroesophageal reflux disease.
9. Arthritis.
CONDITION ON DISCHARGE: Fair.
The patient was discharged to rehabilitation at this time.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 7853**] 12-869
Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36
D: [**2191-7-27**] 10:33
T: [**2191-7-27**] 10:41
JOB#: [**Job Number 24272**]
|
[
"412",
"482.41",
"491.21",
"780.57",
"276.3",
"427.31",
"441.01",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1740, 1797
|
8611, 8865
|
5454, 8590
|
3410, 5436
|
171, 1291
|
1313, 1723
|
1814, 3387
|
8890, 9183
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,638
| 133,678
|
15380
|
Discharge summary
|
report
|
Admission Date: [**2179-9-16**] Discharge Date: [**2179-9-22**]
Date of Birth: [**2108-5-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Hypovolemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 year old F with PMH significant for advanced ischemic
cardiomyopathy EF 15%, atrial fibrillation with ICD and CKD who
presented to [**Hospital **] hospital [**2179-9-14**] for generalized weakness.
Patient reports gaining fluid (notably abdomen and lower
extremity) since early [**Month (only) 462**] and consequently toresmide was
increased and metolazone started. Per OMR notes patient's
creatinine increased to 4.7, had 15 pound weight loss (177 from
dry weight 190lb), lower blood pressures and was consequently
referred to [**Hospital **] Hospital. Due to weight loss all diuretics
were on hold since [**2179-9-7**]. Patient reports 1 month history of
increasing fatigue, weakness and shortness of breath. Denies
increase in orthopnea, PND. Denies syncope, pre-syncope or
dizziness. Denies chest pain. Denies fever, chills, cough or
increase in urination.
.
Patient's presenting vitals to [**Hospital **] Hospital were temperature
97.1, HR 70, RR 20, blood pressure 78/56. Labs notable for
creatinine of 4.7, Hematocrit 26.1, CBC 2.5, plt 60,000, INR
2.6. She was given 3 units pRBC and 2.5+ L of fluid. Cardiology
was consulted. Patient did not require pressor support. Heme was
consulted for pancytopenia felt to be secondary to hypersplenism
(demonstrated on ultrasound, new since 5/[**2177**]). Patient was
transferred to [**Hospital1 18**] CCU for further care.
.
On review of systems, she denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative
Past Medical History:
1. ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD
2. Coronary artery disease status post PTCA and stenting of the
LAD in [**2164**].
3. h/o PE secondary to DVT s/p IVC filter
4. Atrial fibrillation status post cardioversion and
biventricular pacemaker implantation.
5. HTN
6. Obesity
7. PVD
8. small VSD
9. hypothyroidism
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: + Dyslipidemia
2. CARDIAC HISTORY:
-Ischemic cardiomyopathy EF %15-20 s/p biv ICD
-CAD s/p post PTCA and stenting of the LAD in [**2164**].
-CABG: None
-PACING/ICD: atrial fibrillation on anticoagulation and ICD
biventricular pacemaker
3. OTHER PAST MEDICAL HISTORY:
chronic kidney disease
bilateral DVT s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter
pulmonary embolism
osteoarthritis
hyperkalemia
Social History:
Pt lives alone. She is not married. She reports a 20 pack year
history, however she quit 30 yrs ago. Denies EtOH or illicit
drug use.
Family History:
Mother had MI at age 50. Father in good health. Maternal uncle
died of MI in his 50's.
Physical Exam:
Gen: alert, talkative, NAD
HEENT: supple, no LAd, Pos JVD at 12 cm
CV: RRR, 2/6 systolic murmur at apex
RESP: CTAB, no crackles or wheezes
ABD: distended, soft, pos fluid wave, umbilical hernia,
EXTR: 1+ edema bilat. right > L
NEURO: alert, oriented,
Extremeties: Groin
Pulses:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Skin: intact
Access: PIV
Tubes: Foley d/c'ed.
Pertinent Results:
[**2179-9-22**] 06:50AM BLOOD WBC-3.8* RBC-3.30* Hgb-10.8* Hct-31.7*
MCV-96 MCH-32.7* MCHC-34.0 RDW-17.1* Plt Ct-95*
[**2179-9-16**] 10:40PM BLOOD Neuts-86.4* Lymphs-8.9* Monos-3.3 Eos-1.0
Baso-0.4
[**2179-9-22**] 06:50AM BLOOD Plt Ct-95*
[**2179-9-22**] 06:50AM BLOOD Glucose-91 UreaN-83* Creat-2.3* Na-135
K-4.5 Cl-99 HCO3-27 AnGap-14
.
CXR [**9-17**]:
AP chest compared to [**2175-9-20**]:
Severe cardiomegaly has progressed. Lungs are clear. Pulmonary
and
mediastinal vasculature are unremarkable and there is no pleural
effusion.
Transvenous right atrial and left ventricular pacer leads and
right
ventricular pacer defibrillator lead are unchanged in their
respective
positions. No pneumothorax.
.
Right Leg Ultrasound: [**2179-9-17**]
Grayscale color and Doppler son[**Name (NI) 1417**] of the right common
femoral,
superficial femoral, popliteal, and tibial veins were performed.
There is
normal flow, compression and augmentation seen in all of the
vessels.
IMPRESSION: No evidence of deep vein thrombosis in the right
leg.
.
Abdominal Ultrasound: [**2179-9-17**]
IMPRESSION:
1. Mild splenomegaly.
2. No thrombus identified within the IVC.
3. Large amount of ascites.
Brief Hospital Course:
70 year old female with severe biventricular failure with
profoundly reduced left ventricular ejection fraction of 15%,
moderate mitral regurgitation and tricuspid regurgitation with
moderate pulmonary hypertension presented to outside hospital
for fatigue and hypotension. Transferred to [**Hospital1 18**] for further
treatment of her renal failure and heart failure.
.
# PUMP: Patient with known ischemic cardiomyopathy EF 15%. New
splenomegaly concerning for worsening of EF. On admission, pt
was 7 lbs below her dry weight (190) and with poor renal
function therefore there was some concern for over-diuresis.
Gentle IVF was given and pt was allow to re-equilibrate. She
appeared to be perfusing well and did not require ionotropic
support. Her renal function improved over the course of her
stay, as did her edema with PO intake and holding her diuretics.
She was continued on her home cardiac meds including lisinopril
(decreased to 2.5/day), carvedilol and ASA. She will be
discharged on 20 mg toresemide daily for diuresis. Her Fluid
status will need to be monitored very closely as she is quite
fragile. Daily weights will need to be monitored and as her
wieght increases, she will need to have more diuretics added on.
Please contact [**Name (NI) **] [**Last Name (NamePattern1) **] NP, her heart failure NP for
further management at [**Telephone/Fax (1) 62**].
.
# RHYTHM: Mrs [**Known lastname **] is AV paced with right bundle branch
block with underlying A Fib. She was treated with coumadin,
amiodarone and carvedilol. Her coumadin was decreased on
discharge for elevated INR, and she will follow up for repeat
INR and warfarin adjustment. She was seen by EP for evaluation
of her pacer settings, however adjustments were deferred to the
outpatient setting as changes need to be done under echo,
therefore she has an appointment scheduled this month for
adjustment of pacer settings.
.
# CORONARIES: One vessel coronary artery disease with patent
prior LAD stent. Last cath [**2171**]. No chest pain during this
admission. ASA, carvedilol and statin were continued.
.
# Acute on chronic renal failure: Her baseline creatinine is
1.3-2, during this visit creatinine peaked at 3.2 and was
thought to be pre-renal in the setting of over-diuresis. Her
renal function improved with diuretics and encouraging PO
intake.
.
# Pancytopenia: Heme consulted at OSH - felt to be secondary to
splenomegaly secondary to CHF. Platelets were stable during
this admission. Would recommend following as an outpatient with
hematology.
.
# Asymmetric lower extremity swelling: Right > Left. LENI OSH
negative. Patient reports no recent instrumentation. This was
felt to be a chronic issue related to positioning as it is no
worse than baseline and the patient tends to lie primarily on
her right side.
.
# Hypothyroid: Her levothyroxine was continued at outpatient
doses.
.
# LE muscle spasm
Not a [**Last Name **] problem, pt states started about mid [**Month (only) **].
Interfering with activity, not able to walk now and is assist of
two to chair. Unclear how much hospitalization and
deconditioning are contributing. No improvement with hydration.
Electolytes WNL. Pt was started on Ca and will follow-up as an
outpatient. Dr. [**Last Name (STitle) **], a neurologist from [**Location (un) **] has been
contact[**Name (NI) **] to see the pt as soon as possible, her sister, will
help with setting this appt up in a timely manner.
Medications on Admission:
- omeprazole 20 mg po qd
- simvastatin 20mg po qd
- amiodarone 200 mg qd
- carvedilol 25 mg po [**12-18**] tab in am and 1 tab pm
- Levoxyl 112 mg po qd
- recently stopped coumadin, allopurinol, colchecine,
lisinopril, Metolazone 2.5mg twice a week, torsemide 40 mg [**Hospital1 **],
digoxin
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Pt's home dose is 4mg daily. Please check INR on [**9-24**].
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
this will need to be uptitrated as weight increases over dry
weight. .
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 1439**]
Discharge Diagnosis:
Acute on Chronic systolic Congestive Heart Failure
Atrial fibrillation
Acute on chronic Kidney Disease
Pancytopenia
Hx of Bilateral DVT s/p filter
Discharge Condition:
stable
weight= 85.4kg. This is pt's dry weight.
BP= 80's-90's/50's. This is pts baseline
HR= 70's.
O2 sat on RA= 97%
Discharge Instructions:
You had too much fluid taken off and your kidneys did not
function well. We stopped all of your diuretics and gave you
some intravenous fluid. Your kidney function is now better and
we will restart the Torsemide at a very low dose. You will need
to be followed closely over the next few weeks because you will
need to have more of your medicines restarted. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is
the CHF NP who follows you on a regular basis. She can be
reached with any questions at [**Telephone/Fax (1) 62**].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Follow a low sodium (2000mg) diet
Do not drink more than 6 cups of fluid per day or about 1.5
liters.
We have set up an outpatient appt to see a neurologist about
your muscle spasms.
.
Medication changes:
1. Decrease your Torsemide to 20 mg daily
2. Decrease your Lisinopril to 2.5 mg daily
3. Decrease Warfarin to 2mg daily until your INR is < 3.0, then
increase to 4mg daily.
4. Do not take Colchicine or Allopurinol unless your gout comes
back (you were not taking this at home)
5. START taking Calcium and Vitamin D to prevent osteoporosis.
Followup Instructions:
Primary Care:
[**Last Name (LF) 44661**],[**First Name3 (LF) 25**] M. Phone: [**Telephone/Fax (1) 44659**] Date/time: Please call for
an appt after you get out of rehabilitation.
Cardiology:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-9-29**]
10:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-10-6**]
10:00
.
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2179-10-6**] 10:30
Neurology:
Dr. [**Last Name (STitle) **] Phone: [**Telephone/Fax (1) 44662**] Date/Time: Office will call with
an appt.
Completed by:[**2179-9-22**]
|
[
"V45.02",
"584.9",
"414.8",
"789.2",
"V58.61",
"424.0",
"278.00",
"745.4",
"V12.51",
"397.0",
"715.90",
"728.85",
"284.1",
"427.31",
"244.9",
"403.90",
"443.9",
"V45.82",
"428.0",
"416.8",
"428.23",
"585.9",
"426.4",
"414.01",
"729.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9755, 9829
|
4724, 8167
|
327, 334
|
10020, 10139
|
3519, 4701
|
11378, 12108
|
3033, 3121
|
8510, 9732
|
9850, 9999
|
8193, 8487
|
10163, 10994
|
3136, 3500
|
2475, 2676
|
11014, 11355
|
276, 289
|
362, 2048
|
2707, 2865
|
2415, 2455
|
2881, 3017
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,019
| 137,087
|
7230
|
Discharge summary
|
report
|
Admission Date: [**2106-12-24**] Discharge Date: [**2106-12-28**]
Date of Birth: [**2042-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
[**2107-1-3**] Aortic valve replacement ([**First Name8 (NamePattern2) 11688**] [**Male First Name (un) 923**] Epic Porcine)
History of Present Illness:
64-year-old male with severe AS by
ECHO, mild-moderate MR, hyperlipidemia, diabetes, 1-vessel CAD
s/p PCI in [**2103**] with stenting of distal RCA with two Cypher DES,
stenting of mid RCA with DES, who had syncope today while
shoveling snow. He also had associated bilateral arm discomfort,
lightheadedness, nauseated, and vomiting. He passed out while
walking up the steps and hit his nose in the process and was a
little difficult to arouse. He went to [**Hospital3 **] and was
admitted for a syncope evaluation. He is being followed for
aortic stenosis for the past several years with ECHO with [**Location (un) 109**] of
0.6 cm2 in [**2103**]. In the past 4-5 months, he endorses feeling
"winded" climbing one flight of [**Year (4 digits) 5927**], which is new for him.
Patient was also noted to develop temperature of 102-103 with
leukocytosis. At OSH with EKG taken for what appeared to be
questionable seizure vs. rigors vs. hypoglycemia. EKG showed
some
ST downsloping and segments and depressions with question of
rate-related versus ischemic. He also had headache, nausea, and
some vomiting. CXR was "clear." He developed some chest pain
requiring nitroglycerin with good effect. He also developed
hypoxemia requiring supplemental O2. CXR subsequently showed
pneumonia, which had appeared since admission CXR. He was moved
to the ICU until his transfer to [**Hospital1 18**]. He also had elevated
troponins with initial set 0.06 with rise to 0.28. He was
diagnosed with aspiration pneumonitis. Treated and it was
determined that his lungs should get time to completely clear as
well as undergoing a plavix washout. Discharged [**12-16**]. Referred
for surgery.
Past Medical History:
Iron deficiency anemia (recent Hct around 30) with EGD in [**11-26**]
showing moderate gastritis. Last colonoscopy in [**2103**] with only
hemorrhoids.
s/p excision for squamous cell carcionoma on face, right
antecubital fossa, right arm and head
Diabetes (A1c in [**3-27**] of 6.9 %).
Plantar fascitis
aspiration pneumonitis
Prior heavy ETOH, quit 38 years ago
Aortic stenosis s/p AVR
CAD- s/p PTCA and DES of distal RCA [**2103**]
NSTEMI [**11-26**]
Past Surgical History:
Hernia repair
Ankle surgery
Thumb surgery for dislocation
Social History:
(-) CIGS: quit 25 years ago
-ETOH: Prior heavy ETOH, quit 38 years ago
-Illicit drugs: none
Married, retired firefighter.
Family History:
Strong family history of MI (uncle died at age 58 from MI, dad
died at age 64 from CHF/MI).
Physical Exam:
Pulse:84 Resp:24 O2 sat:98/Ra
B/P Right:128/65 Left:133/68
Height:5'[**05**]" Weight:184 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] MMM, normal oropharynx
Neck: Supple [x] Full ROM [x], no [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft[x] non-distended[x] non-tender[x] +BS[x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, MAE-follows commands, non focal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: - Left: 2+
Carotid Bruit : no
Pertinent Results:
[**2106-12-28**] 04:30AM BLOOD WBC-9.9 RBC-3.38* Hgb-10.3* Hct-29.4*
MCV-87 MCH-30.5 MCHC-35.0 RDW-14.3 Plt Ct-385
[**2106-12-28**] 04:30AM BLOOD UreaN-30* Creat-0.9 Na-136 K-4.8 Cl-99
[**2106-12-28**] 04:30AM BLOOD Mg-2.0
Conclusions
PRE BYPASS The left atrium is markedly dilated. Mild spontaneous
echo contrast is seen in the body of the left atrium and left
atrial appendage. No mass/thrombus is seen in the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. 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
are complex (>4mm) atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is moderate to
severe aortic valve stenosis (valve area 1.1 cm2). Moderate (2+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are moderately thickened. Due to
co-existing aortic regurgitation, the pressure half-time
estimate of mitral valve area may be an OVERestimation of true
mitral valve area. Mild (1+) mitral regurgitation is seen. Dr.
[**Last Name (STitle) **] was notified in person of the results in the operating
room at the time of the study.
POST BYPASS The patient is being atrially paced. There is normal
biventricular systolic function. There is a bioprosthesis in the
aortic position. It appears well seated. The leaflets cannot be
seen. No aortic regurgitation is seen. The maximum gradient
through the valve was 27 mmHg with a mean of 16 mmHg at a
cardiac output of about 5.5 liters/minute. The effective orifice
area of the valve was about 1.8 cm2. The mitral regurgitation is
now trivial. The thoracic aorta is intact after decannulation.
No other significant changes from the pre-bypass exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2106-12-24**] 18:51
Brief Hospital Course:
Admitted [**12-24**] and underwent AVR with Dr. [**Last Name (STitle) **]. Transferred to
the CVICU in stable condition on titrated phenylephrine and
propofol drips. Extubated the next morning and remained in the
ICU for BP mgmt. Transferred to the floor on POD #2 to begin
increasing his activity level. Chest tubes and pacing wires
removed per protocol. Gently diuresed toward his preop weight.
COntinued to make good progress and was cleared for discharge to
home with VNA on POD #4. All f/u appts were advised.
Medications on Admission:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: constipation.
Disp:*60 Capsule(s)* Refills:*2*
8. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day:
constipation.
Disp:*60 Capsule(s)* Refills:*2*
9. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day: with meals.
Disp:*90 Tablet(s)* Refills:*2*
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 4 weeks.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
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 once a
day.
Disp:*30 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg twice a day until [**1-2**] then decrease to 400 mg
once a day until [**1-9**] then decrease to 200 mg daily until follow
up with cardiologist .
Disp:*55 Tablet(s)* Refills:*0*
6. metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
9. rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day): 75 mg three times a day .
Disp:*270 Tablet(s)* Refills:*0*
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
13. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Iron deficiency anemia
Diabetes Mellitus type 2
Coronary artery disease s/p PTCA and DES of distal RCA [**2103**]
NSTEMI [**11-26**]
squamous cell CA
prior ETOH abuse
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage - dermabond
intact
Edema - trace bilateral lower extremities
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:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2107-1-20**] 1:00 pm
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 24202**] in [**3-22**] weeks [**Telephone/Fax (1) 14328**]
Cardiologist: Dr [**Last Name (STitle) **] in [**3-22**] weeks [**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**
Completed by:[**2106-12-28**]
|
[
"V45.82",
"424.1",
"410.72",
"427.31",
"401.9",
"414.01",
"250.00",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9129, 9188
|
5906, 6422
|
284, 411
|
9423, 9640
|
3654, 5883
|
10481, 11052
|
2827, 2920
|
7500, 9106
|
9209, 9402
|
6448, 7477
|
9664, 10458
|
2610, 2670
|
2935, 3635
|
237, 246
|
439, 2113
|
2135, 2587
|
2686, 2811
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,296
| 138,686
|
33567
|
Discharge summary
|
report
|
Admission Date: [**2174-4-8**] Discharge Date: [**2174-4-13**]
Date of Birth: [**2112-12-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2174-4-8**] Mitral valve repair with a [**Doctor Last Name 4726**]-Tex neocord and mitral
valve annuloplasty with 30 mm Physio annuloplasty ring
History of Present Illness:
61 y/o male with hypertension c/o one week of exertional chest
pressure and shortness of breath. Admitted at OSH, ruled out for
myocardial infarction, but found to have severe mitral
regurgitation. Referred for cardiac surgery.
Past Medical History:
Mitral Regurgitaion, Hypertension, Hypercholesterolemia, Mild
Obesity
Social History:
Denies tobacco use. Admits to several ETOH drinks with dinner.
Family History:
NC
Physical Exam:
VS: 87 16 134/74 5'9"
Gen: WDWN male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD, -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR 2/6 SEM
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**4-12**] CXR:
[**4-8**] Echo: PRE-BYPASS: The left atrium is mildly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. The left ventricular cavity is
mildly dilated. The right ventricular cavity is mildly dilated
with moderate global free wall hypokinesis. The ascending,
transverse and descending thoracic aorta are normal in diameter
. There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
myxomatous. The mitral valve leaflets are elongated. There is
partial mitral leaflet flail. An eccentric, posteriorly directed
jet of Severe (4+) mitral regurgitation is seen. There is no
pericardial effusion. POST CPB: 1. Improved global biventricular
systolic function with inotropic support. EF = 45-50%. 2.
Annuloplasty ring in mitral position. Well seates and stable,
with good leaflet excursion. 3. Gortex chord visualized in the
LV cavity attached to the undersurface of the anterior mitral
leaflet, with chordal [**Male First Name (un) **] without any LVOT gradient. 4. Trace
perivalvular mitral regurgitation regurgitation at 7 o'clock
position which was conf0ormed with 3D echcoardiography.
[**2174-4-8**] 10:50AM BLOOD WBC-19.1*# RBC-3.68* Hgb-11.2* Hct-32.8*
MCV-89 MCH-30.5 MCHC-34.2 RDW-14.5 Plt Ct-321
[**2174-4-12**] 09:10AM BLOOD WBC-10.7 RBC-3.28* Hgb-10.0* Hct-29.1*
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.8 Plt Ct-258
[**2174-4-8**] 10:50AM BLOOD PT-15.3* PTT-31.9 INR(PT)-1.3*
[**2174-4-8**] 11:55AM BLOOD Glucose-218* UreaN-20 Creat-0.9 Na-141
K-4.1 Cl-104 HCO3-27 AnGap-14
[**2174-4-12**] 09:10AM BLOOD Glucose-86 UreaN-21* Creat-0.8 Na-138
K-4.1 Cl-99 HCO3-30 AnGap-13
[**2174-4-12**] 09:10AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 77804**] was a same day admit after undergoing all
pre-operative work-up prior to admission. On day of admission he
was brought to the operating room where he underwent a mitral
valve repair. 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. He
continued to progress, physical therapy worked with him on
stregth and mobility. On POD 1 he was startedon beta blockers
and amiodarone for atrial fibrillation that converted to normal
sinus rhythm. He was gently diuresed towards his preoperative
weight. He was transferred to the floor on POD 3 were he
received the rest of his post op care. He was treated with IV
vancomycin for right arm phlebitis, which improved and his WBC
was normal. He was discharged home on POD 6 on oral antibiotics
with follow up wound check on [**2174-4-15**] with NP.
Medications on Admission:
Lisinopril 10mg qd, Lasix 40mg qd, Lopressor 25mg qd, Aspirin
325mg qd, MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg twice a day for 5 days then decrease
to 400mg once a day for 7 days then decrease to 200mg daily and
follow with cardiologist .
Disp:*80 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 7 days.
Disp:*7 Tablet Sustained Release(s)* Refills:*0*
Lisinopril was not restarted due to blood pressure
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Mitral Regurgitaion s/p Mitral Valve Repair
Acute on chronic systolic heart failure
Post-operative Atrial Fibrillation
PMH: Hypertension, Hypercholesterolemia, Mild Obesity
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) **] in 4 weeks
Dr. [**Last Name (STitle) 11493**] in [**1-30**] weeks
Dr. [**Last Name (STitle) **] in [**12-29**] weeks
[**Hospital Ward Name 121**] 6 wound check - Friday [**4-15**] with NP/PA for evaluation
of arm please call in am with time [**Telephone/Fax (1) 3071**]
Completed by:[**2174-4-13**]
|
[
"427.31",
"428.23",
"997.1",
"451.82",
"272.0",
"401.9",
"E878.8",
"424.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
5747, 5815
|
3220, 4224
|
341, 490
|
6032, 6038
|
1242, 2160
|
6549, 6880
|
936, 940
|
4350, 5724
|
5836, 6011
|
4250, 4327
|
6062, 6526
|
955, 1223
|
282, 303
|
518, 747
|
769, 840
|
856, 920
|
2170, 3197
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,745
| 166,467
|
37167
|
Discharge summary
|
report
|
Admission Date: [**2187-12-31**] Discharge Date: [**2188-1-14**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Pneumothorax
Major Surgical or Invasive Procedure:
Right chest tube placement
Flexible bronchoscopy
History of Present Illness:
[**Age over 90 **] yo F resident at [**Hospital3 **] with chronic respiratory
failure/trached and tracheobronchomalasia presenting with R
sided pneumothorax. Patient is at rehab for vent weaning (has
been there for 2 years) and on trach mask most of the day and
ventilated at night. It was noted he was having some difficulty
with ventilation. He underwent a bronchoscopy, which showed that
his previous tracheostomy was being blocked by granulation
tissue, and concern for tracheobronchomalasia per discussion
with patient's pulmonologist, Dr. [**Last Name (STitle) **]. A replacement
trachestomy was performed at that time. A CXR after the
procedure showed a right sided PTX, so the patient was sent to
[**Hospital1 18**] for evaluation. Per his pulmonologist at [**Hospital1 **],
patient's baseline MS is extremely poor: he withdraws only to
painful stimuli and does not track to voice.
In the ED, initial VS were 96.9 96 159/69 20 100% on AC 400x12
FiO2 100%. Repeat CXR showed a tension PTX. He underwent a
needle thoracostomy with chest tube with good rush of air.
Repeat CXR and Chest CT non-contrast showed good lung
re-inflation. WBC in ED was 15.7 (up from 9 at rehab), got 1
gram of IV Vancomycin in ED.
.
Currently in MICU, initial difficulty with ventilating the
patient. Bronchoscopy was performed which showed posterior
invagination of tracheal tissue blocking the trach -- this
improved with increased PEEP to 10 mg.
Past Medical History:
Paroxysmal Atrial fibrillation
Parkinson's disease
Chronic respiratory failure, trached ventilator dependent (due
to aspiration PNA/cardiac arrest in [**1-18**] at [**Hospital 8**] Hospital).
Anoxic brain injury [**2-12**] cardiac arrest
DMII
CKD
Tracheobronchomalasia
h/o C. Difficile
Chronic foley due to massive inoperable inguinal hernia, gets
continuous bladder irrigation
Social History:
chronic habitation at [**Hospital1 **] x2 years for vent weaning.
Family denies any illicits (neg tobacco use, neg alcohol use or
IVDU).
Family History:
no history of pulmonary or cardiac disease.
Physical Exam:
On admission -
GENERAL: intubated
HEENT: pupils minimally reactive to light.
CARDIAC: bradycardic S1/S2 present no m/g/r
LUNG: ventilated BS
ABDOMEN: distended, soft, no g/rt.
EXT: wwp no edema
Scrotum: enlarged, edematous
NEURO: moves only to painful stimuli
Pertinent Results:
============
Labs
============
[**2187-12-31**] 12:20PM BLOOD WBC-15.7* RBC-4.11* Hgb-11.5* Hct-36.7*
MCV-89 MCH-28.1 MCHC-31.5 RDW-14.0 Plt Ct-279
[**2188-1-1**] 03:13AM BLOOD WBC-7.4# RBC-3.17* Hgb-8.8* Hct-27.5*#
MCV-87 MCH-27.8 MCHC-32.0 RDW-14.2 Plt Ct-259
[**2188-1-1**] 04:47PM BLOOD Hct-29.1*
[**2187-12-31**] 12:20PM BLOOD Neuts-65.3 Lymphs-27.0 Monos-3.2 Eos-3.8
Baso-0.8
[**2188-1-1**] 03:13AM BLOOD PT-12.0 PTT-28.9 INR(PT)-1.0
[**2188-1-1**] 03:13AM BLOOD Glucose-196* UreaN-82* Creat-2.2* Na-133
K-4.6 Cl-95* HCO3-33* AnGap-10
[**2188-1-1**] 03:13AM BLOOD ALT-24 AST-27 LD(LDH)-161 AlkPhos-93
TotBili-0.3
[**2187-12-31**] 12:20PM BLOOD CK(CPK)-79
[**2187-12-31**] 12:20PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2188-1-1**] 03:13AM BLOOD Calcium-8.3* Phos-4.7* Mg-2.5
[**2188-1-1**] 12:04AM BLOOD Type-ART pO2-168* pCO2-67* pH-7.33*
calTCO2-37* Base XS-6
[**2188-1-1**] 12:04AM BLOOD Lactate-1.0
===========
Micro
===========
URINE CULTURE (Final [**2188-1-2**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
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
[**2188-1-1**] 4:01 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2188-1-2**]**
MRSA SCREEN (Final [**2188-1-2**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
===========
Radiology
===========
CXR [**12-30**]:
UPRIGHT AP VIEW OF THE CHEST: There is a large right basilar
pneumothorax
occupying approximately one-half of the thoracic height, with
leftward
mediastinal and cardiac shift. There is also a small apical
component of the
right pneumothorax.
IMPRESSION: Large right basilar pneumothorax, with small apical
component.
Significant leftward shift of mediastinal contents
CT Scan [**12-30**]:
1. Small right basilar pneumothorax with right basilar chest
tube in
apparently satisfactory position.
2. Endotracheal tube in satisfactory position.
3. Significant segmental atelectasis of the right lower lobe
without total
collapse.
CXR [**1-1**]:
No large obvious pneumothorax, however, the right apex is
obscured by the head position. A short-term followup radiograph
is
recommended.
CXR [**1-2**]
In comparison with the study of [**1-3**], there is no change in the
appearance of the tracheostomy device and the right central
catheter. Cardiac silhouette is unchanged. Some continued
retrocardiac opacification, most likely consistent with
atelectasis. Right hemidiaphragm is not sharply seen, though
this could be positional. No definite acute focal pneumonia.
Brief Hospital Course:
Mr. [**Known lastname **] was brought to [**Hospital1 18**] with an acute right sided
pneumothorax. A chest tube was placed with rapid resolution of
his pneumothorax. The origin of his pneumothorax is unclear but
it likely not related to the tracheostomy manipulation. Given
his difficulty ventilating and high airway pressures after
resolution of his pneumothorax, an initial bronchoscopy was done
which showed posterior invagination of tracheal tissue blocking
the trach. Initially, his PEEP was raised to 10 to combat this
collapse. He was evaluated by the interventional pulmonary
service who performed a repeat bronchoscopy and adjusted the
placement of his tracheostomy with resolution of his ventilation
difficulties. We then started to ween down his PEEP. His chest
tube was then placed on water seal and then clamped the next day
with repeat chest x-rays showing no recurrence of his
pneumothorax. The chest tube was removed on [**1-3**]. On [**1-6**]
tacheostomy tube was changed by IP at the bedside to a fixed
[**Last Name (un) **] #8 (120 mm) in length. Repeat CXR confrimed that trach
tip was in good position. While he was in hospital, his foley
became dislodged and was replaced by urology. Continuous bladder
irrigation was continued during his admission. He was found to
have a UTI and grew pan-sensitive klebsiella, and completed a
course of cipro. His diabetes was managed with lantus and a
sliding scale.
Medications on Admission:
Atropine 1 mg IV PRN
Bisacodyl 10 mg PR qdaily: PRN
Glycerin PR qdaily: PRN
Guaifenesin 200 mg PO q6H:RPN
Magnesium Hydroxide 30 PO qdaily:PRN
Nitoglycerin SL: PRN
Senna 10 mL PO QHS:PRN
Simethicone 80 mg PO QID
Prazosin 1 mg PO
Sodium bicarbonate 8.4% vial qMWF
Tylenol 650 mg PO QID:PRN
Combivent inhalers q2H:PRN
Artificial Tears 2 drops both eyes daily
ASA 324 mg PO qdaily
Glipizide 5 mg PO qdaily
Regular insulin sliding scale
Lactobacillus acidophilus 1 packet PO qdaily
Lanolin/mineral oil/petrolatum QHS
Lansoprazole 30 mg PO qMWF
Levothyroxine 75 mcg PO qdaily
Methylcellulose
MVI
petrolatum QID
Combivent nebs q6H
Acetic acid for bladder irrigation
Amlodipine 2.5 mg PO qMWF
Bacitracin ointment
Chlorhexidine 0.12% orally [**Hospital1 **]
Discharge Medications:
1. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
2. Glycerin (Adult) Suppository [**Hospital1 **]: One (1) Suppository
Rectal PRN (as needed) as needed for constipation.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
6. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB, wheeze.
8. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-12**]
Drops Ophthalmic QDAILY ().
10. Aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QMOWEFR (Monday
-Wednesday-Friday).
15. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
16. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml
Injection TID (3 times a day).
17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
1-2 Puffs Inhalation Q2H (every 2 hours) as needed for wheeze.
18. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Six
(6) Puff Inhalation Q6H (every 6 hours) as needed for wheezing.
19. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
20. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: See printed
sliding scale Injection ASDIR (AS DIRECTED): See printed
sliding scale.
21. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day).
22. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Eight (8) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right pneumothorax
Urinary tract infection
Tracheobroncomalacia
Chronic respiratory failure
Discharge Condition:
Ventilated
Unresponsive at baseline
Afebrile, all vital signs stable
Discharge Instructions:
You were admitted with a pneumothorax (air around the lung).
This air was drained with a tube which was removed prior to you
leaving the hospital. Your tracheostomy was evaluated and
changed to best prevent any occlusions. You were found to have a
urinary tract infection and treated with antibiotics (cipro) for
a total of 7 days.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] within the next one to two
weeks.
Completed by:[**2188-1-17**]
|
[
"403.90",
"518.83",
"041.3",
"788.20",
"250.00",
"564.00",
"519.19",
"V46.11",
"348.1",
"244.9",
"550.90",
"427.31",
"512.0",
"332.0",
"285.9",
"276.1",
"V44.1",
"519.09",
"599.0",
"585.9",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"97.23",
"38.93",
"34.04",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10821, 10900
|
5942, 7372
|
252, 302
|
11036, 11107
|
2682, 5919
|
11487, 11603
|
2339, 2384
|
8172, 10798
|
10921, 11015
|
7398, 8149
|
11131, 11464
|
2399, 2663
|
200, 214
|
330, 1766
|
1788, 2168
|
2184, 2323
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,463
| 174,336
|
45906
|
Discharge summary
|
report
|
Admission Date: [**2133-6-30**] Discharge Date: [**2133-7-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
shaking chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 year old man with coronary artery disease s/p CABG [**2120**],
congestive heart failure with [**Hospital1 **]-ventricular systolic
dysfunction (ef 35%), atrial fibrillation, BPH s/p TURP,
requiring 3x daily intermittent catheterization on chronic
keflex with multiple UTI's who presents with one day of acute
onset shaking chill.
.
Patient reports tripping over step while carrying groceries
about a week ago, fell and hit bridge of his nose and right
ribs. Went to [**Hospital **] hospital, negative CT and no rib
fractures, has had some continued nose bleeding since that time,
now minimal. (Coumadin held for past few days.)
.
Then today, reports developing shaking chills while lying next
to his wife. Says otherwise, only mild intermittent non
productive cough with eating (peanuts). Says has been
catheterizing himself about three times a day, no change
recently and has not noted change in color or odor of urine.
Also developed possible small volume hemoptysis x 1 today, says
small amount in mucous today. No other specific complaints,
generally feeling malaise since recent fall.
.
Denies chest pain, orthopnea, pnd, doe. At baseline, goes
golfing, help with care as his wife is demented and requires 24
hour assistance but he can perform all his ADL's.
.
No hematochezia, melena, other bleeding besides nose.
.
In the ED low grade fever to 99.4, hypotensive to sbp's in the
80's and initially 88% on room air. To 95% on 3 liters and bp
improved to 100's with 3 liters NS. Initially tachy to 110's in
er, now in 70's. WBC was 21 with 93% neutrophils, he received
ceftriaxone 1g IV, azithromycin 500mg IV, aspirin 325mg po, and
acetominophen 1g po.
Past Medical History:
1. Coronary artery disease status post CABG in [**2120**], no cath
since then.
2. Atrial fibrillation on coumadin.
3. Biventricular heart failure with an EF of 35%.
4. Mild AS, MR [**First Name (Titles) **] [**Last Name (Titles) **]
5. Benign Prostatic hypertrophy status post TURP x 2, now 3x
daily catheterizations and keflex chronic suppression.
6. Anemia for which he receives darbepoetin every 2 weeks.
7. Macular degeneration in left eye.
8. Multiple UTIs last culture [**2132-6-26**] showed E.coli and
corynebacterium (diphtheroid) resistant to
cipro/levo/bactrim/amp, but sensitive to ceftriaxone; UTI in
[**2130**] grew bactrim, ticarcillin and fq resistant bacteria; UTI in
[**2129**] grew pan sensitive enterobacter cloacae
9. Parkinson's disease
Social History:
Former smoker - quit 40 years ago. He drank EtOH regularly until
25 years ago, and now only drinks rarely. Lives at home with
wife. Wife with dementia-has 24 hour caretaker. Active, walks
independently and independent of ADLs plays golf. Family very
involved with his care. HCP = [**Name (NI) 17**] [**Name (NI) 1182**] cell [**Telephone/Fax (1) 97770**],
and daughter [**Name (NI) **] [**Telephone/Fax (1) 97771**] is second HCP. [**Name (NI) **] used to be in
the navy, then worked in a creamery, and then owned two
restaurants and was in catering before he retired.
Family History:
Non-contributory
Physical Exam:
VS - Temp 99.4, BP 92/40, HR 75, RR 16, O2Sat 93% rm airL
I/O: 3liters/500cc
GENERAL: Elderly male laying in bed, NAD, pleasant
HEENT: right pupil round and reactive to light; surgical left
pupil; EOMI, no scleral icterus; OP clear; moist mucous dry, dry
blood over bridge of nose, no active nasal/oral bleeding, no JVD
NECK: supple, no LAD, JVD - 8cm
LUNGS: crackles [**2-10**] way up bilaterally
CARD: irregular rhythm; III/VI systolic murmur--previously noted
ABD: +b/s, soft, NT/ND,
EXT: no edema; weak dorsalis pedis pulses
SKIN: multiple ecchymoses
NEURO: alert, oriented x 3; CN III-XII intact; mild left facial
droop, which the patient says he's had for a long time; speaks
slowly, but attentive; jokes and tells stories
Pertinent Results:
[**2133-6-30**] 08:20AM WBC-21.2*# RBC-3.30* HGB-11.9* HCT-35.1*
MCV-106* MCH-36.0* MCHC-33.9 RDW-22.1*
[**2133-6-30**] 08:20AM NEUTS-93.1* BANDS-0 LYMPHS-3.0* MONOS-2.7
EOS-0.7 BASOS-0.5
[**2133-6-30**] 08:20AM PLT COUNT-243
.
[**2133-6-30**] 01:36PM VIT B12-1338* FOLATE-GREATER THAN 20
.
[**2133-6-30**] 08:20AM PT-16.3* PTT-21.8* INR(PT)-1.5*
.
[**2133-6-30**] 08:00AM GLUCOSE-167* UREA N-22* CREAT-1.1 SODIUM-138
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
ALT 11, AST 28, ALK PHOS 57, T BILI 1.5, LDH 194, ALB 3.3
.
CORTISOL 29.5
.
[**2133-6-30**] 08:10AM LACTATE-1.9
.
[**2133-6-30**] 01:36PM DIGOXIN-0.7*
.
[**2133-6-30**] 08:20AM CK-MB-NotDone
[**2133-6-30**] 08:20AM cTropnT-0.03*
[**2133-6-30**] 01:36PM CK-MB-7 cTropnT-0.16*
[**2133-6-30**] 08:28PM CK-MB-7 cTropnT-0.13*
.
SPEP: WNL
UPEP: ONLY ALBUMIN
.
[**2133-6-30**] 09:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2133-6-30**] 09:00AM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-5.0
LEUK-NEG
[**2133-6-30**] 09:00AM URINE RBC-[**4-13**]* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-[**4-13**]
.
BLOOD CX: NO GROWTH
.
[**2133-6-30**] 9:00 am URINE Site: CATHETER
**FINAL REPORT [**2133-7-2**]**
URINE CULTURE (Final [**2133-7-2**]):
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
URINE CX [**2133-7-1**]: NO GROWTH
.
[**2133-6-30**] 8:56 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2133-7-3**]**
GRAM STAIN (Final [**2133-7-1**]):
[**12-3**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2133-7-3**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). RARE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
.
EKG:
Atrial fibrillation with rapid ventricular response
Leftward axis
Left bundle branch block
Since previous tracing of [**2132-10-1**], intraventricular conduction
delay is new
.
CHEST (PORTABLE AP) [**2133-6-30**] 7:38 AM
FINDINGS: Compared with [**2132-10-2**], the moderate left ventricular
cardiomegaly appears essentially unchanged. Status post CABG.
There is engorgement of the pulmonary vessels suggesting an
element of CHF.
Additionally, there is more confluent airspace opacity overlying
the right mid lung field, consistent with pneumonia.
.
ECHO [**2133-7-1**]:
The left atrium is markedly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is
11-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is mild to
moderate global left ventricular hypokinesis. Right ventricular
chamber size and free wall motion are normal. The aortic root
is mildly dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2130-2-15**], the
ascending aorta is larger. Otherwise, the findings are similar.
.
CT HEAD W/O CONTRAST [**2133-7-3**] 9:07 AM
FINDINGS: The study is somewhat limited by motion artifact.
However, there is no evidence of hemorrhage. There is no mass
effect. The ventricles and sulci are mildly prominent. There is
a focal lacune in the right caudate head. These findings have
not changed since the prior study. The right maxillary sinus
appears small and there may be a surgical defect in its medial
wall. There is partial opacification of the ethmoid air cells
and mucosal thickening in the maxillary air cells bilaterally
and in the sphenoid sinus. There are no fluid levels within the
sinuses.
Incidentally noted are hypodensities in the cerebellar
hemispheres bilaterally that presumably represent lacunar
infarctions.
CONCLUSION: No evidence of hemorrhage or other acute
abnormality. Old lacunes in the right caudate head and in the
cerebellar hemispheres bilaterally. These findings are unchanged
since [**2132-6-24**].
.
VIDEO OROPHARYNGEAL SWALLOW [**2133-7-3**] 9:03 AM
FINDINGS: The oral phase demonstrated difficulty bolus
formation. Transition from oral to laryngeal phase was mildly
delayed. No epiglottic deflection was identified. Penetration
aspiration were noted with thin liquid and nectar. Chin tuck
improved aspiration with thin liquids with no effect on
aspiration with nectar. Moderate retention within the valleculae
was noted throughout the exam. Cough reflex was initiated
induced by aspiration.
IMPRESSION: Relatively unchanged aspiration with thin liquid and
nectar that is partially responsive to chin-tuck. Please refer
to the speech pathologist note in CCC for further details.
Brief Hospital Course:
# Urosepsis: Patient was initially admitted to the ICU for care
and started on meropenem and azithromycin -> imipenem/vancomycin
for broad antibiotic coverage. Blood pressure stabilized with
IVF boluses. [**Last Name (un) **] stim was appropriate. Following
hemodynamically stability and the results of his urine culture,
antibiotics were scaled back to levofloxacin (for the UTI) with
the addition of flagyl (given concern for concurrent aspiration
pneumonia). Blood cultures were negative. Patient will
complete a total of 10 days of antibiotics. Case discussed with
Dr. [**Last Name (STitle) 770**] who was comfortable with discontinuation of
indwelling foley placed on admission and resumption of patient's
regimen of regular straight catheterization. Emphasis with
compliance with his tid regimen was made prior to discharge
given his recent urinary tract infection.
.
# Troponin leak with new LBBB: Patient's cardiologist followed
along while the patient was in the unit. CKMB remained flat and
ECHO was essentially unchanged. The patient was thought to most
likely have had demand ischemia in the setting of his
hypotension. He was continued on his ASA and ACEI. No beta
blocker, reportedly due to severe bradycardia. LDL 52 off any
statin.
.
# Atrial fibrillation: Coumadin was initially held on admission
but restarted prior to discharge. He is on digoxin for rate
control and had no rate issues.
.
# Aspiration pneumonia: Patient has a history of aspiration
pneumonia. He has been permitted thin liquids in the past but
video eval concerning and given recurrent episodes, speech
recommends nectar thick liquids with soft solids to be continued
at home as well. Patient is completing a 10 day course of
levo/flagyl for his current aspiration pneumonia. He is stable
on room air at the time of discharge, including with ambulation.
.
# S/p fall: Patient had a mechanical fall 1 week prior to
admission. He complained of right rib pain but CXR without
overt fracture. No evidence of hematoma/overlying bruising. He
did undergo a CT while in house given complaints of a mild
headache. This showed no evidence of intracranial bleeding.
.
# Orthostatic hypotension: Noted on PT evaluation. SPEP, UPEP,
folate, B12, and lytes all normal. Patient given a fluid bolus
to improve his volume status and will follow-up with his primary
for continued monitoring. Likely the digoxin is contributing to
a blunted heart rate response. Patient warned to be slow and
deliberate with positional changes to minimize his risk of
falling.
.
# [**Hospital1 **]-ventricular heart failure (EF 35%): Patient was restarted
on his home lasix and ACEI prior to discharge.
.
# Parkinson's: Stable on carbidopa//levodopa
.
# FEN: nectar thick liquids and soft solids with aspiration
precautions, ensure pudding tid given low albumin
.
# Code: Full
.
# Communication: HCP = [**Name (NI) 17**] [**Name (NI) 1182**] cell [**Telephone/Fax (1) 97770**], and
daughter [**Name (NI) **] [**Telephone/Fax (1) 97771**] is second HCP.
.
# Dispo: patient was discharged home with services for vitals
check, home PT, and medication assistance
Medications on Admission:
1. Lisinopril 5 mg daily
2. Omeprazole 20 mg daily.
3. Aspirin 81 mg daily.
4. Digoxin 125 mcg daily
5. Carbidopa/levodopa 25/100 tid
6. Colace 100 [**Hospital1 **]
7. Lasix 20 mg daily
8. Warfarin--being held
9. MVI
10. keflex 500mg daily
Discharge Medications:
1. Coumadin 5 mg Tablet Sig: 1-2 Tablets PO once a day: please
resume your regular coumadin regimen.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY DAY
EXCEPT FRIDAY ().
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
primary:
urosepsis
aspiration pneumonia
s/p mechanical fall
orthostatic hypotension
secondary:
atrial fibrillation
CAD s/p CABG
biventricular heart failure
Parkinson's disease
Discharge Condition:
good: ambulating with PT, stable on room air, blood pressure
normal
Discharge Instructions:
Please call your doctor or go to the emergency room if you
experience temperature > 101, chills, chest pain, worsening
cough, or other concerning symptoms.
Because you have a diagnosis of heart failure, you should:
# Weigh yourself every morning, call your doctor if your weight
increases by 3 lbs or more
# Limit yourself to 2 gm of sodium per day
# Adhere to a 1.5 liter Fluid Restriction per day
Because right now, there is evidence that you are aspirating
thin liquids, you MUST thicken all of your liquids until you
have a repeat swallow test that shows you are no longer
aspirating.
To maintain your nutrition, please take 3 ensure puddings per
day.
Given your current urinary tract infection, you MUST straight
cath at least 3 times per day.
Be sure to follow-up with Dr. [**Last Name (STitle) 1270**] to discuss:
# the results of tests sent to work-up the decrease in your
blood pressure when you stand and to discuss if further testing
is needed
# to schedule a follow-up swallow study in 1 month
# to continue adjustment of your coumadin, as needed
Please follow the speech/swallow recommendations to decrease
your risk of aspirating:
1. you must add thickener to all liquids to create nectar
thickened consistency
2. any solid food you eat should be of a soft consistency
3. always do a chin tuck, as you were instructed, when you
swallow to decrease your risk of aspirating
4. Crush all your pills and put them in puree.
Followup Instructions:
Dr.[**Name (NI) 15895**] office will contact you with an appointment to
see him within 2 weeks. Please call tomorrow to confirm the
time/date of your appointment. Phone: [**Telephone/Fax (1) 5027**]
Please call to schedule follow-up with Dr. [**Last Name (STitle) 770**] within 2
weeks. Phone: [**Telephone/Fax (1) 5727**]
|
[
"V45.81",
"995.91",
"427.31",
"332.0",
"276.51",
"428.0",
"414.00",
"507.0",
"E888.9",
"038.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15027, 15102
|
10607, 13750
|
276, 283
|
15322, 15392
|
4143, 10584
|
16880, 17208
|
3358, 3376
|
14040, 15004
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15123, 15301
|
13776, 14017
|
15416, 16857
|
3391, 4124
|
222, 238
|
311, 1973
|
1995, 2755
|
2771, 3342
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,639
| 150,720
|
2045
|
Discharge summary
|
report
|
Admission Date: [**2133-4-17**] Discharge Date: [**2133-5-1**]
Service: MEDICINE
Allergies:
Procardia / Verapamil / Neurontin
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Right hip pain, following a fall
Major Surgical or Invasive Procedure:
Right long trochanteric fixation nail
Upper endoscopy x2
Multiple blood transfusions
IVC filter placement
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] y/o woman who presents with right hip pain
after a fall from standing. She was unable to get up
thereafter. She was bending over to take off her husband's socks
and lost her balance. Denies headstrike or loss of consciousness
at the time. On presentation to the ED, she was noted to have
hip xrays demonstrating a hip fracture, and was initially
admitted to the orthopedics service. She subsequently required
transfer to the medical ICU and later the hospital medicine
service, for ongoing medical issues that arose during her
admission.
Past Medical History:
Severe aortic stenosis
Hypertension
Hyperlipidemia
Hypothyroidism
TIA
Asthma
Gout
Polymyalgia rheumatica
Discoid [**Age over 90 11168**]
h/o CHB s/p PPM [**2126-12-9**]
h/o pulmonary embolus [**2122**] s/p coumadin
h/o Left DVT
s/p Right total knee replacement [**4-12**]
s/p Left total hip replacement [**11-10**]
s/p R Mastoidectomy
Social History:
married x 60 years, lives with husband. 4 kids. Worked as an
office manager at local newspaper. No tobacco, alcohol, drug
use. ambulates on own.
Family History:
sister-TIAs
brother with CAD died at age 45
nephews with CAD at age <40
MS [**First Name (Titles) **] [**Last Name (Titles) 11168**] also in the family
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION to the orthopedics service:
NAD, AOx3, VSS
BLE skin clean and intact
RLE shortened and externally rotated. No deformity, erythema,
edema, induration or ecchymosis.
Thighs and legs are soft
R hip pain with any motion
Saph Sural DPN SPN MPN LPN SITLT
Flexion/extension intact toes, ankle and knee bilaterally
w/inability to range R hip
1+ PT and DP pulses
Contralateral extremity examined with good range of motion,
SILT, motor intact and no pain or edema
Pertinent findings on discharge:
The patient was alert and oriented x 3, appropriate fluent
speech.
She had no evidence of rales on bilateral lung exam. Cardiac
murmur consistent with aortic stenosis remained present. JVP did
not appear elevated.
The patient's wound was healing well.
Pertinent Results:
Initial labs:
[**2133-4-17**] 10:58PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2133-4-17**] 10:58PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2133-4-17**] 10:00PM GLUCOSE-120* UREA N-43* CREAT-1.6* SODIUM-140
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17
[**2133-4-17**] 10:00PM WBC-8.6 RBC-3.57* HGB-11.4* HCT-33.3* MCV-93
MCH-32.0 MCHC-34.4 RDW-15.0
[**2133-4-17**] 10:00PM NEUTS-78.6* LYMPHS-11.8* MONOS-6.4 EOS-1.9
BASOS-1.3
[**2133-4-17**] 10:00PM PT-10.4 PTT-27.5 INR(PT)-1.0
CBC:
[**2133-4-19**] 04:50AM BLOOD WBC-7.8 RBC-2.65* Hgb-8.3* Hct-23.9*
MCV-90 MCH-31.3 MCHC-34.7 RDW-17.9* Plt Ct-91*
[**2133-4-23**] 08:45AM BLOOD Hct-21.7*
[**2133-4-24**] 04:30AM BLOOD WBC-10.9 RBC-2.89* Hgb-8.9* Hct-25.6*
MCV-89 MCH-30.8 MCHC-34.6 RDW-15.4 Plt Ct-139*
[**2133-4-26**] 02:08AM BLOOD WBC-11.2* RBC-3.11* Hgb-9.4* Hct-27.8*
MCV-90 MCH-30.1 MCHC-33.6 RDW-15.3 Plt Ct-159
[**2133-4-27**] 02:49AM BLOOD WBC-9.5 RBC-2.68* Hgb-8.2* Hct-24.4*
MCV-91 MCH-30.6 MCHC-33.6 RDW-16.2* Plt Ct-174
[**2133-4-28**] 05:36AM BLOOD WBC-11.0 RBC-3.07* Hgb-9.4* Hct-27.7*
MCV-90 MCH-30.6 MCHC-34.0 RDW-15.8* Plt Ct-205
[**2133-4-29**] 06:00AM BLOOD WBC-10.1 RBC-3.24* Hgb-10.0* Hct-29.5*
MCV-91 MCH-30.9 MCHC-34.0 RDW-15.7* Plt Ct-224
[**2133-4-30**] 08:50AM BLOOD WBC-11.5* RBC-3.38* Hgb-10.2* Hct-30.8*
MCV-91 MCH-30.3 MCHC-33.2 RDW-16.0* Plt Ct-206
[**2133-5-1**] 05:50AM BLOOD Hct-30.0*
Chemistry:
[**2133-4-28**] 05:36AM BOOD Glucose-89 UreaN-45* Creat-1.1 Na-144
K-3.7 Cl-116* HCO3-21* AnGap-11
[**2133-4-29**] 12:35PM BLOOD UreaN-35* Creat-1.2* Na-147* K-3.5
Cl-116* HCO3-19* AnGap-16
[**2133-4-30**] 08:50AM BLOOD UreaN-30* Creat-1.2* Na-144 K-3.2*
Cl-114* HCO3-23 AnGap-10
[**2133-5-1**] 05:50AM BLOOD UreaN-25* Creat-1.1 Na-144 K-3.4 Cl-114*
HCO3-23 AnGap-10
Radiology:
Hip films:
IMPRESSION: Complete comminuted fracture through the right
greater
trochanter.
Endoscopy:
Impression: Esophagitis
No blood or lesions noted in stomach.
Duodenal ulcer (injection, endoclip)
Otherwise normal EGD to second part of the duodenum
Recommendations: Source of melena appears to be duodenal bulb
ulcer with adherent clot. Injection and endoclip placed.
Aggressive manipulation of clot not performed as stated above.
Recommend continued ICU close monitoring, NPO, PPI gtt, hold
anticoagulation. If recurrent significant bleed with likely
require IR intervention.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with known critical aortic
stenosis, CKD, CAD s/p CABG, and hypothyroidism who was
initially admitted to the Orthopaedic Surgery Trauma service
after a fall in which she sustained a right intertrochanteric
hip fracture while helping her husband get dressed. Her hospital
course was significant for peri-operative cardiac arrest and
hypotension and later a GI bleeding episode requiring ICU stay.
During the orthopedic initial course: The patient was taken to
the Operating Room on [**2133-4-18**] with Dr. [**Last Name (STitle) **] to undergo open
reduction and internal fixation of the right hip with a
Trochanteric Fixation Nail. Her intraoperative course was
complicated by an episode of hypotension during the anesthesia
induction period. Please see Operative Report for full details.
Post-operatively, the patient was taken to the recovery room
before being transferred to the floor.
On POD#1, she was transfused 2 units of packed red blood cells
for acute blood loss anemia. She was also noted to be confused
that day, and the Geriatrics service was consulted for acute
mental status changes. A CT scan of the head was recommended to
evaluate for an acute bleed; this study was found to be negative
for an acute intracranial process, but did show age-related
involution and chronic small vessel ischemic disease.
The patient's mental status improved over the next few days.
She continued to work with Physical Therapy and made [**Last Name (STitle) 4374**]
progress. She was transfused 2 units of pRBCs on [**2133-4-21**], again
for acute blood loss anemia, as well as 1 unit of FFP.
On the morning of POD#5, the patient was noted to become acutely
hypotensive to 70s/40s in the setting of appearing pale and
complaining of lightheadedness, dizziness, and palpitations.
Her hematocrit had decreased from 29.1 the day before to 24.3;
upon being rechecked 3 hours later, the hematocrit had decreased
to 21.7. The patient was ordered for STAT packed red blood cell
transfusion, and in the interim she received crystalloid for
volume resuscitation. A Trigger was called, and STAT EKG, CXR,
and cardiac enzymes were ordered. The Medicine and Cardiology
services were contact[**Name (NI) **] and presented urgently to see the
patient. The ICU was also contact[**Name (NI) **] given concern for acute
blood loss anemia. Her right (operative) thigh remained soft
and did not appear to be full or acutely swollen.
The patient was transferred to the T/SICU, shortly after which
time she produced a large amount of melena of approximately 1
liter. The GI service was consulted urgently, and EGD was
performed that was significant for severe erosive gastritis and
a duodenal ulcer. Please see report for full details. She was
then transferred to the MICU for further evaluation and
management of her GI bleed.
MICU & Floor Course:
# GIB: Upon admission to the MICU she underwent EGD, which
showed erosive esophagitis and multiple duodenal ulcers, which
were not intervened upon. Her Lovenox was discontinued and she
was placed on Heparin SQ and pneumoboots for DVT ppx. She was
transfused a total of 2 units pRBCs over the course of 48 hours.
Her HCT remained stable and she was called out to the floor. She
initially did well on the floor, but subsequently had several
large melanotic BMs and a significant HCT drop 25-->22. She was
then readmittted to the MICU, where she received another 4 units
pRBCs with HCT 22-->29. Repeat EGD showed slowly bleeding
duodenal ulcer and she had epi injection and hemostatic clips
placed x2 to the site of bleeding. She remained hemodynamically
stable on PPI gtt. On [**4-27**] she had IVC filter placed because she
could not be anticoagulated and is at very high risk for DVT.
Her HCTs were trended and she was called back out to the floor.
She had no further melanotic stools and her hematocrits were
stable on the floor. She remained off of DVT prophylaxis due to
her severe GI bleeding during this admission.
# s/p Cardiac Arrest: Shortly after induction in the OR pt
becmae hypotensive requiring compressions and EPI with immediate
RSC. Her arrest was likely related to anestehsia induced
hypotension given prompt resolution with CPR/EPI. She remained
hemodynamically stable after these events, including throughout
her hospital medicine team course.
# Right hip fracture: The patient is weight-bearing as tolerated
per the orthopedics service. She will follow up with them in
clinic for further evaluation and for removal of her incisional
staples. She required planned [**Hospital 3058**] rehabilitation on
discharge for ongoing therapy, but per report of the PT team,
she was making the desired progress in her ambulation and ADLs
during her inpatient course.
# Resolved encephalopathy/confusion: These resolved symptoms
earlier in her course were attributed to poor perfusion from
active bleed and hypotension. Also with risk of recent delirium,
likely related to surgery and ICU stay. Her mental status
improved throughout her hospital course and she was awake,
alert, oriented, and appropriate on discharge.
# CKD: Pt's Cr is currently at baseline, likely hypertensive
nephropathy. It remained stable throughout her hospital course.
# Thrombocytopenia: Pt has been chronically thrombocytopenic
since [**2126**] per out records. Platelets 140 on admission to the
MICU. Unclear cause, though would monitor for consumptive
process given recent bleed.
# CAD s/p CABG/AVR: Currently euvolemic, denies CP. She was
restarted on her home metoprolol dose prior to discharge, but
the other antihypertensives were held as the patient was not
hypertensive. She was continued on rosuvastatin.
# Hypothyroidism: The patient recevied levothyroxine.
Transitional Issues:
# Hypertension/medication changes: The patient will be gradually
weaned back on to her home antihypertensive regimen as required
based on her blood pressure. These recommendations were outlined
in the discharge paperwork to assist the rehab facility in
determining which agents would be most prudent to add back at
which timing.
# Hypokalemia: The patient has slightly low potassium. She was
encouraged to eat foods high in potassium.
Medications on Admission:
advair, crestor 40, ASA 81, allopurinol 100, HCTZ 25, lisinopril
2.5, synthroid 88, amlodipine 5, gabapentin 100, metoprolol ER
100
Discharge Medications:
1. Carafate 100 mg/mL Suspension Sig: One (1) tablespoon PO
twice a day for 2 weeks.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
8 weeks.
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Right hip intertrochanteric fracture
Bleeding duodenal ulcer
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 Mrs. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted to the hospital for a broken right hip. While in the
hospital, you developed bleeding from an ulcer in your
intestines. You were admitted to the ICU and had blood
transfusions and two endoscopies that found the source of the
bleeding, and it eventually stopped. You blood counts have been
normal for the last few days. You will need to follow up with
the orthopedic surgeons for your broken hip and with the
gastroenterologists for your bleeding ulcer.
Wound Care:
- Keep incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be weight-bearing as tolerated
- You should not lift anything greater than 5 pounds.
- Elevate right leg to decrease pain and swelling.
Other Instructions
- Resume your regular diet. Eat a banana daily to get enough
potassium.
Medication changes:
DO NOT take aspirin or any other blood thinners until you see
the gastroenterologists in clinic
pantoprazole 40 mg PO q12h for 8 weeks
sucralfate one tablespoon oral suspension PO BID for two weeks
acetaminophen 650 mg PO q6h prn pain
Followup Instructions:
Department: [**Location (un) 2352**] ADULT SPECIALTIES/ORTHOPEDICS
When: THURSDAY [**2133-5-7**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11169**], MD [**Telephone/Fax (1) 1142**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2133-5-12**] at 2:00 PM
With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2133-5-1**]
|
[
"530.19",
"272.0",
"276.8",
"V17.3",
"V12.54",
"244.9",
"V12.51",
"433.10",
"997.1",
"V45.81",
"599.0",
"785.59",
"585.9",
"V42.2",
"427.5",
"532.40",
"564.00",
"E938.4",
"293.0",
"493.90",
"V12.72",
"V43.64",
"287.5",
"E885.9",
"E878.1",
"820.21",
"V45.01",
"V12.55",
"V43.65",
"285.1",
"411.89",
"403.90",
"288.60",
"276.0",
"362.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"99.60",
"45.13",
"44.43",
"79.15"
] |
icd9pcs
|
[
[
[]
]
] |
12335, 12471
|
4967, 10743
|
273, 381
|
12576, 12576
|
2502, 4944
|
14141, 14886
|
1537, 1690
|
11386, 12312
|
12492, 12555
|
11229, 11363
|
12759, 13330
|
1705, 2215
|
2229, 2483
|
10765, 10780
|
13882, 14118
|
201, 235
|
13342, 13862
|
409, 1000
|
12591, 12735
|
1022, 1358
|
1374, 1521
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,688
| 106,805
|
45472
|
Discharge summary
|
report
|
Admission Date: [**2198-2-11**] Discharge Date: [**2198-2-20**]
Date of Birth: [**2132-6-5**] Sex: F
Service: MEDICINE
Allergies:
Nsaids / Lovenox / Pravastatin / Zetia
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Mesenteric angiography
Transfusion of PRBC's
Colonscopy
Femoral line placement
PICC line placement
Flexible sigmoidoscopy
History of Present Illness:
Ms. [**Known lastname 6330**] is a 65 yo woman with DM2, CHF, diverticulosis, and
recent hospitalization at [**Hospital 8**] Hospital for aspiration
pneumonia c/b C diff colitis and LGIB, and several
hosptalizations/rehab stays for last 4 months. She was sent to
[**Hospital 8**] Hospital ED this a.m. from [**Hospital1 **] with hematochezia
and LLQ tenderness x 4 days. Pt did not see hematochezia herself
but was told by nursing staff that this was present. Hct there
was 26 and she was transfused 2uPRBC ([**1-14**] 35). Transferred to
[**Hospital1 18**] for further management d/t no capacity for embolization or
surgery. NG lavage in the ER revealed bile only, no evidence of
blood. The GI team saw pt in the ER and recommended tagged RBC
scan. In the ER the pt had stable vital signs except tachycardia
to 120s. She received 4 units PRBC's in ED (although 2 of these
may have included [**Name (NI) 8**] [**Name (NI) **] - unclear), 3.5 L of NS.
.
Pt recently in [**Hospital 8**] hospital [**1-27**] with pneumonia treated
with Zosyn and developed Cfdiff, treated with PO flagyl. Had
some GI bleeding at that time and did not perform c-scope given
her infection. Also had some CP during that stay with negative
cardiac w/u including persantine mibi, and was started on dilt
and asa at that time. Has been in rehab for 5 days since
discharge from [**Hospital1 8**].
.
The patient presented to the MICU after tagged red cell scan was
completed. She complains of her usual back pain in the setting
of known spinal stenosis and rectal pain in setting of loose
stools/hematochezia. She has occasional abdominal pain, crampy,
that has been present since her last admission to [**Hospital 8**]
hospital and is no better or worse. Not exacerbated by food. No
recent NSAID use (allergic to ibuprofen). No fevers, chills,
nausea, vomiting. Last colonoscopy 5 yrs ago with
diverticulosis.
.
ROS: no fevers, chills, + cough with greenish sputum, improving,
no sore throat, congestion, HA, diploplia, chest pain, SOB. +
whole body pain and fatigue. occ. dysuria with foley catheter
chronically in place.
Past Medical History:
Pneumonia
Recent LGIB at OSH
DM 2 - followed by [**Last Name (un) **]
Diabetic neuropathy
CRI
Hypercholesterolemia
COPD
HTN
CHF - PMIBI by report at OSH was normal with EF 70%
Hypothyroidism
Diverticulosis
Glaucoma
Spinal stenosis
? Dermatomyositis
UTIs with indwelling foley for bladder atony
Sleep apnea on bipap overnight
Ectopic pregnancy
Social History:
40 pack yr history, quit 26 yrs ago, 2 glasses of wine with
dinner, no IVDU, lives with husband who takes care of her, sits
in chair all day long
Family History:
Father died of CVA at 50
Mother with gastric cancer
Brother with MI at 50
No GI disorders
Physical Exam:
PE: 97.7, 117, 102/50, 15, 97% on RA
Gen: Obese, lying in bed, moaning d/t back pain, sleepy from
dilaudid
HEENT: PERRL, EOMI, MM dry, OP clear, neck full and unable to
assess JVP
Cor: RRR, NL S1 and S2, no MRG
Pulm: CTAB ant
Abd: obese, +BS, nontender (just recieved pain meds), no
rebound, no guarding
Ext: 3+ LE edema and anasarce, LE cool, dopplerable pulses
Neuro: CN III-XII intact, [**6-16**] UE strength, [**5-17**] left LE, [**4-16**]
right LE, toes downgoing
Skin: no obvious sores anteriorly, but known sacral decub (will
examine when nursing turns patient)
Pertinent Results:
[**2198-2-11**] 07:03AM BLOOD WBC-15.4* RBC-3.07* Hgb-9.4* Hct-27.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-16.3* Plt Ct-463*
LABS:
.
[**2198-2-19**] 05:52AM BLOOD WBC-10.5 RBC-3.85* Hgb-11.7* Hct-34.1*
MCV-89 MCH-30.3 MCHC-34.2 RDW-16.2* Plt Ct-302
[**2198-2-11**] 07:03AM BLOOD Neuts-86* Bands-0 Lymphs-7* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2198-2-17**] 05:43AM BLOOD Neuts-67.5 Lymphs-24.1 Monos-4.9 Eos-3.2
Baso-0.3
[**2198-2-11**] 07:03AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2198-2-11**] 07:03AM BLOOD PT-13.4* PTT-25.5 INR(PT)-1.1
[**2198-2-18**] 05:22AM BLOOD PT-11.8 PTT-24.6 INR(PT)-1.0
[**2198-2-11**] 07:03AM BLOOD Glucose-262* UreaN-9 Creat-1.0 Na-134
K-4.6 Cl-97 HCO3-26 AnGap-16
[**2198-2-19**] 05:52AM BLOOD Glucose-203* UreaN-12 Creat-1.4* Na-133
K-3.7 Cl-95* HCO3-29 AnGap-13
[**2198-2-13**] 03:57PM BLOOD ALT-13 AST-16 AlkPhos-65 TotBili-0.3
[**2198-2-12**] 02:30AM BLOOD Lipase-13
[**2198-2-14**] 12:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2198-2-11**] 01:51PM BLOOD Calcium-7.9* Phos-4.3 Mg-1.6
[**2198-2-18**] 05:22AM BLOOD Calcium-8.5 Phos-4.7* Mg-1.5*
[**2198-2-12**] 09:00PM BLOOD Type-ART pO2-78* pCO2-61* pH-7.34*
calTCO2-34* Base XS-4 Intubat-NOT INTUBA
[**2198-2-11**] 09:05AM BLOOD Lactate-1.8
[**2198-2-12**] 09:00PM BLOOD O2 Sat-94
.
DIAGNOSTICS:
.
TAGGED RBC'S [**2198-2-11**]: Passage of blood clots with tagged RBCs
confirms active GI bleeding; localization is difficult but
appears likely in the sigmoid colon (first focus appears in the
first 5 minutes of the scan).
.
Emergency mesenteric angiography via left transfemoral approach
[**2198-2-11**]:
1. No active bleeding demonstrated angiographically.
2. Nonvisualization of the inferior mesenteric artery.
3. Unremarkable celiac axis and superior mesenteric artery
branches.
.
CT ABDOMEN/PELVIS [**2198-2-14**]:
1. Markedly limited examination due to patient's body habitus.
No definite CT evidence of colitis.
2. Small bilateral pleural effusions and bibasilar airspace
disease.
.
UNILAT UP EXT VEINS US LEFT [**2198-2-15**] 6:34 PM
No evidence of left upper extremity deep venous thrombosis. Left
brachial vein PICC line.
.
FLEX SIGMOIDOSCOPY:
Ulceration, friability and erythema in the rectum compatible
with ulcerative colitis, although Crohn's colitis possible
(biopsy). Otherwise normal sigmoidoscopy to rectum
Brief Hospital Course:
65yo woman with MMP including DM, recent pneumonia with Cdiff,
presents with hematochezia and tachycardia, transferred from
MICU to general medicine floor on [**2-16**], Hct and hemodynamics
stable.
.
#. GI Bleed:
Hematochezia with stable BP/tachycardia suggestive of likely
lower GI source. Differential includes diverticular bleed, AVM,
Cdiff colitis, ischemic colitis. Appreciate GI seeing pt in ER.
Normal lactate not suggestive of ischemia, unlikely to have this
degree of hematochezia from Cdiff, although possible, pt with
known diverticulosis making this leading differential. Last
scope 5 years ago was reportedly clean so malignancy less likely
but possible. Stool cultures for hemorrhagic bacterial
infections were negative. Tagged red cell scan positive. Patient
transfused total of 4 units in MICU and 1 unit platelets with
eventual stabilization of Hct. Angio could not localize
bleeding. Colonospcopy [**2198-2-13**] showed large blood and clots up to
20 cm from anus and therefore limited study. Repeat CTA of
abdomen/pelvis performed at request of GI for evaluation of
colon wall and source of bleed. CTA limited secondary to body
habitus but no contrast extravasation or frank colitis. Femoral
line discontinued [**2-14**], tip culture no growth. Due to limited
studies and uncertainty regarding location of bleeding, patient
had a flex sigmoidoscopy on [**2198-2-19**]. It revealed ulceration,
friability and erythema in the rectum compatible with ulcerative
colitis, although Crohn's colitis possible (biopsy). Pt remained
hemodynamically stable on general medicine floor.
- mesalamine enema qHS, suppository qAM
- await biopsy results
- Hct stable, monitor daily
- on PPI
- hold anticoagulation, including ASA
.
#. Pneumonia at OSH, now resolved:
LLL infiltrate with GNR in sputum diagnosed on [**1-27**] at OSH.
Patient was s/p 10 day course of zosyn (ended [**2-6**]). Upond
arrival to MICU, patient continued to have leukocytosis and
sputum production. CXR without infiltrate. Sputum culture
ordered but patient without productive cough in MICU and unable
to produce expectorate. Remained afebrile, sats stable on
baseline supplemental oxygen, without increased requirement.
.
#. C. diff dx'd at OSH:
Completed full course flagyl, not having loose stools. Toxin
assay negative. Afebrile without leukocytosis at during hospital
course.
.
#. COPD:
No evidence of COPD flare. Continued pt's outpatient regimen.
Unclear if this is why pt was on prednisone from OSH. Lung exam
unremarkable. Steroid taper discontinued [**2197-2-13**]. Sats stable in
mid-90s on 2L at discharge.
- albuteral nebs, spireva
- humidified oxygen
.
# CHF:
Patient has hx of diastolic heart failure, EF 70% on recent
persantine MIBI from OSH. She takes lasix at home and did not
come in with dyspnea but does have severe peripheral edema
secondary to heart failure. Lasix was continued at home dose.
.
#. CRI:
Pt with admission Cr 1.8, normalized after volume, now 0.9.
Received bicarb and mucomyst prior to angio embolization.
Remained stable with adequate urine output. Cr increased to 1.4
on [**2-19**]. Unclear etiology as there have been no change in meds,
pt not dry on exam, BP normotensive. Last contrast study was on
[**2-15**] for CT abd, decreasing chance for contrast-induce
nephropathy which tends to occur in 48hrs. Fractional excretion
of urea was 45% indicating pre-renal etiology due to hypovolemia
as patient appeared dry on exam.
- avoid nephrotoxins
- cont lasix 80 IV BID for diuresis
- monitor UOP via foley
.
#. Cardiac:
Pt apparently had CP at OSH 2w ago and had a negative persantine
mibi by report. At that time she was started on asa and dilt by
cardiology. BP stable throughout MICU stay. EKG without changes
and cardiac enzymes negative.
- continue to hold ASA in setting of recent lower GI bleed
.
#. Back pain control:
Pt has history of spinal stenosis. Continued pt's usual pain
regimen of morphine SR and dilaudid initially. Patient became
over-sedated on initial regime and was switched to dilaudid prn.
Avoiding standing doses of morphine [**3-16**] sedation.
- dilaudid prn
- followup with outpatient neurologist
.
# UTI/indwelling foley:
Patient has hx of recurrent UTIs due to chronic indwelling foley
catheter, which has been changed intermittently. She was found
to have a UTI prior to discharge and placed on antibiotics. She
has had a foley for urinary frequency and urgency, had
cystoscopy last year by urologist in [**Hospital1 2436**] and found to
have scarring in bladder. Urologist at [**Hospital1 18**] recommended against
suprapubic catheter placement as it does not reduce the risk of
frequent infections and thus not indicated in this patient.
- cipro 500mg x 5 days
.
#. Skin breakdown:
Stage II ulcer on R buttock and ?cellulitis on L thigh at recent
bx site.
- continue ketoconacole topically to buttock wound
- daily wound care
- applying antibiotic ointment to L thigh at bx site
- rectal tube in place
.
#. LUE swelling:
Pt had Power PICC, changed over wire [**2198-2-15**] b/c occluded; UE
ultrasound performed. No evidence of left upper extremity deep
venous thrombosis.
- keep arms raised on pillows to prevent orthostatic edema
.
#. Hypothyroidism:
- continue levoxyl
.
#. DM2:
[**Last Name (un) **] followed patient during hospital stay, modifying insulin
coverage. Patient's FSBG were well-controlled on following
regimen.
- continue insulin with FS checks qachs
- 36 units lantus standing dose with dinner, humalog sliding
scale
- neurontin for peripheral neuropathy
.
#. Glaucoma:
- continue eye drops
.
#. PPX:
- hep SQ, pneumoboots
.
#. Code status: FULL
.
#. DISPO:
DC to rehab. Follow up with GI outpatient. Consider making an
appointment with [**Hospital 511**] [**Hospital **] [**Hospital 36418**] Obesity Consult
Center at [**Telephone/Fax (1) 97026**] for physical fitness and weight loss
management.
Medications on Admission:
Flagyl 500mg po tid
lantus 128 units
lispro 8units sc with meals
albuterol 1-2 puffs [**Hospital1 **]
asa 81mg po qday
diltiazem 120 q6h
baclofen 5mg po bid
timolol 1 drop tid
dorzolamide 1 drop tid
cymbalta 60mg po qday
advair 500/50 1 puff [**Hospital1 **]
lasix 80mg po bid
neurontin 30 qam?/600qhs
heparin 5000u tid SQ (due to prolonged hospitalizations she has
been on this)
levoxyl 100mg po qday
MS contin 60 PO tid
Morphine IR 5 mg PO Q6prn
spiriva 18mcg qday
protonix 40mg po qday
prednisone 5mg po qday
ketoconazole cream
Kdur 20meq po qday
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
10. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Albuterol Sulfate 0.083 % Solution Sig: [**2-13**] Inhalation Q6H
(every 6 hours) as needed.
16. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal QDAY ().
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
18. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Insulin Glargine 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous QAHS.
20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
21. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
22. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
23. Mesalamine 4 g/60 mL Enema Sig: One (1) Rectal HS (at
bedtime).
24. Mesalamine 1,000 mg Suppository Sig: One (1) Suppository
Rectal QAM (once a day (in the morning)).
25. Sodium Chloride 0.65 % Aerosol, Spray Sig: One (1) Spray
Nasal PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
Lower GI bleeding
Ulcerative colitis
Urinary tract infection
.
Secondary diagnoses:
Recent pna hospitalization
recent LGIB at OSH, no intervention d/t c. diff and PNA
DM 2- pt at [**Last Name (un) **]. c/b neuropathy
CRI - Cr 1.6 in past, however 1.0 today nephrologist Dr. [**Last Name (STitle) 97027**]
at OSH
hypercholesterolemia
COPD
HTN
CHF - PMIBI by report at OSH was normal with EF 70%
hypothyroidism
diverticulosis
glaucoma
spinal stenosis
?dermatomyositis
UTIs with indwelling foley for bladder atony
sleep apnea on bipap overnight
ectopic pregnancy
Discharge Condition:
Stable, BP normotensive, no GI bleeding
Discharge Instructions:
You were admitted for bleeding per rectum and found to have a
very low blood count. You were stabilized in the Medicine
intensive care unit. You underwent several studies to determine
cause of bleeding and were found to have ulcerative colitis and
started on treatment.
.
You were also found to have a urinary tract infection and were
placed on short course of antibiotic treatment.
.
Please take all your medications as prescribed. You are being
discharged to [**Hospital **] Rehab.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD [**First Name (Titles) **] [**Last Name (Titles) 18**] GI
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2198-3-13**] 3:00
|
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"578.9",
"562.10",
"428.30",
"356.9",
"707.05",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23",
"88.47",
"96.34",
"48.24",
"38.93"
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icd9pcs
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[
[]
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15719, 15761
|
3791, 6173
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15117, 15199
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15785, 16270
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3202, 3772
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15220, 15698
|
258, 265
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454, 2551
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2573, 2917
|
2933, 3080
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,574
| 118,464
|
36983
|
Discharge summary
|
report
|
Admission Date: [**2100-6-7**] Discharge Date: [**2100-6-9**]
Date of Birth: [**2044-4-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
History of Present Illness: Mr. [**Known lastname 83415**] is a 56 year old male
with PMH notable for metastatic cancer (unknown primary)
undergoing chemo now presenting with lighheadedness and
hemoptysis. Pt is undergoing chemo with gemcitabine ([**2100-5-24**],
[**2100-5-31**]) for malignant neoplasm of unknown primary with multiple
bone, muscle, and soft-tissue metastases. He came to the
hospital to start RT to L femur today. Pt reports a couple days
of lightheadedness, nonpositional. Pt reports one episode of
hemoptysis [**2100-6-3**] but none since then. No sig lung lesions on
chest CT [**2100-5-27**]. Was scheduled to have transfusion on the day
of admission. Orthostatics at Dr.[**Name (NI) 83416**] office were Lying BP
94/52, pulse regular at 64. Standing BP 90/52; pulse 66. In the
ED, initial VS were: T98, P50, RR16, BP87/43, O2 100% RA. (Per
Dr. [**Last Name (STitle) **] (rad/onc) pt generally has SBP 90s-100s). He received
5.5L NS (put out 2.5L urine). He was started on Vanc infustion
but developed red itchy arm and it was stopped. He was given
benadryl with good effect. Pt did receive Cefepime 2g IV. Labs
notable for a white count of 2.2, Hct 22.9 (Hct 25 on [**5-31**]).
Chemistries were unremarkable. CXR was clear. CTA showed no PE,
stable ground glass opacities and lytic lesions. LENIs negative
for DVT. On transfer, pt's VS were T 97.6, P62, R16, BP98/59, O2
99% on RA. On arrival to the MICU, patient's VS. T98.1, HR68,
BP101/61, P70, 98%RA. Pt denies fever, chills, night sweats,
cough, nausea/vomiting, diarrhea, dysuria. Endorses constipation
with last BM two days ago. Denies bloody stool or melena. BP was
in the 80's systolic. He received 5L of fluid since admission.
2.5L urine output in the ED. One unit PRBCS was given for
chronic anemia. HCT 20.6 on admission, bumped to 24 with the
unit of blood. CTA ruled out PE. No lung mets but there are
ground glass opacities but similar to prior study 2 wks ago for
staging purposes. Blood cultures were sent. No fevers.
Baseline leukopenia. bactrim and keflex for LLE cellulitis, was
being treated prior to admission.
Past Medical History:
1. Hypercholesterolemia.
2. Tobacco use (30 pack years).
3. Hypothyroidism.
4. Asthma.
5. Depression.
6. Gastroesophageal reflux.
7. History of normal stress test.
8. Recently evaluated by vascular surgery, imaging showed
atherosclerotic plaque in the infrarenal aorta which causes a
moderate to moderately severe stenosis.
9. Recently dx w/HCAP by his PCP, [**8-20**] = day [**4-25**] of
levofloxacin.
.
PAST SURGICAL HISTORY:
1. Bilateral inguinal hernia repair.
2. Umbilical hernia repair.
3. Epigastric hernia repair.
4. Endoscopy.
Social History:
The patient used to work in construction and is a facilities
manager. Currently disabled. He is able to walk except as
described above. He uses a cane when necessary. He currently
smokes a pack a day and has done so for 30 years. He drinks
rarely.
Family History:
There is a family history of heart disease, diabetes and
hypercholesterolemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T98, P50, RR16, BP87/43, O2 100% RA.
General: Alert, oriented, no acute distress
CV: Regular rate and rhythm, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: +BS, soft, non-distended, mild tenderness to palpation,
no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
T98.5, P54, RR16, BP 108/75, O2 99% RA.
General: Alert, oriented, no acute distress
CV: Regular rate and rhythm, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: +BS, soft, non-distended, mild tenderness to palpation,
no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
#ADMISSION LABS:
[**2100-6-7**] 10:20AM BLOOD WBC-2.2*# RBC-2.46*# Hgb-7.4*# Hct-22.9*
MCV-93# MCH-30.2# MCHC-32.4 RDW-17.9* Plt Ct-45*#
[**2100-6-7**] 10:20AM BLOOD Neuts-62 Bands-1 Lymphs-30 Monos-4 Eos-3
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2100-6-7**] 10:20AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
[**2100-6-7**] 10:20AM BLOOD Plt Smr-VERY LOW Plt Ct-45*#
[**2100-6-7**] 10:20AM BLOOD Glucose-103* UreaN-8 Creat-0.9 Na-137
K-3.9 Cl-101 HCO3-27 AnGap-13
[**2100-6-7**] 10:20AM BLOOD Calcium-8.6 Mg-1.9
[**2100-6-7**] 10:20AM BLOOD Cortsol-11.8
#PERTINENT LABS:
[**2100-6-8**] 12:38PM BLOOD Hct-24.1*
[**2100-6-8**] 06:02AM BLOOD WBC-2.5* RBC-2.55* Hgb-7.8* Hct-24.0*
MCV-94 MCH-30.7 MCHC-32.5 RDW-17.3* Plt Ct-32*
[**2100-6-8**] 12:34AM BLOOD WBC-2.0* RBC-2.22* Hgb-6.7* Hct-20.6*
MCV-93 MCH-30.4 MCHC-32.7 RDW-17.6* Plt Ct-32*
[**2100-6-8**] 06:02AM BLOOD Plt Ct-32*
[**2100-6-8**] 12:34AM BLOOD Plt Ct-32*
[**2100-6-8**] 12:34AM BLOOD Ret Aut-0.2*
[**2100-6-8**] 12:34AM BLOOD Glucose-91 UreaN-7 Creat-0.8 Na-141 K-4.3
Cl-108 HCO3-24 AnGap-13
[**2100-6-8**] 12:34AM BLOOD ALT-57* AST-56* AlkPhos-75 TotBili-0.1
[**2100-6-8**] 12:34AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.4*
Mg-2.0 Iron-33*
[**2100-6-8**] 12:34AM BLOOD calTIBC-176* Ferritn-452* TRF-135*
[**2100-6-8**] 02:46AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2100-6-8**] 02:46AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2100-6-8**] 02:46AM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
#DISCHARGE LABS:
[**2100-6-9**] 06:35AM BLOOD WBC-3.1* RBC-2.57* Hgb-7.9* Hct-23.9*
MCV-93 MCH-30.9 MCHC-33.2 RDW-18.1* Plt Ct-30*
[**2100-6-9**] 06:35AM BLOOD Plt Ct-30*
[**2100-6-9**] 06:35AM BLOOD Glucose-107* UreaN-9 Creat-1.0 Na-138
K-4.4 Cl-102 HCO3-28 AnGap-12
[**2100-6-9**] 06:35AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
#MICROBIOLOGY:
[][**2100-6-7**] 6:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
[][**2100-6-8**] 2:46 am URINE Source: CVS.
**FINAL REPORT [**2100-6-9**]**
URINE CULTURE (Final [**2100-6-9**]): NO GROWTH.
#RADIOLOGY/STUDIES:
[][**6-7**] LENIs - no evidence DVT
[][**6-7**] CT chest/abdomen 1. No pulmonary embolism or acute
intra-abdominal process. 2. Numerous bilateral bronchovascular
ground-glass opacities, right greater than left, similar to or
minimally increased from [**2100-5-27**]. Smooth interlobular
septal thickening and slight bronchial wall thickening. This
combination of findings is potentially due to bronchopneumonia
with a component of pulmonary congestion. However, organizing
pneumonia or small foci of hemorrhage cannot be excluded.
3. Numerous lytic osseous lesions, similar to prior, involving
lower lumbar vertebra and pelvic bones. Other known osseous
lesions are not imaged. 4. Eccentric soft and calcified
abdominal aortic plaques.
[][**6-7**] CXR: no intrathoracic process
Brief Hospital Course:
[]BRIEF CLINICAL HISTORY:
56 year old male with PMH notable for metastatic cancer (unknown
primary) undergoing chemo, being treated for LE cullitis,
presenting with lighheadedness [**12-17**] hypotension, s/p ICU
transfer. At the time of discharge, patient is afebrile,
normotensive and not orthostatic.
[]ISSUES:
# Hypotension: Pt presented to the ED with lightheadedness and
was found to have systolic blood pressures in the 80s. The
patient was fluid resuscited with good effect. Initially it was
unclear if his presentation was infectious in etiology. Blood
cultures from [**6-3**] at [**Location (un) **] were NGTD. CT chest unchanged from
baseline. Although afebrile, pt may not have been able to mount
a white count and therefore might have remained afebrile despite
infection. Pt was at baseline blood pressure after fluids in ED.
Likely not obstructive shock as pt with negative CTA and
negative LENIs. Cardiogenic shock also unlikely given normal
baseline EKG. Hypovolemic shock not likely as good urine output
with IVF. Urine culture showed no growth. He remained afebrile
until discharge and was no longer orthostatic.
# Anemia: Unclear baseline - did have Hct of 29 a year ago. Pt
had episode of hemoptysis 4 days prior to admission. Pt had Hct
of 25 one week ago and is now at 23. After significant fluid
resuscitation in ED will likely have dilutional anemia. H/o
rectal bleeding so this was considered a possible source. There
also [**Month (only) 116**] have been bleeding into his mets. The patient was also
on gemcitabine which suppresses the bone marrow which is
consistent with his low retic count of 0.2. Iron studies c/w
anemia of chronic inflammation (normocytic, high ferritin, low
TIBC and low transferrin). HCT remained stable since transfer
from ICU to floor (24 --> 23.9).
# Cellulitis: patient began treatment with bactrim as an
outpatient less than a week before admission. There was
moderate improvement in the erythema and swelling of the left
lower extremity by the time of admission. He was started on
combination therapy with bactrim/keflex and had substantial
improvement in his cellulits that largely resolved by the time
of discharge. He was sent home to finish his course of
antibiotics and f/u with his PCP.
# Malignant epithelioid cancer of unknown primary (possibly
carcinoma per path report): Patient received 2nd of 8 scheduled
XRT while in house with f/u to complete the final 6 sessions.
Patient is to f/u with primary oncologist as an outpatient.
# Hypothyroidism:
-Continued on outpatient levothyroxine
# Asthma:
-Continued on outpatient flovent, albuterol PRN
# Depression:
-Continued on outpatient fluoxetine
# GERD:
-Continued on outpatient pantoprazole
# HLD:
-Continued outpatient simvastatin, niacin
[]TRANSITIONAL ISSUES:
1.) patient with neoplasm of unknown primary that will be
investigated by primary oncologist.
2.) PCP will follow up for resolution of cellulitis.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientwebOMR.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheeze
2. Fluoxetine 40 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
5. Gabapentin 300 mg PO TID
6. Levothyroxine Sodium 137 mcg PO DAILY
7. Lorazepam 1 mg PO Q8H:PRN nausea, anxiety or insomnia
8. Milk of Magnesia 15-30 mL PO PRN constipation
9. Morphine SR (MS Contin) 90 mg PO Q8H
10. Ondansetron 8 mg PO Q 8H
11. OxycoDONE (Immediate Release) 10-20 mg PO Q4-6HRS PRN pain
12. Pantoprazole 40 mg PO Q12H
13. Prochlorperazine 10 mg PO Q8H:PRN nausea
14. Simvastatin 40 mg PO DAILY
15. Docusate Sodium 100 mg PO TID
16. Ibuprofen 200-400 mg PO Q4-6HRS PRN pain
17. Magnesium Oxide 400 mg PO BID
18. Niacin 500 mg PO DAILY
19. Fish Oil (Omega 3) 1000 mg PO TID
20. Senna 1 TAB PO HS
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheeze
2. Docusate Sodium 100 mg PO TID
3. Fish Oil (Omega 3) 1000 mg PO TID
4. Fluoxetine 40 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Gabapentin 300 mg PO TID
8. Ibuprofen 200-400 mg PO Q4-6HRS PRN pain
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Lorazepam 1 mg PO Q8H:PRN nausea, anxiety or insomnia
11. Magnesium Oxide 400 mg PO BID
12. Milk of Magnesia 15-30 mL PO PRN constipation
13. Morphine SR (MS Contin) 90 mg PO Q8H
14. Niacin 500 mg PO DAILY
15. Ondansetron 8 mg PO Q 8H
16. OxycoDONE (Immediate Release) 10-20 mg PO Q4-6HRS PRN pain
17. Pantoprazole 40 mg PO Q12H
18. Prochlorperazine 10 mg PO Q8H:PRN nausea
19. Senna 1 TAB PO HS
20. Simvastatin 40 mg PO DAILY
21. Cephalexin 500 mg PO Q12H
RX *cephalexin 500 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
22. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth twice a day Disp #*4 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypotension
Secondary Diagnosis:
malignant epithelioid neoplasm of unknown primary
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 83415**],
It was a pleasure treating you.
You were admitted to the [**Hospital1 69**]
for low blood pressure and dizziness. You were initially sent
to the intensive care unit to stabilize your blood pressures.
There was initial concern for infection and you were given
intravenous fluids and antibiotics. You quickly stabilized and
were transfered to the regular inpatient floor. You underwent
two sessions of radiotherapy while here as well. You will
follow up with both your primary care physician and with your
primary oncologist. We wish you and your family the best.
Please continue taking your medications as prescribed, EXCEPT:
CONTINUE bactrim for 2 days
ADD Cephalexin for 2 days
Followup Instructions:
1.) You will follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**First Name (STitle) 2429**] T. Guerzon on [**First Name (STitle) 2974**] [**6-11**] at 10AM .
2.) You will follow up with your primary oncologist, Dr. [**First Name (STitle) **] R.
[**Doctor Last Name 10919**] on [**Last Name (LF) 2974**], [**6-18**] at 11AM.
|
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icd9cm
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24,436
| 118,896
|
12853
|
Discharge summary
|
report
|
Admission Date: [**2121-7-23**] Discharge Date: [**2121-7-29**]
Service: CCU
CHIEF COMPLAINT: Hypercarbic respiratory arrest status post
ET tube placement.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old man,
without previously documented coronary artery disease, who
presented to [**Hospital 1474**] Hospital on [**7-22**] after developing
chest pain while getting an abdominal MRI. On arrival to
[**Hospital1 1474**], he was complaining of chest pain but otherwise was
a poor historian. Heart rate was 62, blood pressure 151/95,
oxygen saturation 94%. He was reportedly pain free with
sublingual Nitroglycerin in the Emergency Room.
Electrocardiogram revealed new inferolateral biphasic
T-waves, and the patient was started on Aspirin, Lovenox, and
Nitroglycerin drip, and was admitted to the Intensive Care
Unit.
During the hospitalization, the patient ruled in with a peak
CK of 308 on arrival. The troponin was negative. On the
morning of [**7-23**], the patient had recurrent chest pain
with deep T-wave inversions inferolaterally. The patient was
seen by Cardiology and started on Heparin and Aggrastat, with
plans for transfer to [**Hospital6 256**]
for left heart catheterization.
On transport to [**Hospital6 256**], the
patient reportedly was agitated and received 2 g Ativan plus
or minus Morphine Sulfate, but it was not documented
properly. He was found in the holding area to be minimally
responsive, although hemodynamically stable with spontaneous
respirations. He was given Narcan without effect. Arterial
blood gases revealed 7.20, pCO2 of 93, pO2 of 272, on
non-rebreather, consistent with hypercarbic respiratory
failure. The patient was intubated and taken to the CCU for
further management.
PAST MEDICAL HISTORY: Significant for history of syncope,
benign prostatic hypertrophy, and gastroesophageal reflux
disease.
MEDICATIONS: He was not on any medications at home. On
transfer he was on Aspirin 325 p.o. q.d., Lopressor 12.5 p.o.
b.i.d., Lipitor 10 p.o. q.d., Lovenox 70, Nitroglycerin drip,
Aggrastat drip, Pepcid 20 p.o. q.d., Zantac 150 mg p.o.
b.i.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: He lives at home with his wife. [**Name (NI) **] is a
retired [**Hospital Ward Name **]. He has occasional alcohol use. Tobacco
history of one pack per week.
PHYSICAL EXAMINATION: General: He was a thin, elderly man,
intubated and sedated, status post ET tube placement. Vitals
signs: Temperature 97.8??????, blood pressure 137/71, pulse 76,
assist control at 12, total volume of 600, FI02 100%, PEEP 5.
HEENT: He was anicteric with pinpoint pupils. He had marked
jugular venous distention. Lungs: Clear to auscultation
anteriorly and laterally with good air movement bilaterally.
Heart: Regular, rate and rhythm. Occasional pauses. S1 and
S2. Questionable S3. No murmurs or rubs. Abdomen: Soft
and nontender. Active bowel sounds. Extremities: No
clubbing, cyanosis or edema. Faint pulses of dorsalis pedis
and posterior tibial. Neurological: He was sedated. He
moved all four extremities spontaneously. He was not
arousable status post ET tube placement. He did not
withdrawal to pain in the arms.
LABORATORY DATA: On admission white blood cell count was
5.0, hematocrit 33.8, platelet count 240,000; CHEM7 notable
for a creatinine of 1.5, which later dropped to 1.1; CK on
admission was 308, with an MB fraction of 10, index 3.3, the
CK later dropped to 295 and then 263, troponin less than 0.3;
urinalysis was negative.
Electrocardiogram on arrival to [**Hospital1 1474**] revealed
questionable atopic atrial beats at 65, left axis deviation,
Q-waves in V1 and V2, left ventricular hypertrophy, and
inferolateral biphasic T-waves.
On arrival to [**Hospital6 256**], he was in
sinus rhythm in the 70s with slight pauses, left anterior
descending with poor R-wave progression, slight biphasic
T-waves inferiorly and laterally.
Chest x-ray at [**Hospital1 1474**] per report was negative.
HOSPITAL COURSE: The patient was admitted, and left heart
catheterization was postponed on the day of admission because
the patient was sedated and unable to give consent. It was
later postponed because of an episode of hemoptysis late
Thursday night into early Friday morning.
Left heart catheterization was finally done on [**2121-7-28**]. This revealed mildly elevated left ventricular and
diastolic pressure. Left ventriculography revealed global
hypokinesis, with an ejection fraction of 40%. Codominant
anatomy with left main coronary artery patent, left anterior
descending with minimal irregularity, left circumflex with
minimal luminal irregularity, and right coronary with
proximal 40% lesion.
Other issues during the hospitalization included agitation in
the patient at times which was treated successfully with
Haldol and a 1:1 sitter. The patient was initially on
Aggrastat, Heparin drip, and Nitroglycerin drip, and these
were all stopped, and all of his cardiac medications were
discontinued after the left heart catheterization revealed
insignificant coronary artery disease. After
catheterization, the right groin site revealed no hematoma
and no bruit.
DISCHARGE STATUS: The patient is stable.
DISCHARGE PLAN: The patient is to be discharged either to
home or to a nursing rehabilitation center on no medications,
just as he entered the hospital, with follow-up with his
primary care physician.
DISCHARGE DIAGNOSIS: Chest pain of unknown etiology. The
patient did not have a myocardial infarction. The patient
did not have unstable angina.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2121-7-29**] 11:12
T: [**2121-7-29**] 12:18
JOB#: [**Job Number 39542**]
|
[
"518.81",
"530.81",
"600.0",
"300.01"
] |
icd9cm
|
[
[
[]
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[
"88.53",
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] |
icd9pcs
|
[
[
[]
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5444, 5834
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4012, 5219
|
2356, 3994
|
107, 170
|
199, 1744
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5236, 5422
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|
2171, 2333
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,505
| 107,978
|
4283+55565
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-6-18**] Discharge Date: [**2120-6-25**]
Date of Birth: [**2045-10-23**] Sex: F
Service: CARDIAC S.
CHIEF COMPLAINT: Worsening dyspnea on exertion.
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname **] is a 74-year-old
female who presents with aortic stenosis. Over the past year
she has been having worsening symptoms of dyspnea on
exertion. She became short of breath after climbing one
flight of stairs or walking two blocks on a flat surface.
She also had some lightheadedness when she was walking, but
denied any syncope. The last echocardiogram was in [**2120-1-9**], which showed mild left ventricular hypertrophy with
normal wall motion and ejection fraction of 60% and a
severely stenotic aortic valve with a mean gradient of 43
mmHg and a peak gradient of 65 mmHg. The calcified valve
area was 0.6 cm squared.
PAST MEDICAL HISTORY: History is notable for the following:
1. Hypertension.
2. Arthritis.
3. Urinary frequency.
4. Status post hysterectomy.
5. Status post cholecystectomy.
6. Status post bladder suspension.
MEDICATIONS:
1. Premarin 0.625 mg PO q.d.
2. Miconazole 12.5 mg P.o.q.d.
3. Detrol 4 mg P.o.b.i.d.
4. Calcium 600 mg p.o.q.d.
5. Multivitamin PO q.d.
6. Tylenol arthritis p.r.n.
ALLERGIES: NAPROSYN GIVES HER HIVES AND LOPID GIVES HER
INCREASED LIVER FUNCTION TESTS.
PHYSICAL EXAMINATION: On physical examination, the blood
pressure is 136/65; heart rate 72. NECK: Without carotid
bruit. HEART: Regular rate and rhythm with a systolic
murmur. LUNGS: Lungs were clear to auscultation
bilaterally. ABDOMEN: Soft, nontender. EXTREMITIES:
Palpable peripheral pulses with no varicosities. Cardiac
catheterization demonstrated moderate-to-severe aortic
stenosis with nonobstructive coronaries and normal pulmonary
artery pressures along with a preserved left ventricular
ejection fraction.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service on [**2120-6-18**], following her cardiac
catheterization. The following day she was taken to the
operating room, where she had an aortic valve replacement
with a tissue prosthetic valve. She received a #21 CE valve.
The procedure was remarkable for a transfusion requirement of
5 units of packed red blood cells, 4 units of fresh-frozen
plasma and two units of platelets. Total cardiopulmonary
bypass time was 92 minutes. Cross-clamp time was 70 minutes.
Postoperatively, the patient was taken intubated to the
Cardiac Surgery Intensive Care Unit. In the Cardiac Surgery
Intensive Care Unit she was extubated overnight, but required
a Neo-Synephrine drip to maintain her blood pressure. She
was slowly weaned off this drip throughout the course of the
first postoperative day. By the morning of the second day
she was stable enough to be transferred to the floor.
However, that evening, she became tachycardiac to a pulse
rate of approximately 120 to 130. The EKG at that time
demonstrated a junctional tachycardia that was narrow complex
in nature and very regular. She required significant doses
of intravenously Lopressor in order to control her rate. She
ultimately required 25 units of Lopressor IV and she was also
transfused with one more unit of packed red blood cells. She
remained stable overnight, but the following morning she had
a recurrence of her tachycardia. In addition, she started to
have some bronchospasm that was secondary to the IV Lopressor
and she may have also had an element of congestive heart
failure. She was given intravenous Lasix and treated with IV
Diltiazem. She converted after 15 mg bolus and she was
started on a drip at 10 mg an hour. After this time, she
remained stable. All of beta blockers were discontinued.
The following day, she started to be loaded with oral
Diltiazem. By the 5th postoperative day, the oral Diltiazem
dosage increased and her drip was decreased. In addition, it
became apparent at this time that she was going to need rehab
following her surgery. She was started on subcutaneous
heparin and screening for rehabilitation was initiated.
During this time, she continued to be diuresed. She was
essentially without complaint. She did require some
intravenous doses of Diltiazem for heart rates between 100
and 110 as her drip was being weaned and her oral doses were
taking effect.
On [**2120-6-24**], the hospitalization was dictated in
anticipation of her transfer to rehabilitation. We are
anticipating that she is transferred to rehabilitation on
[**6-25**], off her Diltiazem drip, taking 90 mg PO q.i.d.
DISCHARGE MEDICATIONS:
1. Diltiazem anticipated to be 90 mg PO q.i.d.
2. Colace 100 mg p.o.b.i.d.
3. Zantac 150 mg PO b.i.d.
4. Lasix 20 mg b.i.d. times seven days.
5. Potassium chloride 20 mEq b.i.d. times seven days.
6. Premarin 0.625 mg PO q.d.
7. Percocet 5/325 one to two PO q.4h. to 6h.p.r.n.
8. Tylenol 650 mg PO q.4h. to 6h.p.r.n.
9. Heparin 5000 units subcutaneously b.i.d.
10. Oxazepam 10 mg PO q.h.s.p.r.n.
11. Milk of Magnesia 30 cc PO q.6h.p.r.n.
On the afternoon of this dictation, a diabetes mellitus
consultation was obtained as the patient has had some
elevated blood sugars during this hospitalization and it
could be that she has undiagnosed diabetes mellitus at which
time she will likely be placed on an oral [**Doctor Last Name 360**].
The patient is to followup with her family physician,
[**Last Name (NamePattern4) **]. [**Last Name (un) **] in approximately two weeks. In addition, she
is to followup with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in approximately
four weeks.
DISCHARGE DIAGNOSES: Aortic stenosis now status post tissue
aortic valve replacement.
SECONDARY DIAGNOSIS:
1. Hypertension, controlled.
2. Previously undiagnosed adult onset diabetes mellitus.
3. Junctional tachycardia, controlled.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2120-6-24**] 15:56
T: [**2120-6-24**] 16:10
JOB#: [**Job Number 18558**]
Name: [**Known lastname 3023**], [**Known firstname 3024**] Unit No: [**Numeric Identifier 3025**]
Admission Date: [**2120-6-18**] Discharge Date: [**2120-7-1**]
Date of Birth: [**2045-10-23**] Sex: F
Service:
DISCHARGE SUMMARY ADDENDUM: This is an addendum to a
previously dictated discharge summary. The patient's
discharge summary included through [**2120-6-25**]. This
addendum is from [**2120-6-26**] through [**2120-7-1**].
On postoperative day seven [**2120-6-26**], the patient
remained on Diltiazem drip and was weaned off her po
Diltiazem dose was increased and she remained hemodynamically
stable off a Diltiazem drip with a heart rate between 100 and
105 and a blood pressure of 120/65. Other than that her
activity was being slowly increased with the assistance of
the nursing staff and physical therapists. Her epicardial
pacing wires were also discontinued on postoperative day
seven.
On postoperative day eight she had no acute events. Her
Diltiazem dose continued to be adjusted upwards in an effort
to control her heart rate. She did have one transient episode
of atrial fibrillation on that day.
On postoperative day nine the patient again had intermittent
episodes of atrial fibrillation otherwise she was in normal
sinus rhythm and hemodynamically stable. We loaded her with
IV Amiodarone and started her on a po Amiodarone dose on
postoperative day nine. She did convert back to normal sinus
rhythm following her IV Amiodarone load.
On postoperative day the patient continued to be
hemodynamically stable in a sinus rhythm with a heart rate of
84 and a blood pressure of 110/63. Her activity level
continued to be increased and she was following an uneventful
postoperative cardiac surgery course. She was being screened
by rehabilitation centers at that time and from a cardiac
surgery standpoint was ready to be transferred to
rehabilitation whenever a bed became available.
On postoperative day ten a bed was still not available and
rehabilitation. She remained in sinus rhythm, hemodynamically
stable. Of note an old IV site was noted to be somewhat
erythematous and she was started on po Keflex. The IV was
discontinued. She mounted neither a white count nor a fever
with minimal erythema from her IV site.
On postoperative day eleven the day of discharge, the patient
remained hemodynamically stable in sinus rhythm. At that time
her physical examination is as follows:
Vital signs - temperature 98.3 F, heart rate 89 sinus rhythm
blood pressure 120/53, respiratory rate 20, O2 saturation 93%
on one and a half liters nasal prongs.
Labs on day of discharge - white count 10, hematocrit 31,
platelet count 314,000. Sodium 137, potassium 5.1, chloride
98, CO2 28, BUN 8, creatinine 0.6, glucose 104.
Physical examination - Alert and oriented times 3,
conversant, moves all extremities, in no acute distress.
Lungs are clear to auscultation bilaterally. Heart sounds
normal S1, S2, regular rate and rhythm. Sternum is stable.
Incision is intact, clean and dry, open to air. Abdomen is
soft, nontender, nondistended with normoactive bowel sounds.
Th[**Last Name (STitle) 1293**] is to be discharged to rehabilitation. She is to
have follow up with Dr. [**Last Name (un) 3026**] in two weeks and follow
up with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Name8 (MD) 3027**]
MEDQUIST36
D: [**2120-7-1**] 09:00
T: [**2120-7-1**] 09:41
JOB#: [**Job Number 3028**]
|
[
"427.31",
"998.11",
"272.0",
"250.00",
"997.1",
"424.1",
"458.2",
"716.90",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.23",
"39.61",
"35.21",
"99.29",
"89.68",
"99.69"
] |
icd9pcs
|
[
[
[]
]
] |
5618, 5684
|
4586, 5596
|
1915, 4563
|
1391, 1897
|
162, 876
|
5705, 9675
|
899, 1368
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,877
| 119,003
|
24256
|
Discharge summary
|
report
|
Admission Date: [**2168-5-7**] Discharge Date: [**2168-6-15**]
Date of Birth: [**2123-7-5**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
44 year old man with traumatic head injury; Right frontotemporal
contusion and right MCA stroke.
Major Surgical or Invasive Procedure:
right frontal intracranial pressure monitor
PEG placed [**6-8**]
History of Present Illness:
44 year-old man with an unknown history transferred from
[**Hospital6 8283**] after traumatic head injury. Pt was
working on his house when nailgun he was using misfired and hit
him in right supraorbital region, associated with loss of
consciousness. Per records, he was noted to be "thrashing" at
the
scene. Initial evaluation revealed a depressed skull fracture
with intracranial hemorrhages and he was transferred to [**Hospital1 18**]
for
further management.
Past Medical History:
unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
PE on Admission:
Tm 101 Tc 100.5 BP 120s-140/40s-60s HR 50s-60s
General: Appears stated age, intubated
HEENT: +Significant ecchymosis right orbit, right eye swollen
shut. Sclera anicteric. OP clear
Neck: In hard collar
Lungs: Clear to auscultation bilaterally
CV: RRR, nl S1, S2, no murmur.
Abd: Soft, nontender, normoactive bowel sounds
Extr: No edema, warm and well perfused
Neurologic Examination: Intubated, off propofol ~15 minutes
Mental Status: Arouses to voice, stimulation. No apparent
neglect. Follows commands: open/close eyes, stick out tongue,
squeeze/let go hand, moves arms and legs, shows 2 fingers
bilaterally.
Cranial Nerves: Pupils: Rt 3mm, left 5mm, both reactive. Left
eye
crosses midline, unable to assess right eye due to severe lid
swelling. Closes eyes tightly to resist eye opening. No obvious
asymmetry in face, but right orbital trauma and intubation makes
assessment difficult.
Motor: Normal bulk and tone bilaterally, fasiculations absent in
upper and lower extremities. No tremor. Holds both arms up
equally, triceps full bilaterally, moves both legs equally
except
no movement left toes. Withdraws slightly less briskly on left
side compared with right.
Sensation: withdraws to noxious in all 4 extremities.
Reflexes: DTRs normal and symmetric throughout. Toes were
downgoing on right, mute on left
Discharge PE
Pertinent Results:
Admission Labs
[**2168-5-7**] 09:12PM TYPE-ART TEMP-37.5 PO2-311* PCO2-37 PH-7.42
TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED
[**2168-5-7**] 09:12PM LACTATE-1.5
[**2168-5-7**] 09:12PM freeCa-1.10*
[**2168-5-7**] 09:05PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2168-5-7**] 09:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2168-5-7**] 09:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2168-5-7**] 06:10PM GLUCOSE-109* LACTATE-3.1* NA+-138 K+-4.1
CL--99* TCO2-23
[**2168-5-7**] 06:00PM UREA N-18 CREAT-0.9
[**2168-5-7**] 06:00PM AMYLASE-34
[**2168-5-7**] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-5-7**] 06:00PM WBC-20.4* RBC-4.65 HGB-13.2* HCT-39.0* MCV-84
MCH-28.4 MCHC-33.8 RDW-12.7
[**2168-5-7**] 06:00PM PLT COUNT-314
[**2168-5-7**] 06:00PM PT-13.0 PTT-18.8* INR(PT)-1.1
[**2168-5-7**] 06:00PM FIBRINOGE-246
CT HEAD W/O CONTRAST [**2168-5-11**] 12:18 AM
No significant change when compared to the prior study. There is
again noted a large area of infarct with brain edema causing
subfalcine herniation and shift of normally midline structures
to the left. The appearance of the cisterns appears unchanged
allowing for technical differences. However, due to the position
of the patient, cannot rule out uncal herniation.
Chest Radiograph [**2168-6-8**]: New patchy opacity within the right
mid lung medially, possibly representing atelectasis versus
consolidation within the right lower lobe. Stable bilateral
pleural effusions and bibasilar atelectasis.
CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST [**2168-6-6**].
Compared to the prior study of [**5-11**], the right middle
cerebral artery infarct now essentially involves the entire
cortex within this vascular territory, but relatively little of
the subjacent white matter. There is underlying dilatation of
the right temporal [**Doctor Last Name 534**], suggesting that this infarct is
subacute to chronic in age. There may be a small amount of
hemorrhage along the most deeply situated portion of this
infarct, which is within the right frontal lobe superior to the
bodies of the lateral ventricles. A probable subacute right
posterior cerebral artery infarct is seen within the right
occipital lobe, possibly with tiny amount of associated
hemorrhage. There is no shift of normally midline structures.
There is fairly extensive opacification of the frontal sinus,
more evident to the right side. The previously noted right-sided
superior orbital hemorrhage is seen with a jagged 1 cm area of
calcific density, probably representing residual orbital roof
fracture fragment. There is mild to moderate polypoid mucosal
thickening with slight frothy secretions superior to these
regions in both sphenoid air cells. There is slight thickening
of the posterior nasopharyngeal soft tissues near the left fossa
of Rosenmuller. This finding was not clearly demonstrably on
prior CT scans and deserves potential further evaluation by ENT
consultation.
OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION([**2168-6-7**])
EVALUATION:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with Radiology. Thin liquid,
Nectar-thick
liquid, pureed consistency barium, one cookie coated with barium
and one barium pill were administered. Results follow:
ORAL PHASE:
The oral phase was noted for mild deficits primarily impacted by
cognitive deficits such that the pt required verbal cues to open
his mouth sufficiently to accept po solids. Additionally, oral
transit time was prolonged, there was piecemealing of both
solids
and liquids and mild loss of bolus control with premature
spillover of liquids to the intermittently to the valleculae and
less often to the pyriform sinuses.
Attempted the 13 mm barium tablet, however the pt chewed the
barium tablet, despite verbal cues and directions to the
contrary.
PHARYNGEAL PHASE:
The pharyngeal phase was judged to be wfl fora timely swallow
initiation with adequate velar elevation, hyolaryngeal
excursion,
laryngeal valve closure, epiglottic deflection and
pharyngoesophageal sphincter opening.
There was mild residue of the cookie bolus in the valleculae and
also in the pyriform sinuses. Residue in the pyriform sinuses
was
likely related to presence of the NG tube however. Additionally,
residue cleared with follow up sips of liquids.
ASPIRATION/PENETRATION:
No aspiration or penetration occurred during the exam.
TREATMENT TECHNIQUES:
Alternating between bites and sips helped to clear pharyngeal
residue, as well as oral residue. Pt also required verbal cues,
especially with solids, to initiate oral transit, to chew, and
to
swallow.
SUMMARY:
Mr. [**Known lastname 39190**] presents with a mild oral dysphagia at this time.
The
pt's cognitive deficits are limiting his awareness with regards
to initiating the oral phase of swallowing such that the pt
requires consistent verbal cues to engage in the act of
eating/drinking. Therefore, longer term enteral
nutrition/hydration (PEG) tube is still recommended as it is not
likely that the pt will be able to meet his nutritional
requirements via po route alone. Pt is a good rehab candidate
and goal of weaning from tube feedings will appropriate during
rehab stay. Pt can also begin po diet consistency of regular
solids and thin liquids, but will require assistance and
supervision for all po's.
RECOMMENDATIONS:
1.PO diet consistency of regular texture solids and thin
liquids.
2.PO meds as tolerated, may need to be crushed or placed
via PEG tube.
3.Follow up speech therapy at rehab re:weaning off tube
feedings, and cognitive-linguistic remediation related to
TBI.
Signed by [**Last Name (NamePattern4) 57715**] [**Last Name (NamePattern1) 15102**], CCC-SLP on [**2168-6-7**]
Affiliation: [**Hospital1 18**]
Brief Hospital Course:
54M s/p orbital trauma with traumatic subarachnoid and subdural
hemorrhage requiring intubation admitted to neurosurgery service
on [**2168-5-7**].Ophtomology consulted for retroorbital hematoma and
preformed lateral canthotomyand lysis of Right eye [**5-7**] by
ophtolmology. Repeat Head CT revealed evolution of large R MCA
infarct on [**2168-5-8**]. Neurological exam is relatively normal, with
only minimally decreased motor function of left and no other
obvious deficits. Neurology service consulted for new Right MCA
stroke.On [**5-10**] right frontal [**Last Name (un) 8745**] palced for ICP monitoring
secondary to increased mass effect resulting from the
right-sided infarct, as demonstrated by substantial compression
of the right lateral ventricle and right to left subfalcine
herniation.There is also increased mass effect and herniation
into the ambien cisterns.Kefzol added to regimen until [**Last Name (un) 8745**]
removed.Pateint intracranial pressure were fluctuating anywhere
from 6 to 90's , treated medically. pateint placed on penbarb
coma due to increase ICP's.EEG monitoring while on pentbarb
coma. Held a family meeting on [**2168-5-11**] regarding patient
prognosis, we continued agressive effort to decrease ICP's with
mannitol, goal PCO2 of 30-35, temperature of around 96 F,
followed serum osm and serum sodium level to aid mannitol
thereapy and other labs. pentabarb coma d/c ed [**5-23**].Continued to
monitior ICP wiht right frontal [**Last Name (un) 8745**]. [**5-24**] [**Last Name (un) 8745**] replaced
under steril technique with good wave form.Patient graduallay
started wake up from pentbarb coma.
Screened for DVT's there was no evidence of DVT on bilateral
lower extremities doppler study completed on [**2168-5-27**]. Continues
to be on SQ heparin and pboots.[**5-28**] sputum culture showed
enterobacter Aerogenes which treated wiht levoflox, catheter tip
culture grew coagulase negative staph (6/17_)sensetive to
vancomycin.
Hematocrit dropped to 20.9 requiring 3units of PRBC transfusion
on [**2168-5-30**].[**Last Name (un) **] removed on [**5-30**], and started to localize upper
extremities and slugishly witdrawing bilateral lower
extremities, corneal and gag reflexes are present, still
remains orally intubated.Central line catheter replaced over
guidewire and sent catheter tip culture by SICU team on [**5-30**]
also planned for PEG and Trache, later on the day patient
strated to awaken, and hold off on Trache, which he was able to
be extubated on [**2168-6-2**].
[**6-3**] Patient failed speech/swallow eval due to evidence of
aspiration with thin liquids.Patient remained NPO per speech
pathologist recommendations, continued with Nasogastric tube
feeds.
[**6-6**] Patient repeat speech/swallow eval no evidence of
aspiration but speech pathologist felt that patient
initiation/awareness is lacking. When pt engaged in
questioning re: eating/drinking, pt expressed no desire to
eat/drink and concept of eating/drinking did not appear
motivating to him given his current cognitive limitations per
speech pathologist.
[**2168-6-6**] opthalmology reevaluated regarding retroorbital hematoma
and recommended follow up with [**Hospital3 **] Eye Clinic([**Hospital Ward Name 23**]
building [**Location (un) 442**]([**Telephone/Fax (1) 253**]) in [**1-14**] weeks after discharge
from hopital with Dr [**Last Name (STitle) **].
Transferred to stedown unit on [**6-7**], more alert, follows
commands, moves all extremities.
Patient also underwent oropharyngeal videofluoroscopic
swallowing evaluation on [**6-7**] presents a mild oral dysphagia at
this time. The pt's cognitive deficits are limiting his
awareness with regards to initiating the oral phase of
swallowing such that the pt requires consistent verbal cues to
engage in the act of eating/drinking.Speech pathologist
recommended 1.PO diet consistency of regular texture solids and
thin liquids. 2.PO meds as tolerated, may need to be crushed or
placed via PEG tube.3.Follow up speech therapy at rehab
re:weaning off tube feedings, and cognitive-linguistic
remediation related to TBI.(see complete note on pertinent
results.)
Gastrostomy tube inserted by intervnetional radiology department
on [**2168-6-8**]. PEG feeding started after 24 hours of insertion,
nutritionist also continued to follow as regarding patient
dietary requirements.
On [**6-8**] CXR RML pneumonia and was placed on Levaquin for 10
days.
Patient developed Polycyclic erythematous papules/plaques
coalescent in many areas
noted over chest, abdomen, arms b/l, and thighs b/l. Back
mostly confluent. Almost all areas are completely blanching,
but non-blanching component noted on upper extremities.
Blanching erythema noted to cheeks, forehead, chin. No
particular
facial edema noted.Dermatology felt that generalized
erythematous papules/plaques most likely drug related
hypersensitivit(dilantin/keppra/levocephalosporin/contrast)
topicals ordered as derm recommended, received several dose of
dexamethasone. On discharge rash appears to be almost completely
resolved.LFT's have been elevated but trending downward, felt to
be related to durg reaction/rash. LFT's should be followed
weekly.
His c-collar was clinically cleared he had no neck pain and CT
of his C-Spine showed no fractures.
His tube feedings are now at goal.
Discharge Medications:
1. Bacitracin-Polymyxin B unit/g Ointment Sig: One (1) Appl
Ophthalmic Q8H (every 8 hours).
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a
day).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days: last dose [**2168-6-17**].
9. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO BID
(2 times a day) as needed for itching.
10. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Acetaminophen 160 mg/5 mL Elixir Sig: 0.5-1 Elixir PO Q4-6H
(every 4 to 6 hours) as needed for fever.
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right frontotemporal contusion.
Right MCA stroke.
Discharge Condition:
neurologically stable
Discharge Instructions:
Monitor for mental status changes.
Aggressive physical and occupational therapy
Followup Instructions:
Follow up with [**Hospital3 **] Eye Clinic in [**1-14**] weeks ([**Hospital Ward Name 23**]
Bldg, [**Location (un) 442**]). call for an appointment [**Telephone/Fax (1) 253**] with Dr
[**Last Name (STitle) **].
Follow up in 6 weeks with Dr [**Last Name (STitle) 739**] with head CT.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2168-6-15**]
|
[
"958.8",
"486",
"E922.5",
"376.89",
"804.26",
"921.2",
"434.91",
"693.0",
"348.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"43.11",
"99.04",
"38.91",
"01.18",
"96.6",
"08.51",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
15263, 15333
|
8435, 13754
|
415, 482
|
15427, 15450
|
2445, 8412
|
15578, 15987
|
1048, 1057
|
13777, 15240
|
15354, 15406
|
15474, 15555
|
1072, 1075
|
278, 377
|
510, 976
|
1721, 2426
|
1089, 1453
|
1528, 1705
|
1477, 1513
|
998, 1007
|
1023, 1032
|
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